Ketamine in Borderline Personality Disorder

Study Overview
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Brief Summary
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The purpose of this study is to test the potential of the rapid-acting anti-depressant ketamine to decrease suicidality in Borderline Personality Disorder (BPD). The rate of completed suicide in BPD is similar to that of depression or schizophrenia. There is currently no specific medication treatment for BPD. Ketamine is an FDA-approved anesthetic agent that has been shown to rapidly decrease suicidality and improve mood in people with Major Depressive Disorder (MDD). Though symptoms overlap, effective treatments for MDD and BPD differ. This clinical trial tests if ketamine also decreases suicidality and improves mood in BPD. This trial will also measure several other outcomes after ketamine versus placebo in BPD: adverse events, BPD symptoms, pain, social cognition, and neuroplasticity.

Detailed Description
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This clinical trial primarily tests the impact of ketamine on suicidal thoughts in Borderline Personality Disorder (BPD). It also tests the impact of ketamine on symptom intensity (for mood, BPD, and pain symptoms), social cognition, and neuroplasticity in people with BPD. Suicidal ideation and action are too common in BPD, occurring at rates similar to those in people with depression or schizophrenia. Intensive psychotherapy helps, but many people with BPD do not have access to that treatment, and not everyone responds to psychotherapy if they do get access. No medication is FDA-approved for BPD, and no medication has been shown to decrease suicidality in BPD. Ketamine is a promising medication for this problem. It is an FDA-approved anesthetic medication with N-methyl D-aspartate activity. Sub-anesthetic doses of ketamine decrease suicidality and improve mood in people with Major Depressive Disorder (MDD). This effect is rapid, with symptom improvement within hours that endures approximately two weeks. People with BPD can have symptoms that overlap with those of MDD, however, the effective treatments for BPD and MDD differ. This clinical trial will test if ketamine, which is effective in MDD, is also effective in BPD. The investigators will use semi-structured interviews and self-report questionnaires to measure suicidal ideation and clinical symptoms (adverse events, mood symptoms, BPD symptoms, and pain). Social cognition will be also be measured using both interviews/questionnaires and cognitive psychology tasks. One proposed mechanism of ketamine's effect in MDD is increased neuroplasticity - opening a window during which new learning can occur. This mechanism has been demonstrated in rodent models of depression. In BPD, negatively-biased social interpretations impede meaningful recovery and increase suicide risk over time. A post-ketamine neuro-plastic window may provide an opportunity for revisions of rigid social attributions. The investigators will test for changes in neuroplasticity using a cognitive psychology task and electro-encephalography. Baseline measures of demographics, life experiences, and symptoms may also be used to predict outcomes or as co-variates in our analyses.

Official Title
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A Randomized Active Placebo Controlled Trial of Ketamine in Borderline Personality Disorder

Conditions
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Borderline Personality Disorder

Intervention / Treatment
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* Drug: Ketamine
* Drug: Midazolam


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 21-60 Clinical diagnosis of Borderline Personality Disorder Has suicidal ideation. Fluent in English Has a current mental health treater, and agrees for study to communicate with treater Exclusion Criteria: Current suicidal intent Med changes in last 4 weeks Any ketamine in any context in the last one year. Current prescription for topiramate, lamotrigine, or lithium. Psychotic disorder in self or first-degree relative Current substance dependence including alcohol dependence Any history of NMDA (N-methyl-D-aspartate )-antagonist abuse Any history of opiate abuse History of major medical illness especially neurologic or cardiovascular condition, or any other medical contra-indication to ketamine administration at the discretion of the study MD. Positive urine test for drugs of abuse screening on day of ketamine administration Positive pregnancy test on day of ketamine administration At the discretion of study staff

