1. Treatment of Depression with Ketamine and a Reactivation of Traumatic Memories
Keely Elgethun, MD PGY4
May 25, 2017

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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