Cited by 82Treatment of Major DepressionElectroconvulsive Therapy StudiesTranscranial Magnetic Stimulation Studies

International pooled patient-level meta-analysis of ketamine infusion for depression: In search of clinical moderators

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Price, Rebecca B., Kissel, Nicholas, Baumeister, Andrew, Rohac, Rebecca, Woody, Mary L., Ballard, Elizabeth D., Zarate, Carlos A., Deakin, William +25 more·2022·Molecular Psychiatry

Abstract

Depression is disabling and highly prevalent. Intravenous (IV) ketamine displays rapid-onset antidepressant properties, but little is known regarding which patients are most likely to benefit, limiting personalized prescriptions. We identified randomized controlled trials of IV ketamine that recruited individuals with a relevant psychiatric diagnosis (e.g., unipolar or bipolar depression; post-traumatic stress disorder), included one or more control arms, did not provide any other study-administered treatment in conjunction with ketamine (although clinically prescribed concurrent treatments were allowable), and assessed outcome using either the Montgomery-Åsberg Depression Rating Scale or the Hamilton Rating Scale for Depression (HRSD-17). Individual patient-level data for at least one outcome was obtained from 17 of 25 eligible trials [pooled n = 809]. Rates of participant-level data availability across 33 moderators that were solicited from these 17 studies ranged from 10.8% to 100% (median = 55.6%). After data harmonization, moderators available in at least 40% of the dataset were tested sequentially, as well as with a data-driven, combined moderator approach. Robust main effects of ketamine on acute [~24-hours; β *(95% CI) = 0.58 (0.44, 0.72); p < 0.0001] and post-acute [~7 days; β *(95% CI) = 0.38 (0.23, 0.54); p < 0.0001] depression severity were observed. Two study-level moderators emerged as significant: ketamine effects (relative to placebo) were larger in studies that required a higher degree of previous treatment resistance to federal regulatory agency-approved antidepressant medications (≥2 failed trials) for study entry; and in studies that used a crossover design. A comprehensive data-driven search for combined moderators identified statistically significant, but modest and clinically uninformative, effects (effect size r ≤ 0.29, a small-medium effect). Ketamine robustly reduces depressive symptoms in a heterogeneous range of patients, with benefit relative to placebo even greater in patients more resistant to prior medications. In this largest effort to date to apply precision medicine approaches to ketamine treatment, no clinical or demographic patient-level features were detected that could be used to guide ketamine treatment decisions. Review Registration: PROSPERO Identifier: CRD42021235630

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  • Clinical response to ketamine/esketamine is highly heterogeneous, and robust predictors are lacking.

    “Clinical response is highly heterogeneous, and robust predictors are lacking, underscoring the need for biomarkers and stratified treatment strategies [85,91,92,93].”

    From Synaptic Plasticity—Intrinsic Excitability and Antidepressant Discovery (2026) · cites this paper as [91]

    The Conclusions report substantial individual differences in response to IV ketamine and limited ability to predict response before a first infusion. The Limitations state that intranasal esketamine trials were not included, so this paper does not establish the same point for esketamine. (LLM, conf=0.88)

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  1. [26]Collaboration TC: Chapter 8: assessing risk of bias in included studies. In: Higgins JPGS, editor. Cochrane Handbook for Systematic Reviews of Interventions Version 510 (http://handbookcochraneorg/), The Cochrane Collaboration, 2011

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Authors
Price, R. B., Kissel, N., Baumeister, A., Rohac, R., Woody, M. L., Ballard, E. D., Zarate, C. A., Deakin, W., Abdallah, C. G., Feder, A., Charney, D. S., Grunebaum, M. F., Mann, J. J., Mathew, S. J., Gallagher, B., McLoughlin, D. M., Murrough, J. W., Muthukumaraswamy, S., McMillan, R., Sumner, R., Papakostas, G., Fava, M., Hock, R., Phillips, J. L., Blier, P., Shiroma, P., Šóš, P., Su, T.-P., Chen, M.-H., Tiger, M., Lundberg, J., Wilkinson, S. T., & Wallace, M. L.
Affiliations
  • University of Pittsburgh (US)
  • Carnegie Mellon University (US)
  • National Institutes of Health (US)
  • Michael E. DeBakey VA Medical Center (US)
  • Icahn School of Medicine at Mount Sinai (US)
  • Columbia University (US)
  • Trinity College Dublin (IE)
  • University of Auckland (NZ)
  • Harvard University (US)
  • University of Ottawa (CA)
  • Minneapolis VA Medical Center (US)
  • National Yang Ming University (TW)
  • Karolinska Institutet (SE)
  • Yale University (US)
Corresponding author
Price, Rebecca B.
Venue
Molecular Psychiatry
Published
2022-09-07
Volume
27
Issue
12
Pages
5096-5112
ISSN
  • 1359-4184 (ISSN-L)
  • 1476-5578
OpenAlex
W4294876995
Cited by
82
References
65
Citations by year
2026: 11 · 2025: 24 · 2024: 24 · 2023: 21 · 2022: 2
FWCI
2.55
Type
journal article
Language
en
Open access
Locations
  • Molecular Psychiatry (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Digital Commons-TMC (Texas Medical Center) (submittedVersion)
Funders
  • National Institutes of Health (UL1TR001863)
  • National Institute of Mental Health (K23MH119225, R01MH113857)
  • National Center for Advancing Translational Sciences
Topics
  • Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
  • Health Sciences › Medicine › Psychiatry and Mental health › Electroconvulsive Therapy Studies
  • Life Sciences › Neuroscience › Neurology › Transcranial Magnetic Stimulation Studies
Keywords
ketamine, depression, intravenous ketamine, treatment-resistant depression, precision medicine, individual patient data, depression severity, bipolar depression, post-traumatic stress disorder, antidepressant treatment resistance, crossover design
MeSH terms
Antidepressive Agents, Bipolar Disorder, Depression, Humans, Ketamine, Treatment Outcome, Administration, Intravenous

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