A preliminary naturalistic study of low-doseketamine for depression and suicide ideation in the emergency department.
by Larkin GL and Beautrais AL
International Journal of Neuropsychopharmacology. 2011 14:1127-1131.
We examined the preliminary feasibility, tolerability and efficacy of single-dose, intravenous [i.v.] ketamine in depressed emergency department [ED] patients with suicide ideation [SI]. Fourteen depressed ED patients with SI received a single i.v. bolus of ketamine [0.2 mg/kg] over 1-2 min. Patients were monitored for 4 h, then re-contacted daily for 10 d. Treatment response and time to remission were evaluated using the Montgomery-Asberg Depression Rating Scale [MADRS] and Kaplan-Meier survival analysis, respectively. Mean MADRS scores fell significantly from 40.4 [s.e.m.=1.8] at baseline to 11.5 [s.e.m.=2.2] at 240 min. Median time to MADRS score ≤10 was 80 min [interquartile range 0.67-24 h]. SI scores [MADRS item 10] decreased significantly from 3.9 [s.e.m.=0.4] at baseline to 0.6 [s.e.m. =0.2] after 40 min post-administration; SI improvements were sustained over 10 d. These data provide preliminary, open-label support for the feasibility and efficacy of ketamine as a rapid-onset antidepressant in the ED.
"There are no validated approaches to the pharmacotherapy of depression or suicidality in the emergency department (ED) setting. Available antidepressant drugs have slow onset of action, and inherent short-term liabilities. Indeed, many suicidal patients are admitted to hospital for safety reasons alone, despite the disruptive and costly nature of this disposition. However, recent studies suggest that ketamine, an N-methyl-D-aspartic acid (NMDA) glutamate receptor antagonist, may exert a rapid antidepressant effect in research subjects with treatment-resistant depression (TRD), bipolar disorder and suicide ideation (SI). In these studies a slow sub-anaesthetic infusion of intravenous (i.v.) ketamine rapidly reduced depressive symptoms within several hours of drug infusion, with this response maintained in some patients for up to 7 d. Recent studies also suggest an anti-suicidal effect of ketamine. Thus, there is a possibility that rapidly acting antidepressant medications might play a role in alleviating distress, reducing SI, and mitigating hospitalization in some subsets of ED patients. To explore this hypothesis, this study evaluated the effects of a low-dose i.v. ketamine bolus on depression and suicidality in ED patients."
My first post-residency job was running the psychiatric emergency room at Grady Hospital in Atlanta. This was a popular street drug, dusted on other things like marijuana or taken straight out. It can produce a syndrome that looks for all the world like a schizophrenic break, or a catatonic state, or delirium, or an LSD-like trip, or just about anything else. It can clear quickly or last for days. It’s like Scopolamine in that it’s an amnesiac. The idea that "many suicidal patients are admitted to hospital for safety reasons alone, despite the disruptive and costly nature of this disposition" is a reason to give someone a mind numbing, amnesia producing drug so you can send them home is as offensive a concept as I can imagine – a shameful extrapolation of cost-containment to the theater of the absurd. I guess I don’t think much of IV special·K Rx for SI in the ED [even if it works].