Ketamine for suicidal ideations in severe depression

INTRODUCTION

The biggest risks for morbidity and mortality are associated with severe depressive episodes, even though all forms of depression have the capacity to be incapacitating. Consequently, treating severe depression is one of the greatest challenges for clinical psychiatrists. The majority of severe depression cases are treatable, and there are significant advantages for patients, their families, and society at large. One of the most important aspects of caring for people with severe depression is preventing suicide. Up to 80% of people who suffer from severe depression have thought about suicide or plan to do so. An intravenous (IV) ketamine infusion on alternate days should be considered, even if there are no specific treatments that are advised or contraindicated for suicidal individuals.^[1] Ketamine, a dissociative anesthetic and uncompetitive N-MethylD-Aspartate (NMDA) receptor antagonist, has emerged as a new and potent rapid-acting antidepressant.^[2]

CASE REPORT

A 38-year-old woman arrived at our hospital’s psychiatry outpatient department (OPD) complaining of low mood, loss of interest in watching TV and conversing with family, fatigue easily and reluctance to get out of bed, lack of sleep at night, and 20 days of ruminating about the past. The patient also reported feeling less confident and worried that she would not be able to perform even basic everyday household tasks. She frequently broke down in tears because she believed that life had no purpose, that no one could support her, and that her future was bleak. She also claimed to have had frequent suicidal thoughts for 7–8 days. Her depressed state persisted all day and was mostly unaffected by whatever was happening.

For 7–8 years, the patient had a history of recurrent depression. The patient received ongoing pharmacotherapy, including mood stabilizers, antidepressants, and psychotherapy. Both the physical examination and every laboratory test revealed no signs of any previous neurological or medical condition. In addition, the patient had a history of attempted suicides that were stopped for various reasons.

Lamotrigine, desvenlafaxine, mirtazapine, and benzodiazepines were being used to treat the patient’s anxiety symptoms and poor sleep. When she was brought to OPD, she underwent a thorough evaluation using the Hamilton depression rating scale (HDRS). Her HDRS score at first was 33. The patient’s significant depression and active suicidal thoughts need rapid therapy, which led to their admission, investigation, and ketamine infusion planning. The patient was scheduled for a ketamine injection the next morning after being kept nil per oral since midnight. She was moved to the operating room’s pre-operative area and given 50 mg of ketamine intravenously over the course of an hour.

Her vitals, including oxygen saturation, pulse rate, and blood pressure, were continuously tracked. Following the infusion, she was placed under surveillance for 30 min before being returned to the psychiatric ward. Three hours after the ketamine infusion was finished, the HDRS scale was used; the results showed a decrease in suicidal thoughts, with a score of 23. On days 4, 6, and 8 of admission, the patient received three additional ketamine doses before being released. By the time of discharge (day 8), the patient’s HDRS score had improved from 33 at inpatient admission to 3. Following the second dose, the patient reported no suicidal thoughts and a considerable improvement in her HDRS score, as indicated in Table 1. After being discharged, she was monitored for 6 weeks and was doing well on her medication.

DISCUSSION

Before treatment, the patient’s HDRS score was 33; following the first ketamine session, it dropped to 23, and the patient’s suicidal thoughts and behaviors significantly improved after 1^st session.^[3-5] In a groundbreaking randomized controlled trial conducted in 2000, Berman et al. administered a single subanesthetic dosage of IV ketamine (0.5 mg/kg over 40 min) to patients with severe depressive disorder.^[6] GABAergic interneurons’ NMDA receptors, which are often engaged in preventing glutamate release from glutamatergic neurons, are blocked by ketamine. This disinhibition affects synaptogenesis, postsynaptic -amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor activation, acute cortical glutamate surge, and neuroplastic pathways. When giving ketamine off-label, IV treatment (0.5 mg/kg over 40 min) is the gold standard. Since ketamine was less intrusive than electroconvulsive therapy (ECT) and considerably decreased the patient’s suicidal thoughts, it was chosen for this patient. In addition, the patient was afraid of ECT and was not prepared to consent to it.

CONCLUSION

After four ketamine sessions, the patient’s symptoms significantly improved, and her HDRS score went from 33 to 3. After the first session, she showed drastic improvement in suicidal thoughts, and after the second session, she had no suicidal thoughts at all. Since ketamine is typically well tolerated at these sub-anesthetic dosages, it should be taken into consideration in patients with suicidal tendencies who require an instant reaction. However, it ought to be given in appropriate hospital environments while all vital signs are well monitored.