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A Pharmaco–Magnetic Resonance Imaging Study

J. F. William Deakin, PhD, FRCPsych, FmedSci; Jane Lees, BSc, MSc; Shane McKie, MEng, MSc, PhD; Jaime E. C. Hallak, MD, PhD; Steve R. Williams, BA, MA, DPhil; Serdar M. Dursun, MD, PhD, FRCPC

Arch Gen Psychiatry. 2008;65(2):154-164.

Context  Ketamine evokes psychosislike symptoms, and its primary action is to impair N-methyl-D-aspartate glutamate receptor neurotransmission, but it also induces secondary increases in glutamate release.

Objectives  To identify the sites of action of ketamine in inducing symptoms and to determine the role of increased glutamate release using the glutamate release inhibitor lamotrigine.

Design  Two experiments with different participants were performed using a double-blind, placebo-controlled, randomized, crossover, counterbalanced-order design. In the first experiment, the effect of intravenous ketamine hydrochloride on regional blood oxygenation level–dependent (BOLD) signal and correlated symptoms was compared with intravenous saline placebo. In the second experiment, pretreatment with lamotrigine was compared with placebo to identify which effects of ketamine are mediated by increased glutamate release.

Setting  Wellcome Trust Clinical Research Facility, Manchester, England.

Participants  Thirty-three healthy, right-handed men were recruited by advertisements.

Interventions  In experiment 1, participants were given intravenous ketamine (1-minute bolus of 0.26 mg/kg, followed by a maintenance infusion of 0.25 mg/kg/h for the remainder of the session) or placebo (0.9% saline solution). In experiment 2, participants were pretreated with 300 mg of lamotrigine or placebo and then were given the same doses of ketamine as in experiment 1.

Main Outcome Measures  Regional BOLD signal changes during ketamine or placebo infusion and Brief Psychiatric Rating Scale and Clinician-Administered Dissociative States Scale scores.

Results  Ketamine induced a rapid, focal, and unexpected decrease in ventromedial frontal cortex, including orbitofrontal cortex and subgenual cingulate, which strongly predicted its dissociative effects and increased activity in mid-posterior cingulate, thalamus, and temporal cortical regions (r = 0.90). Activations correlated with Brief Psychiatric Rating Scale psychosis scores. Lamotrigine pretreatment prevented many of the BOLD signal changes and the symptoms.

Conclusions  These 2 changes may underpin 2 fundamental processes of psychosis: abnormal perceptual experiences and impaired cognitive-emotional evaluation of their significance. The results are compatible with the theory that the neural and subjective effects of ketamine involve increased glutamate release.

Author Affiliations: Neuroscience and Psychiatry Unit (Drs Deakin, McKie, Hallak, and Dursun and Ms Lees) and Imaging Science and Biomedical Engineering (Dr Williams), The University of Manchester, Manchester, England; and Neurology, Psychiatry, and Psychological Medicine Department, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil (Dr Hallak).