|LETTER TO THE EDITOR
|Ahead of print publication
Intravenous ketamine in refractory depression
Shivang Gandhi, Bhushan Chaudhari, Suprakash Chaudhury
Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Center, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||09-Jul-2021|
|Date of Decision||11-Jul-2021|
|Date of Acceptance||12-Jul-2021|
Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Center, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Major depressive disorder (MDD) is often associated with partial recovery, frequent relapses, and lasting psychosocial and functional impairment. At least 20% of all depressed patients do not respond adequately to several antidepressant drugs. Glutamate is postulated to play a role in mood modulation. Ketamine, a nonnoncompetitive antagonist of the N-methyl-D-aspartate (NMDA) receptors, in early trials was rapidly effective in both MDD and treatment-resistant depression.
A 37-year-old married male, singer by profession, presented to the psychiatry OPD with chief complaints of persistent low mood, decreased interest in day-to-day activities and pleasurable activities, reduced libido, and disturbed sleep and appetite. All his complaints started 3 years back without any stressor and gradually worsened over a time. He had consulted various psychiatrists but had minimal improvement. When he presented to our psychiatry OPD, he had been sequentially treated with paroxetine, amitryptiline, venlafaxine in adequate doses. He was also tried with the combination of antidepressants along with adjuvant lithium and atypical antipsychotics but showed very minimal improvement in depressive symptoms. He was not willing for electroconvulsive therapy. Hence, finally, it was decided to treat him with ketamine infusion therapy. He was given six cycles of intravenous 0.5 mg/kg ketamine on alternate days. He showed significant clinical improvement and did not suffer from any adverse effects due to ketamine. After the sixth infusion, the mean reduction in MADRS scores was 85%. He continued to maintain improvement in his condition on follow-up after a month.
Currently, available antidepressants acting on monoaminergic system have delayed onset of action and limitations in clinical efficacy. In the last few decades, glutamate has been scrutinized as a target of antidepressant therapy. There have been some case reports open-label studies, and randomized double-blind controlled studies which reported the efficacy of ketamine, a noncompetitive antagonist of the NMDA receptors, in treatment-resistant depression.,,, These studies have demonstrated good response and remission rates, good effect on depressive cognition as well as suicidal cognition, and rapid onset of action with ketamine infusion therapy.
Ketamine for the treatment of depression is usually administered in the dose of 0.5 mg/kg, but some patients may respond to doses as low as 0.1 mg/kg, and others may require up to 0.75 mg/kg. The duration of ketamine infusion therapy is conventionally 40 min. While the drug is administered most commonly by the intravenous route, the safety and efficacy of oral, sublingual, intranasal, and intramuscular, routes have been established. The psychotomimetic and dissociative symptoms may complicate the clinical outcome of ketamine infusion therapy. However, other side effects such as dizziness, dry mouth, poor coordination, poor concentration, and hemodynamic changes after ketamine infusion can be the cause of concern. Although the patient presented here showed significant clinical improvement and no adverse effects the ketamine infusion therapy still has a long way to go before its acceptance as treatment modality for the depressive disorder because of the lack long-term efficacy and side effects.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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