Ages Eligible for Study
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Minimum Age: 21 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: midazolam<br>Midazolam IV; 0.04mg/kg over 40 minutes | Drug: Midazolam<br>* 1 single dose of IV midazolam<br>|
| Active Comparator: low dose ketamine<br>ketamine IV; 0.5 mg/kg over 40 minutes | Drug: Ketamine<br>* 1 single dose of IV ketamine<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Suicidal Thoughts as Measured by Item 10 on the Montgomery-Asberg Depression Scale (MADRS) | The MADRS test includes 10 items and uses a 0 to 6 severity scale for each item, with higher scores indicating increasing depressive symptoms. Scores are averaged across items and can range from 0 to 6 (with 0 indicating enjoying life, and 6 indicating explicit plans for suicide). Outcome description updated when results were entered. | Timepoints will be baseline, 1hr post-infusion and at 1, 3, 7, 14, & 28 days after infusion. | 
| Change in Suicidality as Measured by the Columbia Suicide Severity Rating Scale (C-SSRS) | Suicide Rating Scale from 1-5; higher numbers indicate increased suicidal thinking. | Timepoints will be baseline, 1hr post-infusion and at 1, 3, 7, 14, & 28 days after infusion. | 
| Change in Suicidality as Measured by Item-12 on the Quick Inventory of Depressive Symptomatology (QIDS SR-16) | The Quick Inventory of Depressive Symptomatology (QIDS SR-16) is a a self-report measure of depression. Each item is scored from 0-3. Higher scores denote more severe load of depressive symptoms. Item 12 measures thoughts of death or suicide from 0 (no thoughts) to 3 (specific suicide plan or action.). Presented is the mean score across items with a range of 0 to 3 where the higher score indicates greater depressive symptoms. Outcome description was updated at the time of results entry. | Timepoints will be baseline, 1hr post-infusion and at 1, 3, 7, 14, & 28 days after infusion. | 
| Change in Suicidality as Measured by Item 9 on Beck Depression Inventory | When the test is scored, a value of 0 to 3 is assigned for each answer and then the total score is used to quantify the participant's degree of depression from 0 = no depression to 63 = maximally severe depression. Item 9 measures degree of suicidal thoughts or wishes from 0 = no thoughts to 3 = suicidal intent. | Timepoints will be baseline, 1hr post-infusion and at 1, 3, 7, 14, & 28 days after infusion. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Montgomery-Asberg Depression Rating Scale (MADRS) Total Score | The MADRS scale measures the depression level of a participant. The total score was derived by adding the scores of the following 10 items: 1, Apparent sadness; 2, Reported sadness; 3, Inner tension; 4, Reduced sleep; 5, Reduced appetite; 6, Concentration difficulties; 7, Lassitude; 8, Inability to feel; 9, Pessimistic thoughts; 10, Suicidal thoughts. Each item was scored using a scale of 0 to 6 (a higher score indicates increased severity). The maximum total score is 60; 0, no depression; 60, severely depressed. | Timepoints will be baseline, 1hr post-infusion and at 1, 3, 7, 14, & 28 days after infusion. | 
| Change in Beck Depression Inventory Score | The Beck Depression Inventory (BDI) consisted of twenty-one questions about how the subject has been feeling in the last week. Each question has a set of at least four possible answer choices, ranging in intensity. When the test is scored, a value of 0 to 3 is assigned for each answer and then the total score is used to quantify the participant's degree of depression from 0 = no depression to 63 = maximally severe depression. | Timepoints will be baseline, 1hr post-infusion and at 1, 3, 7, 14, & 28 days after infusion. | 
| Change in Beck Anxiety Inventory Score | The Beck Anxiety Inventory (BDI) consisted of twenty-one questions about how the subject has been feeling in the last week. Each question has a set of at least four possible answer choices, ranging in intensity. When the test is scored, a value of 0 to 3 is assigned for each answer and then the total score is used to quantify the participant's degree of anxiety from 0 = no anxiety to 63 = maximally severe anxiety. | Timepoints will be baseline, 1hr post-infusion and at 1, 3, 7, 14, & 28 days after infusion. | 
| Change in Zanarini Rating Scale for Borderline Personality Disorder | A dimensional self-report measure of BPD symptoms that consists of 9 items scored on a 4 point likert scale. Scores range of 0 = minimally symptomatic to 28 = maximally symptomatic for symptoms of Borderline Personality Disorder. Originally, 1hr post-infusion was included as a time frame but this was not collected at this time frame. | Timepoints will be baseline and at 1, 3, 7, 14, & 28 days after infusion. | 
| Change in Preferred Distance in Stop-distance Paradigm (SDP) | The stop-distance paradigm is a measure of preferred interpersonal distance (PID). Subjects begin the task standing face-to-face and 6 feet away from a test confederate. On each of 3 trials, the confederate slowly approaches the subject. The subjects are instructed to say stop to indicate their 1) preferred conversational distance, then a closer distance 2) if you start to feel uncomfortable. After each stop, toe to toe distance is measured using a tape measure, and mean PID for the three trials is computed separately for conversational and uncomfortable distance. A computerized version of the task may also be implemented for remote visits and administered in place of the in-person task. | Timepoints will be at baseline and 3, 7, 14, 28 days after infusion | 
