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Ketamine as a Rapid Antidepressant

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The Massachusetts General Hospital Guide to Depression

Part of the book series: Current Clinical Psychiatry ((CCPSY))

Abstract

In this chapter, we will present an overview of the current status of research on ketamine as a rapid-acting antidepressant agent. We will introduce a brief case vignette, exemplary of the patients presenting at our center for ketamine treatment. At the time of publication of this book ketamine is not yet FDA-approved for depression. We will review guidelines for clinicians regarding the use of ketamine, with emphasis on the contraindications and the limited knowledge about long-term consequences of this still experimental treatment.

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Author information

Authors and Affiliations

  1. Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Cristina Cusin

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  1. Cristina Cusin
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Correspondence to Cristina Cusin .

Editor information

Editors and Affiliations

  1. Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Benjamin G. Shapero

  2. Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    David Mischoulon

  3. Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Cristina Cusin

FAQs: Common Questions and Answers

FAQs: Common Questions and Answers

  • Q1. Who is the right candidate for ketamine treatment ?

  • A1. In 2017, a group of investigators and clinicians published a consensus statement for the use of ketamine in psychiatry [52]. Because of the dearth of controlled data, in particular regarding patient selection, the available information in the literature is limited to adults with TRD without history of psychotic features, without substance use disorder, and without significant medical comorbidity. The role of ketamine within the algorithm for the management of TRD and its possible role in other disorders are not established. Moreover, it is not known whether the safety of ketamine is substantially affected by comorbidities or whether there are unknown interactions with psychiatric medications beyond standard antidepressants.

  • Q2. What are the long-term effects of ketamine?

  • A2. There are extremely limited published data on the long-term effectiveness and safety of ketamine treatment in mood disorders, mostly a few case series. For each patient, risks and benefits must be discussed in detail and frequently re-evaluated, particularly when new data about safety become available. Ongoing assessment of cognitive function, urinary symptoms, and absence of any substance use is recommended.

  • Q3. Who can administer ketamine? Is ketamine safe?

  • A3. There are no specific guidelines regarding the training that clinicians should complete before being allowed to administer ketamine at low dose. Transient increase in blood pressure and heart rate are commonly observed, and serious cardiovascular events and effects on respiratory status are rare (at least in healthy individuals) but may still occur and require medical management. Finally, because of the high likelihood of dissociative or psychotomimetic effects , the clinician should be familiar with behavioral management of patients with altered mental status. Administering facilities should be equipped for monitoring cardiovascular and respiratory status and corrective medications available in case of need.

  • Q4. Is ketamine effective for suicidal ideation ?

  • A4. A number of controlled studies support the efficacy of ketamine in acute suicidal ideation; however, in those studies the use of ketamine was always coupled with hospitalization or other treatments that followed standard of care for specific cases and may themselves have contributed to decreased suicidal ideation. At present, the role of ketamine in acute situations, in which a rapid improvement could be followed by equally rapid worsening at some unknown point after the administration, is not clear.

  • Q5. How long do ketamine effects last?

  • A5. The acute side effects of ketamine last approximately 30–90 minutes. The duration of the positive effects of ketamine, if occurring within 24 h after the administration, is extremely variable, from a few days to a few weeks. At present, there is no known predictor of positive response to ketamine or predictors of the duration of effect. Most patients require ongoing administration of ketamine to sustain the response.

  • Q6. What is the potential for addiction ?

  • A6. Given the high abuse liability of ketamine, it should be administered only in clinical settings where patients can be monitored. The actual incidence of new onset substance use disorder in patients, either with or without past history of alcohol or substance abuse, is not known.

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Cusin, C. (2019). Ketamine as a Rapid Antidepressant. In: Shapero, B., Mischoulon, D., Cusin, C. (eds) The Massachusetts General Hospital Guide to Depression. Current Clinical Psychiatry. Humana Press, Cham. https://doi.org/10.1007/978-3-319-97241-1_10

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  • DOI: https://doi.org/10.1007/978-3-319-97241-1_10

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