Ketamine Use for Suicidal Ideation in the General Hospital: Case Report and Short Review

This case report (n=1) describes an anorexic patient who was treated with repeated dose ketamine (0.5mg/kg, 20mg) following a suicide attempt and persevering suicidal ideation (SI). Although the first dose had little effect, the second dose administered 2 weeks after led to a dramatic decrease in depression, hopelessness, and suicidal ideation.

Abstract

“Introduction: Low-dose infusion of ketamine may have rapid antisuicide properties. Such a treatment may therefore be useful in the general hospital to prevent suicide in an environment that cannot be made safe enough.

Results: We report on the use of ketamine as an efficient, well-tolerated treatment for persistent suicidal ideation in a patient hospitalized in a general hospital after a severe suicide attempt.

Discussion: Based on data in the literature, we suggest that the benefit-risk ratio for ketamine use in such a context is highly favorable.”

Authors: Hélène Vulser, Claire Vulser, Marion Rieutord, Amélie Passeron, Didier Lefebvre, Emilie Baup, Anne-Sophie Seigneurie, Isabelle Thauvin, Frederic Limosin & Cédric Lemogne

Summary

David A. Kahn, MD

Inpatients in general hospitals are at high risk of suicide, and ketamine, a glutamate N-methyl-D-aspartate receptor antagonist, may have rapid antisuicide properties. This report describes the use of ketamine for persistent suicidal ideation in a patient hospitalized in a general hospital after a suicide attempt.

CASE DESCRIPTION

A 47-year-old woman was admitted to the hospital after self-poisoning bromazepam. She was diagnosed with a sacral decubitus ulcer, rhabdomyolysis, and delirium, and was then admitted to the medical ward. The patient had a history of suicidal plans for 6 months, but could not be transferred to the psychiatric ward because of a bacteremia. She was kept under physical restraints and sedation for 11 days, until venlafaxine 75 mg/d was introduced. After full information was given to the patient and her husband, she received a low-dose infusion of ketamine at 0.5 mg/kg (20 mg) over 40 minutes to obtain a rapid antisuicidal effect. The patient’s depressive symptoms decreased slightly after 48 hours, whereas her Beck Hopelessness Scale and Beck Suicidal Ideation Scale scores were nearly identical.

The patient’s depression decreased dramatically after 20 days, and she was admitted to a psychiatric ward. Five months later, she no longer reported suicidal thoughts.

DISCUSSION

In the general hospital, low doses of ketamine are frequently used in patients with refractory pain. Ketamine use seems by far safer than the persistence of severe suicidal intent, and electroconvulsive therapy would have increased the risk of suicide attempt during transports. The patient’s MADRS and BSI scores decreased significantly as reported in previous reports, but perhaps less quickly than generally described. The patient’s low body mass index might also have contributed to the improvement, as well as the fact that venlafaxine was introduced only 1 day before the first infusion.

The patient experienced a sustained improvement several weeks after ketamine treatment, which may have been related to specialized care.

CONCLUSIONS

Ketamine has a favorable safety profile and can be used to treat severe suicidal ideation in inpatients in a general hospital setting. However, nonresponse is the main hazard.