Use of repeated intravenous ketamine therapy in treatment-resistant bipolar depression with suicidal behaviour: a case report from Spain

This case study describes the successful treatment of ‘treatment-resistant’ bipolar depression (BD) with ketamine, but with a relapse in the fifth week of discharge as result of a suicide attempt.

Abstract

“The rapidly-acting antidepressant properties of ketamine are a trend topic in psychiatry. Despite its robust effects, these are ephemeral and can lead to certain adverse events. For this reason, there is still a general concern around the off-label use of ketamine in clinical practice settings. Nonetheless, for refractory depression, it should be an indication to consider. We report the case of a female patient admitted for several months due to a treatment-resistant depressive bipolar episode with chronic suicidal behaviour. After repeated intravenous ketamine infusions without remarkable side effects, the patient experienced a complete clinical recovery during the 4 weeks following hospital discharge. Unfortunately, depressive symptoms reappeared in the 5th week, and the patient was finally readmitted to hospital as a result of a suicide attempt.“

Authors: Álvaro López-Díaz, José Luis Fernández-González, José Evaristo Luján-Jiménez, Sara Galiano-Rus & Luis Gutiérrez-Rojas

Summary

Introduction

Ketamine is a dissociative anaesthetic agent commonly used in paediatric anaesthesiology, but its use in adult patients has been controversial based on dissociative and psychotomimetic side effects.

Ketamine was first used to treat depression 15 years ago. Since then, several systematic reviews and meta-analyses have been published, highlighting the rapid and robust antidepressant and anti-suicidal properties of ketamine, but warnings about its temporary effect and methodological difficulties of double-blind trials have also been highlighted.

Clinical background

A 45-year-old female patient with refractory bipolar depression and chronic suicidal thoughts was admitted to care after an aborted suicide attempt at home. She was treated with ketamine after a detailed technical report was approved by the hospital’s ethics committee.

Intravenous ketamine therapy

According to previously obtained evidence, six sessions of intravenous ketamine were administered over 40 min on Mondays, Wednesdays and Fridays over 2 weeks to treat depressive symptoms, anxiety, impulsivity and sleep disturbances.

Results

A clinical response was registered just a few hours after the first session, and the patient was discharged from hospital and referred to outpatient psychiatric care. Unfortunately, the positive course was cut short in the 5th week, when depressive symptoms abruptly reappeared.

Ketamine side effects were mainly sedative and disappeared entirely within 2 h, and vital signs were undisturbed.

Discussion

Ketamine’s antidepressant effect is complex and not yet well understood, but it might increase synaptic glutamate release and relieve inhibition of brain-derived neurotrophic factor (BDNF) synthesis, and promote synaptogenesis in neural circuits damaged due to chronic depression and stress.