• DeakinJ F WilliamJFNeuroscience and Psychiatry Unit, The University of Manchester, G.907 Stopford Building, Oxford Rd, Manchester M13 9PT, England. bill.deakin@manchester.ac.uk, Jane Lees, Shane McKie, Jaime E C Hallak, Steve R Williams, and Serdar M Dursun.
• Neuroscience and Psychiatry Unit, The University of Manchester, G.907 Stopford Building, Oxford Rd, Manchester M13 9PT, England. bill.deakin@manchester.ac.uk
• Arch. Gen. Psychiatry. 2008 Feb 1; 65 (2): 154-64.

ContextKetamine 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.ObjectivesTo 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.DesignTwo 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.SettingWellcome Trust Clinical Research Facility, Manchester, England.ParticipantsThirty-three healthy, right-handed men were recruited by advertisements.InterventionsIn 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 MeasuresRegional BOLD signal changes during ketamine or placebo infusion and Brief Psychiatric Rating Scale and Clinician-Administered Dissociative States Scale scores.ResultsKetamine 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.ConclusionsThese 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.

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