Treatment of Depression with Ketamine and a Reactivation of Traumatic Memories Keely Elgethun, MD PGY4 May 25, 2017
Case Presentation 55 year old white male with MDD, recurrent severe, PTSD and Alcohol Use DO presenting for consultation for ECT for chronic depression with worsening suicidal thoughts chronic episodes of depression with suicidal ideation that can last months at time of consultation current medications included: Li 900mg daily, Clonazepam 1mg BID, gabapentin 900mg daily, olanzapine 30mg qhs, prazosin 2mg qhs regularly sees a psychiatrist, compliant with medications and attends individual therapy episodes will spontaneously remit and medication has been helpful in reducing intensity of depressive symptoms in between depressive episodes continues to experience frequent flashbacks of sexual abuse from childhood and endorses nightmares, hypervigilance, hypersensitive stare reflex, avoidance and social isolation
Case Presentation recommended RUL UBP ECT received 6 treatments of RUL with minimal response and switched to BL on once a week maintenance ECT with depressive symptoms, SI occurring 5 days post ECT decided to try ketamine infusion prior to ECT treatment
Case Presentation ECT ketamine protocol Pt has negative experience in which he had a re- experiencing of childhood sexual abuse/trauma and became tearful, intensely dysphoric and suicidal resolved post ECT but pt declined additional ketamine treatments due to memory of this experience
Ketamine non-selective NMDA receptor antagonist developed in 1960s and approved for use by the FDA as an anesthetic in 1970 anesthetic, analgesic and anti-convulsant properties in 2000 ketamine was demonstrated to have antidepressant properties use had been limited by potentially harmful psychomimetic effects and risk of abuse
Ketamine exhibits antidepressant properties in different validated models of depression dysfunction of the glutamatergic system has been implicated in MDD, Bipolar DO and PTSD ketamine’s mechanism of action involves the modulation of glutamatergic signaling including glutamatergic synapses in the prefrontal cortex increases BDNF synthesis and release these effects are mediated by activation of different pathways that result in neurogenesis and synaptic consolidation
Ketamine ketamine has been shown to rapidly reduce depressive symptoms in individuals with MDD, Bipolar DO and PTSD high response rate (65-70%) within 24 hours and lasts up to 1 week initial reduction in depressive symptoms within 1-2 hours and maximal reduction within 24 hours
Ketamine has been shown to be effective in treatment resistant depression including those who do not respond to ECT acts much faster than other traditional anti- depressants response to first infusion is predictive of overall effectiveness of the treatment -non responders can be identified and switched to another treatment right away
Ketamine psychotic like symptoms including perceptual disturbances, dissociation and derealization may occur at sub-anesthetic doses of ketamine few documented cases thought to be dose related transitory due to ketamine’s rapid metabolism do not occur without the drug