Depression, Ketamine, Naltrexone, Glia and Inflammation – A Case Report
06/10/2012 — Nancy Sajben MD
Current antidepressant therapies are only modestly effective, may have significant side effects and do not provide universal efficacy.
The role of inflammation and immune systems in the pathogenesis of depression has become well-established since 2000. Immune system activity is mediated by pro-inflammatory cytokines that change behavior.
This 2012 review is the first to summarize genetic variants of the inflammatory system involved in immune activation and Major Depressive Disorder, Major Recurrent Depression, Dysthymia, Childhood Onset Major Depression and Geriatric Depression: The role of immune genes in the association between depression and inflammation: A review of recent clinical studies. They reviewed 52 papers of which 27 are case-controlled studies.
Pro- and anti-inflammatory cytokines are produced by glial cells in the central nervous system (CNS). Glial cells make up 90% of the cells in the CNS; 10% are nerve cells, neurons. When glia are activated, they produce cytokines that lead to inflammation. Glia and inflammatory cytokines play a role in infection, stroke, trauma, chronic pain, Multiple Sclerosis, Alzheimer’s Disease, Parkinson’s Disease, ALS and Major Depression. The Nobel Prize was awarded in 2011 for discoveries of the innate immune system, in particular the mammalian Toll-like receptor 4 (TLR-4) which is the receptor for naltrexone. That discovery incidentally was made by Bruce Beutler at Scripps Research Institute.
You can read more about glia and the inflammatory response posted January 2011: Pain and the Immune System – It’s Not Just About Neurons – Naltrexone. This is not specific to pain but also relates to some with major depression.
Ketamine is a major anti-inflammatory and glial modulator. Naltrexone is a glial modulator that I have prescribed for chronic pain in low dose for almost four years in patients who are not taking opioids, and in ultra low microgram dose for more than eight years in patients who are on opioids for pain. Some of those case reports are posted on this site.
Low dose naltrexone, LDN, may be effective for Autism, Multiple Sclerosis, and some autoimmune diseases. Jarred Younger at Stanford has shown fibromyalgia symptoms are improved by LDN; Jill Smith at Pennsylvania State University, Hershey, has shown remission in Crohn’s Disease with LDN; and Bruce Cree at UCSF has shown improved quality of life in a small study of Multiple Sclerosis that he is pursuing with larger multi-center studies.
This week I saw a young man who traveled from Northern California for me to possibly treat major depression with nasal ketamine. Depression prevented him from working for the last two years. He scored 34 on the Hamilton Depression Rating Scale. Scores over 24 indicate severe depression. On June 4, 2012, we started his treatment using ketamine nasal spray. The daily dose was increased but has not yet reached an effective level. In my experience of prescribing ketamine for pain and depression in the last eleven years, the dose differs for everyone and is not related to age, gender or body weight.
As conveyed by him to me, his progress thus far:
ON JUNE 7, 2012, early morning, he used 40 mg of ketamine by nasal spray. He reported feeling dizzy, experiencing spinning sensation for two hours and then was his usual self, i.e. he felt bad the rest of the day as his usual self but vision was better. His strabismus (lazy eye) usually depends on better mood, but mood was unchanged.
At 3:00 pm, he took naltrexone, a very low dose approximately 4 mg.
ON JUNE 8th: approximately 12 hours later, he woke at 2 AM. He later told me that he was feeling “extremely sharp! I felt great! Clear in mind, quiet and calm. I didn’t realize how noisy my mind is till everything felt calm.” He returned back to sleep.
He woke again at 6 AM feeling great! Not thinking negative thoughts, but no other change, i.e. did not like or love activities or people anymore than in recent years with his depression.
At 1:15 PM, in the office his self-rated improvement of depression was 40% due to the low dose of naltrexone taken yesterday afternoon. He had no effect from ketamine as yet, and had not used any in more than 24 hours.
My plan has been to trial low dose naltrexone for persons with treatment resistant depression. If it is effective, then ketamine is not needed. Ketamine is a short acting medication and may pose issues such as tolerance, whereas low dose naltrexone is simple, once daily, used with few side effects and has never caused tolerance in my clinical experience.
It is very possible that with such rapid improvement overnight and continued treatment, his depression will continue to improve over coming weeks and months.