Background: Recent inpatient studies examining the effect of low-dose ketamine infusions in treatment resistant depression (TRD) have shown promising results in diminishing suicidal ideation (SI). We describe the efficacy of titrated serial ketamine infusions in stopping suicidal ideation and averting ER visits and hospitalizations in a large, naturalistic sample of adult and adolescent outpatients with TRD and complex psychiatric comorbidity in a
real-world psychiatry outpatient practice.
Methods: This is a retrospective chart review of 231 adults and adolescents presenting with TRD and complex psychiatric comorbidity in a large real-world psychiatry office practice with > 5400 visits/year. Each patient underwent a 60-90 min comprehensive consultation by the single treating psychiatrist. Appropriate patients were treated with 6 serial, titrated ketamine infusions (0.5-1.2 mg/kg within 40-50 min) over 2-3 weeks. PHQ-9 was obtained at baseline and before each infusion. The presence, frequency, and intensity of suicidality expressed in PHQ-9 Item 9 was analyzed over the treatment course and correlated to decrease in total PHQ-9. Suicides, suicide attempts, ER visits and hospitalizations were analyzed over the course of treatment and for an additional 4 weeks.
Results: 64% of TRD patients presented with SI. There were no suicides, attempts, ER visits or hospitalizations in this large real-world cohort. SI markedly diminished in 79%, and ceased completely in 59%. Remission of SI was bimodal, occurring after 1 infusion in 36%; the remainder required 3.1 infusions and an average dose of 0.75mg/kg for remission of SI. Suicidal patients experienced higher rates of response and remission of TRD than non-suicidal
Conclusion: This is the first report of serial titrated IV ketamine infusions in a real-world psychiatry office for adults and adolescents with TRD and complex psychiatric comorbidity to safely and rapidly treat severe suicidal ideation and avert suicide, ER evaluation and hospitalization. It represents the largest number of patients to date reported from a single site in studies of IV ketamine infusions for TRD and suicidality, and a potential breakthrough treatment option for psychiatrists to provide in the office.View pdf