A feasibility study of low-dose ketamine for acute management of suicidal ideation

This open-label study (n=14) finds that ketamine (35mg/70kg) infusion significantly reduced suicidal ideation (SI) in patients in the emergency department (ED). The acceptability (willingness to try treatment) was also high (>70%) among patients and physicians. The study is the first to test this in the ED.

Abstract

“Objective: Mood disorders complicated by suicidal ideation (SI) frequently present to the emergency department (ED) for care. Currently, patients with SI in the ED do not typically receive targeted interventions. Ketamine may have a role in treating SI within the ED because subanesthetic doses have rapid-acting antidepressant and antisuicidal properties.

Methods: This single-arm, open-label feasibility study enrolled 14 participants from the ED with acute SI who were awaiting voluntary admission to inpatient psychiatry to receive ketamine at 0.5 mg/kg, administered intravenously. Participants were assessed post administration to evaluate feasibility of administration in the ED and short-term effectiveness. Feasibility was determined by acceptability by patients and physicians as well as tolerability and ability to recruit participants into the study. Efficacy was assessed based on changes in (1) self-reported mood and (2) suicidal ideation pre- and postinfusion of ketamine.

Results: All patients reported severe depression and active SI at baseline. No serious adverse events were reported, and acceptability was rated highly by both participants and physicians (>70%). Two hours after receiving ketamine 0.5 mg/kg, the mean SI and somatic symptom burden were decreased compared to baseline (P < 0.001 and P = 0.005, respectively), and the mean self-reported mood was increased (P = 0.006). Improvements in mood and decreases in suicidality persisted at 6 hours.

Conclusions: Overall, ketamine was well tolerated, considered feasible by both participants and physicians, and demonstrated short-term efficacy. There is a growing body of evidence demonstrating the feasibility of ketamine administration in the ED, and larger randomized trials should be conducted to establish treatment recommendations for patients with SI in the ED.”

Authors: Rachel Gaither, Megan Ranney, Alyssa Peachey, Jeffrey Burock, Jyllian Rogers, Lindsey Bucci & Francesca L. Beaudoin

Summary

Ketamine may have a role in treating suicidal ideation in the emergency department.

1.2 Importance

Ketamine has been shown to have rapid-acting antidepressant and antisuicidal properties in patients with mood disorders. However, few studies have explored the use of ketamine for this purpose in the ED.

2.1 Studydesignandsetting

This is a single-arm, open-label feasibility study of ketamine in patients with mood disorders and SI in the ED.

2.2 Selectionofparticipants

A convenience sample of participants was recruited during hours of psychiatry coverage, and those who met the initial eligibility screen underwent further in-person assessment by a study research assistant.

2.4 Outcomes

This pilot study assessed feasibility and efficacy of ketamine infusion on self-reported mood and suicidal ideation pre and post infusion using the ImmediateMoodScaler and Columbia Suicide Severity Rating Scale.

2.5 Analysisandsamplesize

The study evaluated the feasibility of ketamine administration in an ED and found that it had a significant effect on mood and suicide.

TheBottomLine

All participants scored the maximum value on the severity subsection of the C-SSRS, and 86% reported that they had tried to kill themselves.

3.2 Feasibilityresults

Most participants experienced improved overall mood compared to baseline, and this improvement persisted at 6 hours. No participants experienced a deterioration in mood over the entire study period, and 1 participant completed suicide 2 months after study participation.

4 LIMITATIONS

This study had several limitations, including the lack of a comparison group and a short follow-up time. Further research is needed to determine the durability of the treatment effect and whether it is attenuated after 24 hours.

5 DISCUSSION

In this small open-label pilot study, ketamine was tolerated, acceptable to patients and physicians, and had promising short-term efficacy. It is important to establish safety and durability of effect by following patients beyond the immediate EDperiod, and to establish treatment recommendations for acute care of patients with mood disorders and suicidalideation.