Intranasal racemic ketamine for patients hospitalized with treatment-resistant depression: A retrospective analysis.

Most research describing ketamine as a treatment for depression has relied on intravenous dosing. There remains a need for more research to support this treatment with other routes of administration. This was a retrospective chart review of 30 patients hospitalized with unipolar or bipolar treatment-resistant depression who were treated with up to four doses of compounded intranasal racemic ketamine (50 mg or 75 mg). Treatment courses lasted up to 7 days. Symptom improvement was measured with either the Hamilton Depression Rating Scale or the Montgomery-Åsberg Depression Rating Scale. Ketamine was well tolerated with no severe adverse events or treatment discontinuations due to adverse effects. Blood pressures increased by 4-6 mmHg on average with no patients requiring medication to lower blood pressure. Twenty patients (66.7%) were classified as treatment responders based on depression scores decreasing by more than 50%. Among the 27 patients with moderate to severe suicidal ideation scores at baseline, these decreased by 68.5% on average. Overall, the results suggest that compounded intranasal racemic ketamine was safe and effective in the treatment of depressive symptoms and suicidal ideation in a real-world sample of patients hospitalized with treatment-resistant depression. Additional research comparing intranasal ketamine to esketamine and intravenous racemic ketamine is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Intranasal ketamine as a treatment for psychiatric complications of long COVID: A case report.

Background: Neuropsychiatric symptoms associated with long COVID are a growing concern. A proposed pathophysiology is increased inflammatory mediators. There is evidence that typical serotonergic antidepressants have limited efficacy in the presence of inflammation. Although ketamine has shown promise in MDD, there is limited evidence supporting the use of ketamine to treat depressive symptoms associated with long COVID. Case Report: This case took place on an inpatient psychiatry unit in a Canadian hospital. The patient was admitted with a 10-month history of worsening depression and suicidality following infection with COVID-19. Depressive symptoms and suicidal ideation were assessed throughout treatment using the Montgomery-Asberg Depression Rating Scale (MADRS). Written informed consent was obtained prior to data collection. This patient received 4 doses of intranasal ketamine which resulted in rapid improvement of depressive symptoms and complete resolution of suicidality with no major adverse events. Discussion: There is evidence to support long COVID symptoms result from dysregulated inflammatory processes. The presence of inflammation in patients with MDD has correlated to poor outcomes with first-line antidepressants. It has been demonstrated that IV ketamine is associated with decreased inflammatory mediators and proportional decrease in depressive symptoms. Conclusions: Intranasal ketamine in this case was effective at treating depressive symptoms and suicidal ideation associated with long COVID. This is consistent with available data that demonstrates ketamine's efficacy in reducing inflammatory mediators associated with neuropsychiatric symptoms. Therefore, ketamine may be a potential therapeutic option to treat long COVID and persistent depressive symptoms.

Compounded intranasal racemic ketamine for major depressive disorder: A case report.

Ketamine has been safely used as an anesthetic for over 50 years. More recently sub-anesthetic doses have shown benefit for treatment-resistant depression (TRD). The majority of data on ketamine for depression is based on intravenous administration which is resource intensive and logistically challenging. Due to these concerns, novel modes of administration, including intranasal, are being explored. In 2019, the U.S. Food and Drug Administration (FDA) approved a commercially formulated intranasal s-enantiomer ketamine product, esketamine, for TRD. The cost of intranasal esketamine is significant and phase III clinical trials have not consistently demonstrated benefit over placebo. We describe a case of a patient with major depressive disorder (MDD) and acute suicidality who achieved rapid remission following three treatments with intranasal racemic ketamine. The associated drug cost was $42 USD, significantly cheaper than commercially available esketamine, and treatment was administered on an inpatient psychiatry ward with basic hemodynamic monitoring. Intranasal ketamine was not associated with significant adverse drug effects and facilitated a relatively short hospital admission. The case report provides support for the use of intranasal racemic ketamine as adjunctive treatment for MDD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Opioid toxicity due to CNS depressant polypharmacy: A case report.

The interaction between methadone and central nervous system depressants can cause serious adverse effects, including profound sedation, respiratory depression, coma, and death. This poses a challenge in the treatment of patients with concurrent psychiatric and substance use disorders as the combined use is often unavoidable. We report a case of a patient with opioid use disorder, mood disorder unspecified, chronic pain, and chronic obstructive pulmonary disease who experienced 2 serious episodes of CNS and respiratory depression due to polypharmacy-induced opioid toxicity. Careful consideration of pharmacokinetics, pharmacodynamics, and patient-specific factors was imperative to identify the suspected contributing medications: methadone, lorazepam, divalproex, gabapentin, and cyclobenzaprine. Cognitive and system factors that contributed to these adverse events and strategies to mitigate risk of recurrence were also identified.