Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial
M. Abbar, C. Demattei, W. El-Hage, P. Llorca, L. Samalin, Pierre Demaricourt, R. Gaillard, P. Courtet, G. Vaiva, P. Gorwood, Pascale Fabbro, F. Jollant
British medical journal February 2, 2022 DOI: 10.1136/bmj-2021-067194 via Semantic Scholar
Summary
Two intravenous infusions of ketamine (0.5 mg/kg) given 24 hours apart, added to usual treatment, led to full remission of suicidal ideas by day 3 in 63.0% of hospitalized patients with suicidal ideation, compared to 31.6% with placebo. The benefit was strongest in patients with bipolar disorder (odds ratio 14.1), not significant in those with depressive disorder (odds ratio 1.3), and intermediate for other disorders (odds ratio 3.7). At six weeks, remission remained high in the ketamine group (69.5% vs 56.3%) but was no longer statistically significant. Side effects were limited, with no manic or psychotic symptoms observed. An analgesic effect on mental pain may explain the anti-suicidal action.
Study at a glance
| Characteristics | Randomized controlled trial Placebo-controlled Double-blind Peer reviewed |
|---|---|
| Sample size | 156 |
| Population | Adults aged 18 or older hospitalized voluntarily with current suicidal ideation |
| Keywords | Medicine |
| Citations | 172 |
| Registration | NCT02299440 |
| Key finding | Ketamine produced rapid, short-term remission of suicidal ideation by day 3 versus placebo, with effect varying by diagnosis, most pronounced in bipolar disorder. |
Abstract
Abstract Objective To confirm the rapid onset anti-suicidal benefits of ketamine in the short term and at six weeks, overall and according to diagnostic group. Design Prospective, double blind, superiority, randomised placebo controlled trial. Setting Seven French teaching hospitals between 13 April 2015 and 12 March 2019. Eligibility criteria for participants Aged 18 or older with current suicidal ideation, admitted to hospital voluntarily. Exclusion criteria included a history of schizophrenia or other psychotic disorders, substance dependence, and contraindications for ketamine. Participants 156 participants were recruited and randomised to placebo (n=83) or ketamine (n=73), stratified by centre and diagnosis: bipolar, depressive, or other disorders. Intervention Two 40 minute intravenous infusions of ketamine (0.5 mg/kg) or placebo (saline) were administered at baseline and 24 hours, in addition to usual treatment. Main outcome measures The primary outcome was the rate of patients in full suicidal remission at day 3, according to the scale for suicidal ideation total score ≤3. Analyses were conducted on an intention-to-treat basis. Results More participants receiving ketamine reached full remission of suicidal ideas at day 3 than those receiving placebo: 46 (63.0%) of 83 participants in the ketamine arm and 25 (31.6%) of 73 in the placebo arm (odds ratio 3.7 (95% confidence interval 1.9 to 7.3), P<0.001). This effect differed according to the diagnosis (treatment: P<0.001; interaction: P=0.02): bipolar (odds ratio 14.1 (95% confidence interval 3.0 to 92.2), P<0.001), depressive (1.3 (0.3 to 5.2), P=0.6), or other disorders (3.7 (0.9 to 17.3, P=0.07)). Side effects were limited. No manic or psychotic symptom was seen. Moreover, a mediating effect of mental pain was found. At week 6, remission in the ketamine arm remained high, although non-significantly versus placebo (69.5% v 56.3%; odds ratio 0.8 (95% confidence interval 0.3 to 2.5), P=0.7). Conclusions The findings indicate that ketamine is rapid, safe in the short term, and has persistent benefits for acute care in suicidal patients. Comorbid mental disorders appear to be important moderators. An analgesic effect on mental pain might explain the anti-suicidal effects of ketamine. Trial registration ClinicalTrials.gov NCT02299440.