Ketamine infusion combined with accelerated sequential theta burst stimulation in multi-therapy-resistant bipolar depression: A case report.
Hariprasad Ganapathy Vijayakumar, Varsha Shamanna, Harsh Pathak, Swarna Buddha Nayok, Sudeeksha Subramanya, Karthik Narasimhappa, Anushree Bose, Vanteemar S Sreeraj, Urvakhsh Meherwan Mehta, Ganesan Venkatasubramanian
Asian journal of psychiatry June 1, 2026 Peer reviewed DOI: 10.1016/j.ajp.2026.104994 via PubMed
Summary
A 69-year-old man with chronic Multi-Therapy Resistant Bipolar Depression (MTRBD) achieved significant clinical improvement after receiving intravenous ketamine and sequential theta burst stimulation (sTBS). His Hamilton depression rating scale score improved from 15 to 8, leading to complete remission that lasted two years. Additionally, neuroplasticity measures showed changes consistent with treatment response. This case highlights the effectiveness of combining ketamine with sTBS in treating resistant bipolar depression.
Study at a glance
| Design | case study |
|---|---|
| Sample size | 1 |
| Population | one elderly gentleman with chronic Multi-Therapy Resistant Bipolar Depression |
| Key finding | The combination of ketamine and sequential theta burst stimulation resulted in sustained clinical remission in a patient with MTRBD. |
Abstract
Treatment resistance in bipolar depression is one of the most challenging clinical conditions to treat in psychiatry. We present a case of an elderly gentleman with chronic Multi-Therapy Resistant Bipolar Depression (MTRBD), where ketamine, a preferential NMDAR blocker on cortical GABAergic interneurons, is used adjunctively with sequential theta burst stimulation (sTBS) to achieve remission. Intravenous ketamine thrice a week was administered with sequential bilateral intermittent- and continuous-Theta Burst Stimulation (iTBS and cTBS) in 69-year-old man, with 2 years of bipolar depressive episode with multiple comorbidities, resistant to numerous antidepressants, anticonvulsants and antipsychotic mood stabilizers, individualised psychotherapies, trial of electroconvulsive therapy and sTBS. Roving mismatch negativity (rMMN), a robust passive EEG-ERP paradigm measuring neuroplasticity, was evaluated before and after this treatment protocol RESULT: A significant clinical improvement with Hamilton depression rating scale (HDRS 17) score improving from 15 to 8 with progressive improvement to achieve complete remission that persisted even at the latest 2-year follow-up on stable medications. A pronounced correction of dysregulated repetitive positivity, partial correction of deviant negativity was noted in rMMN after the treatment. The novel combination of ketamine has resulted in sustained clinical remission in a patient with MTRBD. Earlier failure of sTBS and ECT underlines the importance of this combination. The rMMN findings were consistent with changes in short-term adaptive plasticity and may represent a potential neurophysiological correlate of treatment response. Combining Ketamine.