Rapid Onset of Intranasal Esketamine in Patients with Treatment Resistance Depression and Major Depression with Suicide Ideation: A Meta-Analysis
Sheng-Min Wang 1, Nak-Young Kim 2, Hae-Ran Na 1, Hyun Kook Lim 1, Young Sup Woo 1, Chi-Un Pae 1, Won-Myong Bahk 1*
1Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea, 2Department of Psychiatry, Keyo Hospital, Uiwang, Korea
Received: January 29, 2021; Revised: February 15, 2021; Accepted: February 17, 2021; Published online: February 17, 2021.
© The Korean College of Neuropsychopharmacology. All rights reserved.

Abstract
Objective: We performed a meta-analysis of randomized double-blinded placebo controlled trials (DB-RCTs) to investigate efficacy and safety of intranasal esketamine in treating major depressive disorder (MDD) including treatment resistant depression (TRD) and major depression with suicide ideation (MDSI).
Methods: Mean change in total scores on Montgomery-Asberg Depression Rating Scale (MADRS) from baseline to different time-points were our primary outcome measure. Secondary efficacy measures included rate of remission of depression and resolution of suicidality.
Results: Eight DB-RCTs (seven published and one un-published) covering 1488 patients with MDD were included. Esketamine more significantly improved MADRS total scores than placebo starting from 2~4 hours after the first administration (SMD, –0.40 [95%CI, –0.57 to –0.24], P<0.00001), and this superiority maintained until end of double-blinded period (28 days). Sub-group analysis showed that superior antidepressant effects of esketamine over placebo in TRD and MDSI was observed from 2~4 hours, which was maintained until 28 days. Resolution of suicide in MDSI was also greater for esketamine than for placebo at 2~4 hours (OR of 2.04 (95% CIs, 1.37 to 3.05, P < 0.0005)), but two groups did not statistically differ at 24 hours and day 28. Total adverse events (AEs), and other common AEs including dissociation, blood pressure increment, nausea, vertigo, dysgeusia, dizziness, and somnolence were more frequent in esketamine than in placebo group.
Conclusion: Esketamine showed rapid antidepressant effects in patients with MDD, including TRD and MDSI. The study also suggested that esketamine might be associated with rapid anti-suicidal effects for patients with MDSI.
Keywords: Esketamine, Depression, Treatment resistant depression, Suicide, Meta-analysis


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