| Change in Behavior in the Economic Trust Game - Cooperation | The trust game is a multi-round economic exchange game. There are two roles in the game: investor and trustee. Study participants will play as the trustee. Each round, the investor is given a set number of points and can send any amount to the trustee. The investment triples and the trustee decides how much to repay the investor. Outcome measures are cooperation (amount returned to the investor) and coaxing (amount returned to investor on trials when poor prior returns from trustee have led investor to decrease investment). Cooperation was used as part of the evaluation in this study- coaxing was not. Outcome measure description was updated at the time of results entry. | Timepoints will be at baseline and 3, 7, 14, 28 days after infusion | 
| Change in Social Adjustment Scale Self Report (SAS-SR) Short Version Score | This questionaire measures expressive and instrumental performance over the past two weeks in six role areas: (1) work, either as a paid worker, unpaid homemaker, or student, (2) social and leisure activities, (3) relationships with extended family, (4) role as a marital partner, (5) parental role, and (6) role within the family unit, including perceptions about economic functioning.Each question is rated on a five-point scale from which role area means and an overall mean can be obtained, with higher scores denoting greater impairment. Role areas not relevant to the respondent can be skipped. Overall means are based on all items completed by the respondent. Scores range from 0 = no difficulties to 125 = broad difficulties in multiple domains. An overall adjustment | Timepoints will be at baseline and 3, 7, 14, 28 days after infusion | 
| Change in Brief Pain Inventory Score - Intensity | Self report inventory that assesses intensity of pain and its interference with everyday life. Intensity: pain severity as measured by a 0 to 10 visual analogue scale. 0 = no pain, 10 = worst pain imaginable. Interference score: Interference as measured by a 0 to 10 numerical rating scale. 0 = does not interfere, 10 = completely interferes | Timepoints will be at baseline, and post-infusion 1hr, and days 1, 3, 7, 14, & 28. | 
| Change in Brief Pain Inventory Score - Interference | Self report inventory that assesses intensity of pain and its interference with everyday life. Intensity: pain severity as measured by a 0 to 10 visual analogue scale. 0 = no pain, 10 = worst pain imaginable. Interference score: Interference as measured by a 0 to 10 numerical rating scale. 0 = does not interfere, 10 = completely interferes | Timepoints will be at baseline, and post-infusion 1hr, and days 1, 3, 7, 14, & 28. | 
| Change in Clinician-Administered Dissociative States Scale (CADSS) Score | This scale captures the range of possible subjective side effects of ketamine or Midazolam. This consists of 23 questions and scores for each question range from 0-4. The maximum score is 92 with higher scores indicating more dissociative symptoms. | Timepoints: pre- infusion, during infusion +20, +40 minutes, and post-infusion 40 minutes. | 
| Change in Adverse Events | Adverse events were tracked in a log of treatment emergent adverse events, EKG, pulse oximetry, vital signs. A count of any treatment emergent adverse events is presented through Day 28. The outcome measure description as updated when results were entered. | Timepoints: Continuous monitoring throughout infusion; post-infusion days 1, 3, 7, 14, 28. | 
| Change in 'Reading the Mind in the Eyes' Test (RMET) Score | The RMET is an advanced test of theory of mind. It is widely used to assess individual differences in social cognition and emotion recognition across different groups and cultures. This is a score from 0-36 where higher score indicates better performance. | Timepoints: at baseline and 3, 7, 14, 28 days after infusion. | 
| Change in Brief Psychiatric Rating Scale (BPRS) Total Scores | BPRS is an 18-item clinician rated scale with 11 general symptom items, 5 positive-symptom items, and 2 negative symptom items scored on a 7-point scale (1=not present and 7=extremely severe), with higher score indicating greater severity of symptom. Total possible score range=18 to 126. | Timepoints: pre-infusion, during infusion +20, +40 minutes, post-infusion +40 minutes | 
| Change in Beck Suicide Scale Total Score | The Beck Suicide Scale is a 23 item self report scale with items to specifically assess the presence and intensity of thoughts and actions related to suicidality. Each item response is on a 3 point likert (0-2) for each of 21 items, so possible totals range from 0-42. Higher scores indicate higher suicidality. The description was updated when results were entered. | Timepoints will be baseline, 1hr post-infusion and at 1, 3, 7, 14, & 28 days after infusion. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Borderline Personality Disorder, Ketamine, Suicide, Social Cognition