Borderline Personality Disorder (BPD), Treatment-Resistant Major Depressive Disorder, Treatment-resistant Bipolar Depression, Major Depressive Disorder (MDD), Bipolar Disorder (BD), Bipolar Disorder I or II, Suicidal Ideation
Conditions
Keywords
Dialectical Behavioural Therapy (DBT), ketamine, Borderline Personality Disorder, Treatment-Resistant Depression, Bipolar Disorder (BD), Major Depressive Disorder (MDD), Suicidality
Brief summary
The goal of this clinical trial is to learn if intravenous (IV) ketamine with Dialectical Behavioural Therapy (DBT) reduces suicidal ideation in individuals with suicidality who have been diagnosed with Borderline Personality Disorder and either Major Depressive Disorder or Bipolar Disorder. The main question it aims to answer is: Does IV ketamine and DBT produce more rapid and robust improvements in suicidal ideation (SI) severity between baseline and Day 35 compared to IV midazolam and DBT, as measured by changes in the Modified Scale for Suicidal Ideation (MSSI) scores ? Researchers will compare six IV ketamine infusions and DBT to an active placebo (a look-alike substance that mimics some of ketamine's effects and not others) and DBT to see if IV ketamine with DBT is more effective at reducing SI severity. Participants will: * Complete six infusions of either IV ketamine or IV midazolam * Take part in 6 months of DBT (includes both weekly one-on-one sessions, and group sessions, starting week 5 of the trial) * Visit the hospital for scheduled in-person visits * Join a call or videocall for scheduled remote visits * Complete a variety of different mood, cognitive and behavioral assessments
Interventions
DRUGKetamine Hydrochloride
Participants in this arm will receive six ketamine hydrochloride infusions over a month, with doses ranging between 0.5 mg/kg to 0.85 mg/kg
Participants in this arm will receive six midazolam hydrochloride infusions over a month, with doses ranging between 0.02 mg/kg to 0.035 mg/kg
BEHAVIORALDialectical Behavioral Therapy (DBT)
All participants in this trial will receive DBT over six months. Eligible participants will begin with weekly individual sessions, followed by the addition of weekly group sessions beginning in week 5 of the trial.
Sponsors
Joshua Rosenblat
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to 70 Years
Healthy volunteers
No
Inclusion criteria
1. Adults between the age of 18 to 70, inclusive; 2. Meets criteria for BPD, as determined by clinical assessment by a psychiatrist or psychologist and confirmed by the International Personality Disorder Examination (IPDE); 3. Meets DSM-5 criteria for MDD or BD (I or II), currently experiencing a MDE without psychotic features, as diagnosed by a study psychiatrist or psychologist. Diagnosis will be confirmed using the Mini- International Neuropsychiatric Interview (MINI); 4. Current MDE must be moderate to severe, as determined by the MADRS score \>20 with an inadequate response to two or more guideline-concordant treatment trials as defined by the Antidepressant Treatment History Form-Short Form (ATHF- SF); 5. No changes in pharmacotherapy for MDD/BD in the last month or changes in psychotherapy in the past month; 6. Baseline SI as shown by two consecutive MSSI scores \> 10 two weeks apart.
Exclusion criteria
1. Past or current history of a psychotic disorder as determined by clinical assessment and MINI; 2. Current or recent (within the past 3 months) manic or hypomanic episode as determined by clinical assessment via YMRS (score \> 12) and the MINI; 3. Meeting criteria for Moderate to Severe Alcohol or substance use disorders currently or within the past 3 months; 4. Lifetime history of ketamine use disorder or illicit ketamine use. 5. Acute suicide risk requiring involuntary inpatient treatment under the Mental Health Act (MHA). 6. Presence of a relative or absolute contraindication to ketamine or midazolam, including a drug allergy, lifetime history of stroke, uncontrolled hypertension (Systolic BP \> 160 or Diastolic BP \> 100), low or labile blood pressure (Systolic BP \< 100 or Diastolic BP \< 60), recent (within the past 6 months) myocardial infarction, severe coronary artery disease (ascertained through participant's medical history), or moderate to severe renal (GFR scores ≤ 44) or hepatic impairment (A Child-Pugh score of ≥ 7); 7. Currently pregnant or breastfeeding or planning on getting pregnant within the first two months of the trial or planning on getting someone else pregnant within the first two months of trial. Participants who are sexually active must agree to use a highly effective contraceptive method (please see exhaustive list in Section 3.6.1); 8. Current use of prohibited concomitant medications, including other forms of ketamine or esketamine, high dose daily benzodiazepines (greater than 4 mg lorazepam equivalent daily) or monoamine oxidase inhibitors; 9. Currently engaged (or completed within the past year) in DBT treatment. NOTE: Individuals who have received only DBT skills training in the past year will be considered eligible to participate; 10. Those engaged in other forms of psychotherapy must be willing to discontinue for the duration of the 6-month DBT intervention (standard for DBT). There should be no changes in psychotherapy 30 days prior to baseline (i.e., Screening Visit 2).
