Traditional pharmacological treatments for depression have a delayed
therapeutic onset, ranging from several weeks to months, and there is a high
percentage of individuals who never respond to treatment. In contrast, ketamine
produces rapid-onset antidepressant, anti-suicidal and anti-anhedonic actions
following a single administration to depressed patients. Proposed mechanisms of
ketamine’s antidepressant action include
N-methyl-D-aspartate receptor (NMDAR)
modulation, GABAergic interneuron disinhibition, and direct actions of its
hydroxynorketamine (HNK) metabolites. Downstream actions include activation of
mechanistic target of rapamycin (mTOR), deactivation of glycogen synthase
kinase-3 and eukaryotic elongation factor 2 (eEF2), enhanced brain-derived
neurotrophic factor (BDNF) signaling, and activation of
α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid receptors
(AMPARs). These putative mechanisms of ketamine action are not mutually
exclusive and may complement each other to induce potentiation of excitatory
synapses in affective-regulating brain circuits, which results in amelioration
of depression symptoms. We review these proposed mechanisms of ketamine action
in the context of how such mechanisms are informing the development of novel
putative rapid-acting antidepressant drugs. Such drugs that have undergoing
pre-clinical, and in some cases clinical, testing include the muscarinic
acetylcholine receptor antagonist scopolamine, GluN2B-NMDAR antagonists (i.e.,
CP-101,606, MK-0657), (2R,6R)-HNK, NMDAR glycine site
modulators (i.e., 4-chlorokynurenine - pro-drug of the glycineB NMDAR
antagonist 7-chlorokynurenic acid), NMDAR agonists (i.e. GLYX-13 (rapastinel)),
metabotropic glutamate receptor 2/3 (mGluR2/3) antagonists,
GABAA receptor modulators, and drugs acting on various serotonin
receptor subtypes. These ongoing studies suggest that the future acute treatment
of depression will typically occur within hours, rather than months, of
treatment initiation.