To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure no-reply@cambridge.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Longer-term outcome and safety data of repeated subcutaneous racemic ketamine for treatment-resistant depression (TRD) is lacking, as is knowledge of the impact of prior ketamine treatment on subsequent response.
Aims
To evaluate the effectiveness and safety of a 4-week course of subcutaneous racemic ketamine over 6 months and investigate whether prior ketamine treatment influences treatment response.
Method
An open label extension (OLE) of a randomised controlled trial (RCT) was conducted at seven mood disorder centres in Australasia, enrolling consenting trial participants who had a Montgomery-Åsberg Depression Rating Scale (MADRS) score of ≥20 at post-trial assessment. Participants initially received twice-weekly 0.5 mg/kg subcutaneous racemic ketamine (fixed regimen) for 4 weeks. Dosing was revised after a Data Safety Monitoring Board recommendation, to a ‘flexible regimen’ (0.5–0.9 mg/kg with response-guided increments). Depression and safety outcomes were assessed throughout treatment, and 4 weeks and 6 months later.
Results
130 RCT participants entered the OLE phase of whom 32 underwent the fixed OLE regimen and 98 the flexible regimen. At treatment end, 30% (36/116) had responded (MADRS reduction ≥50%), and 4 weeks later 17% (19/110) were ‘responders’. Over 50% experienced <25% MADRS reduction. There was no difference in depression response at any time point between regimens. Those treated with ketamine during the RCT showed a transient reduced response after first OLE treatment but at no other assessment point. There were no reports of suicide or suicidal behaviour requiring admission and only expected side-effects observed.
Conclusions
In a highly treatment-resistant sample, a 4-week course of subcutaneous racemic ketamine produced short-term clinical benefit in a minority of participants, with response rates declining substantially after treatment cessation, and no unexpected safety concerns. Exploratory subgroup analyses showed no association between prior RCT ketamine exposure and OLE outcomes.
Authoritarian incumbents routinely use democratic emulation as a strategy to extend their tenure in power. Yet, there is also evidence that multiparty competition makes electoral authoritarianism more vulnerable to failure. Proceeding from the assumption that the outcomes of authoritarian electoral openings are inherently uncertain, it is argued in this article that the institutionalisation of elections determines whether electoral authoritarianism promotes stability or vulnerability. By ‘institutionalisation’, it is meant the ability of authoritarian regimes to reduce uncertainty over outcomes as they regularly hold multiparty elections. Using discrete‐time event‐history models for competing risks, the effects of sequences of multiparty elections on patterns of regime survival and failure in 262 authoritarian regimes from 1946 to 2010 are assessed, conditioned on their degree of competitiveness. The findings suggest that the institutionalisation of electoral uncertainty enhances authoritarian regime survival. However, for competitive electoral authoritarian regimes this entails substantial risk. The first three elections substantially increase the probability of democratisation, with the danger subsequently diminishing. This suggests that convoking multiparty competition is a risky game with potentially high rewards for autocrats who manage to institutionalise elections. Yet, only a small number of authoritarian regimes survive as competitive beyond the first few elections, suggesting that truly competitive authoritarianism is hard to institutionalise. The study thus finds that the question of whether elections are dangerous or stabilising for authoritarianism is dependent on differences between the ability of competitive and hegemonic forms of electoral authoritarianism to reduce electoral uncertainty.
Party system institutionalization (PSI) is regarded as a critical underpinning of democracies, but its role in non‐democratic systems has been understudied. In this paper, we evaluate whether the concept has meaningful and perhaps unique implications for the durability of competitive authoritarian regimes. We argue that a modified version of electoral volatility – the most common measure of PSI in democracies – conveys useful information about PSI in competitive authoritarian contexts by signalling the ability of the ruling party to manage the opposition. To this end, we construct an original data set that disaggregates electoral volatility into ruling party seat change and opposition party seat volatility and further divides opposition party volatility into Type‐A and Type‐B volatility. We find robust results that democratization becomes more likely when decreases in the ruling party's seat share coincide with an increase in opposition party Type‐B volatility. This paper demonstrates that the concept of PSI has utility for understanding regime dynamics in competitive authoritarian contexts.
This paper examines the opinion congruence of voters and representatives in European Parliament elections taking nation as the constituency of interest, an implied model of representation similar to that in a classic Miller and Stokes analysis. Congruence is greater for some countries than others. MEPs are even less representative of their voters than are candidates in general, and all are more pro–integrationist than the electorate. Differences between countries are explained by variations in electoral systems and in national party systems. A genuine European party system and a common and PR electoral system would make MEPs more representative, but almost certainly less integrationist.
The durability of democracy among modern political systems is based on its ability to provide for its own self-enforcement without recourse to outside compulsion (North, Summerhill, and Weingast 2000; Przeworski 1991). Recourse to outside enforcement is always dangerous because loss of self-restraint by that authority raises the dilemma of “who guards the guardians” (Hurwicz 2008), and holds out the possibility of dictatorship.
Anxiety disorders and treatment-resistant major depressive disorder (TRD) are often comorbid. Studies suggest ketamine has anxiolytic and antidepressant properties.
Aims
To investigate if subcutaneous racemic ketamine, delivered twice weekly for 4 weeks, reduces anxiety in people with TRD.