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in suicidal ideation severity using the Modified Scale for Suicidal Ideation (MSSI) | From Baseline to Day 35 (Primary Endpoint) | The MSSI is a clinician administered scale used to assess presence or absence of suicidal ideation as well as intensity of suicidal ideation in the previous 48 hours. It consists of 18 items, with each item scored from 0 to 3. Total scores are summed and severity can be categorized as low (0-3), mild (9-20), or severe (\>21). |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Changes in suicidal ideation severity over a longer period of time using the Modified Scale for Suicidal Ideation (MSSI) | From Baseline to Month 6 and Month 9 | Evaluating changes in MSSI scores between baseline and Month 6 and between baseline and Month 9. The MSSI is a clinician administered scale used to assess presence or absence of suicidal ideation as well as intensity of suicidal ideation in the previous 48 hours. It consists of 18 items, with each item scored from 0 to 3. Total scores are summed and severity can be categorized as low (0-3), mild (9-20), or severe (\>21). |
| Changes in suicidal behavior (SB) and self-harm (SH) using the Suicide Attempt Self-Injury Interview (SASII) | From Baseline to Months 3, 6, and 9 | The SASII is a semi-structured interview that will measure suicidal behavior and self-harm. The SASII is used to collect details of the topography, intent, medical severity, social context, precipitating and concurrent events, and outcomes of non-suicidal self-injury and suicidal behavior during a target time period (in this trial, the target time period will be 'past 3 months'). |
| Changes in suicidal behavior (SB) and self-harm (SH) using the Lifetime Suicide Attempt Self-Injury Interview (L-SASII) | From Baseline to Months 3, 6, and 9 | The L-SASII will be administered at baseline to obtain a count of lifetime history of suicide attempts and non-suicidal self-injury. |
| Changes in depression severity using the Montgomery Asberg Depression Rating Scale (MADRS) | From Baseline to Day 35 (Primary Endpoint), Month 6 and Month 9 | The MADRS is a clinician-rated scale measuring depression severity. It consists of 10 items, each scored from 0 (normal) to 6 (severe), for a total possible score of 60. A higher score is indicative of greater depressive severity. |
| Changes in personality psychopathology evaluated using the Borderline Symptom List-23 (BSL-23) | From Baseline to Day 35 (Primary Endpoint), Month 6 and Month 9 | Changes in borderline personality disorder symptom severity and general personality psychopathology will be evaluated using the BSL-23, self-report assessment. This scale assesses a list of 23 problems on a scale of 0-4. |
| Changes in personality psychopathology using Level of Personality Functioning Scale (LPFS) | From Baseline to Day 35 (Primary Endpoint), Month 6 and Month 9 | Changes in borderline personality disorder symptom severity and general personality psychopathology will be assessed using the LPFS, an 80-item self-report assessment. Items are rated on a scale from 1 to 4, with 1 indicating "totally false, not true at all" and 4 indicating "very true". |
| Changes in personality psychopathology using the Symptom-Checklist-90-Revised (SCL-90-R) | From Baseline to Day 35 (Primary Endpoint), Month 6 and Month 9 | Changes in borderline personality disorder symptom severity and general personality psychopathology will be assessed using the SCL-90-R, a 90-item self-report assessment. |
| Changes in anxiety as measured by the Generalized Anxiety Disorder-7 (GAD-7) | From Baseline to Day 35 (Primary Endpoint), Month 6 and Month 9 | The GAD-7 is a brief self-report measure of generalized anxiety. It consists of 7 items rated from 0 ('not at all sure') to 3 ('nearly every day'). |
| Safety and tolerability evaluated by Adverse Events | Across 9 Months | Safety and tolerability will be evaluated by acute and sub-acute treatment-emergent adverse events using standardized adverse effects monitoring. |
| Safety and tolerability evaluated by the Brief Psychiatric Rating Scale - Positive Symptom Subscale (BPRS-PS) | Across 9 months | The BPRS is a clinician-administered scale that measures positive symptoms, general psychopathology, and affective symptoms to measure psychopathology severity. The positive symptoms subscale will be administered, which measures symptoms commonly seen in psychosis, including unusual thought content, conceptual disorganization, hallucinatory behaviour, and grandiosity. |
| Safety and tolerability measured by using the Clinician Administered Dissociative Symptom Scale (CADSS) | Across 9 months | Safety and tolerability will be evaluated using CADSS. It is a clinician administered instrument for the measurement of present-state dissociative symptoms. It is a 27-item scale with 19 subject-rated items and 8-items scored by an observer. |
Contacts
CONTACTOrly Lipsitz
CONTACTDeep Grewal
PRINCIPAL_INVESTIGATORJoshua D. Rosenblat, MD, MSc
Toronto Western Hospital, Psychiatry
Outcome results
None listed