Intranasal Ketamine and Cognitive-Behavioral Therapy for Treatment-Refractory Obsessive-Compulsive Disorder

This case study (2017) presents a patient suffering from OCD that was promisingly treated with intranasal ketamine and cognitive behavioral therapy (CBT).

Abstract

No abstract was written for this article. Instead, we provide the brief introduction of this letter addressed to the editor:

“Refractory obsessive-compulsive disorder (OCD) is a common and vexing clinical problem. Agents that modulate glutamate, including the NMDA antagonist ketamine, have been the focus of recent interest for the treatment of this population, but experience to date has been mixed. Ketamine is a rapid-acting antidepressant that enhances cellular mechanisms associated with neural plasticity in prefrontal circuitry associated with extinction learning. This raises the intriguing possibility that ketamine may potentiate extinction-based psychotherapy for OCD.”

Authors: Thomas Adams, Michael Bloch & Christopher Pittenger

Summary

Dear Editors

Ketamine, an NMDA antagonist, has been shown to enhance neural plasticity in prefrontal circuitry associated with extinction learning, suggesting that it may potentiate extinction-based psychotherapy for OCD.

AL1 is a Caucasian male in his late 20s with OCD, comorbid major-depressive disorder with chronic suicidal ideation, social anxiety disorder, and a history of bulimia nervosa. He has been refractory to pharmacological treatments, so we initiated concurrent ketamine and CBT treatment.

AL was treated for 8 weeks on an inpatient psychiatric unit and for 8 weeks as an outpatient with intensive CBT. He also completed some mindfulness exercises and activity scheduling, but the amount of time devoted to these activities was small relative to time spent on ERP.

The pre-treatment OCD and MDD symptoms of AL were severe; however, the symptoms were modestly reduced after 2 weeks of CBT without ketamine. The intranasal ketamine was well tolerated and the symptoms were reduced further following the first week of ketamine.

AL’s OCD and MDD symptoms worsened after returning home, but improved with ongoing CBT. He reported less distress associated with his OCD symptoms and less OCD-related functional impairment.

A patient with OCD was treated with intranasal ketamine, multiple ketamine administrations, and intensive ERP. The patient reported additional symptom reductions following the initiation of ketamine treatments, and drastic reductions in suicidal ideation following the first week of ketamine treatments.