Method
The Ketamine for Adult Depression Study was a multisite 4-week randomised, double-blind, active (midazolam)-controlled trial. The study initially used fixed low dose ketamine (0.5 mg/kg, cohort 1), before protocol revision to flexible, response-guided dosing (0.5–0.9 mg/kg, cohort 2). This secondary analysis assessed anxiety using the Hamilton Anxiety (HAM-A) scale (primary measure) and ‘inner tension’ item 3 of the Montgomery–Åsberg Depression Rating Scale (MADRS), at baseline, 4 weeks (end treatment) and 4 weeks after treatment end. Analyses of change in anxiety between ketamine and midazolam groups included all participants who received at least one treatment (n = 174), with a mixed effects repeated measures model used to assess the primary anxiety measure. The trial was registered at www.anzctr.org.au (ACTRN12616001096448).
Results
In cohort 1 (n = 68) the reduction in HAM-A score was not statistically significant: −1.4 (95% CI [−8.6, 3.2], P = 0.37), whereas a significant reduction was seen for cohort 2 (n = 106) of −4.0 (95% CI [−10.6, −1.9], P = 0.0058), favouring ketamine over midazolam. These effects were mediated by total MADRS and were not maintained at 4 weeks after treatment end. MADRS item 3 was also significantly reduced in cohort 2 (P = 0.026) but not cohort 1 (P = 0.96).
Conclusion
Ketamine reduces anxiety in people with TRD when administered subcutaneously in adequate doses.
This issue marks the last of our six years as the editorial team of Perspectives on Politics. It has been both a richly rewarding and exhausting journey, as well as a labor of love. As with all journeys, some of what we encountered along the way was foreseeable, but much of it was not. For example, we knew that Donald Trump’s presidency would be consequential and in many ways unprecedented when we assumed the helm in June 2017, but not that he would become the first president to be impeached twice, or the first to attempt to overturn presidential election results and violently prevent the peaceful transfer of power, thereby threatening the republic’s very foundations. We had no idea what COVID-19 was, or that it would go on to kill more than one million people in the United States alone. Nor could we foresee that the murder of George Floyd would spark the greatest wave of protest in the United States since the 1960s. Nor yet again did we know that more than seventy-five years after the end of World War II, there would be a major European land war between two former Soviet Republics. Yet we felt compelled to respond to each of these world historical moments as they unfolded in real time, while also attempting to modernize and innovate with respect to the journal’s publication procedures and to stay true to its substantive mission.
Prior trials suggest that intravenous racemic ketamine is a highly effective for treatment-resistant depression (TRD), but phase 3 trials of racemic ketamine are needed.
Aims
To assess the acute efficacy and safety of a 4-week course of subcutaneous racemic ketamine in participants with TRD. Trial registration: ACTRN12616001096448 at www.anzctr.org.au.
Method
This phase 3, double-blind, randomised, active-controlled multicentre trial was conducted at seven mood disorders centres in Australia and New Zealand. Participants received twice-weekly subcutaneous racemic ketamine or midazolam for 4 weeks. Initially, the trial tested fixed-dose ketamine 0.5 mg/kg versus midazolam 0.025 mg/kg (cohort 1). Dosing was revised, after a Data Safety Monitoring Board recommendation, to flexible-dose ketamine 0.5–0.9 mg/kg or midazolam 0.025–0.045 mg/kg, with response-guided dosing increments (cohort 2). The primary outcome was remission (Montgomery-Åsberg Rating Scale for Depression score ≤10) at the end of week 4.
Results
The final analysis (those who received at least one treatment) comprised 68 in cohort 1 (fixed-dose), 106 in cohort 2 (flexible-dose). Ketamine was more efficacious than midazolam in cohort 2 (remission rate 19.6% v. 2.0%; OR = 12.1, 95% CI 2.1–69.2, P = 0.005), but not different in cohort 1 (remission rate 6.3% v. 8.8%; OR = 1.3, 95% CI 0.2–8.2, P = 0.76). Ketamine was well tolerated. Acute adverse effects (psychotomimetic, blood pressure increases) resolved within 2 h.
Conclusions
Adequately dosed subcutaneous racemic ketamine was efficacious and safe in treating TRD over a 4-week treatment period. The subcutaneous route is practical and feasible.
Each year we have the honor to publish an article version of the APSA Presidential Address. In the six years we have done this John Ishiyama is the first comparativist whose work we have featured in this capacity. He presently holds an appointment as University Distinguished Research Professor of Political Science at the University of North Texas. John has long been a fixture in the subfield of comparative politics for his contributions on democratization, political parties, and ethnic politics in both the post-Soviet region and Africa. He has also written extensively on teaching, publishing, and assessment in political science. He has published over 150 articles. And while the outlets and subject matter are too diverse to summarize succinctly, we do want to mention that “The Politics of Intercountry Adoption: Explaining Variation in the Legal Requirements of Sub-Saharan African Countries,” coauthored with Marijke Breuning, won the 2010 APSA Heinz Eulau Award for Best Journal Article published in Perspectives on Politics during the previous year (2009).
New social forces that emerge as part of the process of development turn structural change into political change. Their struggles for representation and incorporation occupy a prominent place in our understanding of regime change. Even elite-driven democratic transitions necessitate moments of mass mobilization that push liberalization into regime change. Many scholars also contend that an active citizenry leads to democratic stability via more effective government. In contrast, others warn that a mobilized and polarized civil society can undermine democracy – particularly if the demands of social forces outstrip the capacity of institutions to process them. In this chapter, we explore the effects of social organization and mobilization on democracy. Using the Varieties of Democracy (V-Dem) and Nonviolent and Violent Campaigns and Outcomes (NAVCO) data, we gauge the extent to which organized and mobilized social forces are responsible for levels and changes in democracy. We find that civil society participation and nonviolent protest positively affect democracy and that rightwing anti-system movements constitute the largest threat to democracy.