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Key points
- Treatment-resistant patients have often lost hope in conventional treatment practices.
- Each case demonstrates the efficacy of ketamine/esketamine’s mechanism of action; blocking the NMDA receptor.
- Known risks should be mitigated with the FDA-approved Risk Evaluation and Mitigation Strategy (REMS) program.
- Before treating with ketamine, patients should have a thorough psychiatric/medical evaluation.
While many wait for the ready availability of emerging psychedelics, the early leader ketamine, is quietly changing and saving lives. This blog will cover 3 brief case studies to illustrate the powerful effect ketamine can have in situations where patients may have lost hope in conventional treatment practices. Ketamine is not always helpful but for many it is life changing. It is not risk free so before treating with ketamine, patients should have a thorough psychiatric/medical evaluation. Known risks should be mitigated with a proven treatment protocol such as the FDA-approved Risk Evaluation and Mitigation Strategy (REMS) program.
Each case below demonstrates the efficacy of ketamine/esketamine’s mechanism of action, blocking the NMDA receptor. Recent evidence suggests that that blocking the NMDA receptor ultimately results in a rapid increase in neuroplasticity or brain growth. It appears that the rapidity of this growth quickly reduces suicidality and improve depression.
Denise: A professional and mother hospitalized 16 times for mental health crises over the past 30 years
Denise is a 47-year-old woman with a long history of mood instability, trauma, anxiety, eating disorder, and insomnia. Denise has a history of physical, sexual and emotional abuse from a parent. She works full time as an attorney and has been very successful in maintaining employment despite her repeated hospitalizations.
Denise has tried eight antidepressants and five mood stabilizers plus she has had six full courses of electroconvulsive therapy (ECT) over 30 years for severe episodes of depression, each preceded by psychiatric hospitalization. Although ECT helped reduce Denise’s symptoms of depression, it was highly disruptive to her life. She did not like ECT induced memory impairment. The memory problems made it hard to function well at work had a negative impact on her personal life. She was in psychotherapy for over 30 years. In addition to her 16 psychiatric hospitalizations, she had one residential treatment for alcohol abuse at the age of twenty-one. She had no history of suicide attempts.
Denise self-administered intranasal (IN) ketamine nightly for two years at 90mg per treatment before coming to our clinic. IN ketamine only reduced her depression a bit, so we changed to intravenous (IV) ketamine starting at 30mg and slowly increasing to 70mg. Her depression resolved completely over the course of the next year. Denise eventually elected to receive ketamine intramuscularly (IM) for convenience. This was administered in our outpatient office setting by nursing staff under the guidance of mental health prescribers following the esketamine REMS protocol and was covered by insurance.
Overall, the ketamine infusions and injections were much more effective and lasted longer than intranasal ketamine, with no additional side effects. Denise was able to discontinue the antidepressant bupropion XL after transitioning to IM ketamine, and her mood was, in her words, “the best it has ever been” for the past three years with no psychiatric hospitalizations or need for further ECT.
Denise enjoys her professional life, is engaged with her children, and looks forward to the future.
Ronna: A young woman subject to self-harm and multiple suicide attempts
Ronna is a 21-year-old female with a history of depression, emotional reactivity, and trauma induced anxiety. She has been harming herself since her teen years, had multiple suicide attempts, and had several hospitalizations. After failing at least five antidepressants, as well as psychotherapy and residential treatment programs, she started IV ketamine infusions. Prior to starting, her depression was severe and she wanted to die.
After a single treatment with IV ketamine, Ronna’s depression and suicidal thoughts improved significantly. Upon completing a standard course of six IV ketamine treatments, her depression and suicidal thoughts resolved completely. She continues regular maintenance ketamine treatments and both depression and suicidal thoughts have been absent for nearly a year.
She states that she looks forward to each day, enjoys her friends, and is relieved to be free of self-destructive thoughts.
Tom: Suffering from anxiety and depression since childhood, ultimately able to discontinue ketamine treatment
Tom is a 51-year-old male who has suffered from anxiety and depression since childhood. Like many treatment-resistant patients, he was hopeless about his case. He had failed five different antidepressant medications and did not respond to psychotherapy. Even after a round of transcranial magnetic stimulation (TMS), Tom’s depression and anxiety remained high. However, he reported no significant suicidal ideation.
After his first treatment with intranasal ketamine at an outside clinic, Tom had an immediate drop in his depression score. Then, after a standard course of six treatments, his depression improved even more. After a month of ketamine maintenance treatment, his depression and anxiety were almost normal. Following another 2 months of maintenance treatment, his depression and anxiety had resolved completely.
During his maintenance treatments, Tom switched from intravenous to intramuscular ketamine treatments. Depression scores continued in the normal to mild range. Over time, he reduced frequency of treatments to every other week, then monthly, and then as needed. Tom has since discontinued ketamine treatments and continues to do well, with his depression in the normal range.
Tom thought he would never be free of sadness and would never enjoy life. Now every day is a gift.
