February 2014  << Back  

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 LETTERS TO THE EDITOR

Treatment-refractory depression: A case of successful treatment with intranasal ketamine 10%

Patricia Clark, MD, MPH

Private Practice, Chapel Hill, North Carolina, USA

ANNALS OF CLINICAL PSYCHIATRY 2014;26(1):e10

Ms. H is a 44-year-old white female with a >10-year history of recurrent major depressive disorder, migraine headaches, and several psychiatric hospitalizations. She has no history of mania, psychosis, or substance abuse by her report and hospital discharge summaries. She has had several trials of psychotropics, as monotherapy and combination treatment, and a series of electroconvulsive therapy (ECT) treatments 12 years ago with only partial benefit.

Ms. H reported significant worsening of her depressive symptoms over the previous 1 to 2 months, including suicidal ideation without intent, which prevented her from going to work on several occasions. Ms. H takes venlafaxine extended-release (ER), 300 mg/d; bupropion ER, 300 mg/d; mirtazapine, 60 mg/d; L-methylfolate 15 mg/d; aripiprazole, 15 mg/d; and olanzapine, 10 mg/d. Ms. H declined referral for ECT treatment. Because of recent reports in the literature1-3 and the media4 describing improvement in treatment-resistant depression (TRD) symptoms with IV ketamine infusions, I attempted to enroll Ms. H in a research trial of IV ketamine.

Because I could not get Ms. H enrolled in an IV ketamine research trial in a timely manner, and because her depressive symptoms were worsening, I referred Ms. H to a neurologist who treats refractory migraine headaches with intranasal ketamine. I hoped that Ms. H would qualify for an intranasal ketamine trial because of her history of migraine headaches, and that the drug might reduce her severe depressive symptoms. I explained to Ms. H that intranasal ketamine for treating depression was experimental and this would be an off-label, compassionate, clinical use of ketamine because there was no research protocol.

Ms. H received intranasal ketamine 10% solution, 5 spray inhalations administered 15 minutes apart each Wednesday and Saturday over 4 months. A compounding pharmacy prepared the intranasal ketamine 10% solution using 100 mg of ketamine per 1 mL of preserved (with benzalkonium chloride) water. Each spray or “actuation” provided 0.1 mL of ketamine solution, which delivered 10 mg of ketamine per spray inhalation and 50 mg of ketamine per treatment session each Wednesday and Saturday; the total weekly dose of ketamine was 100 mg.

The first intranasal ketamine treatment (day 1) was done under my supervision in my office. Ms. H’s depressive symptoms improved significantly by day 3 and further improved over the next 1 to 2 weeks. Ms. H was euthymic for the next 4 months and was able to work while continuing treatment twice a week with intranasal ketamine. Her only treatment-related side effects were brief feelings of being “high” after completing the first few treatment sessions, and mild mood decreases on several occasions on Tuesdays or Fridays (the day before a treatment session).

I hope that this case report will encourage further research into the safe and effective use of intranasal ketamine as a treatment option for patients with severe depression.

DISCLOSURE: Dr. Clark reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

    REFERENCES

  1. Brauser D. Experimental drug may help depression ‘in minutes.” Medscape. http://www.medscape.com/viewarticle/776127. Published December 13 2012. Accessed January 13, 2014.
  2. Stetka B, Feifel D. Hope in treatment-refractory depression. Medscape. http://www.medscape.com/viewarticle/777190. Published January 10 1013. Accessed January 13, 2014.
  3. Pierson R. New J&J anti-depressant related to ‘Special K’ party drug. Reuters. http://www.reuters.com/article/2013/05/23/us-johnsonjohnson-investors-idUSBRE94M0J120130523. Published May 23 2013. Accessed January 13, 2014.
  4.  National Institute of Mental Health. Ketamine cousin rapidly lifts depression without side effects. http://www.nimh.nih.gov/news/science-news/2013/ketamine-cousin-rapidly-lifts-depression-without-side-effects.shtml. Published May 23 2013. Accessed January 13, 2014.

CORRESPONDENCE: Patricia Clark, 307 N. Columbus Street, Chapel Hill, NC, USA 27516, E-MAIL: Trisheclark@aol.com