Alternating intravenous racemic ketamine and electroconvulsive therapy in treatment resistant depression: A case report

A severely depressed and chronically suicidal patient who had not responded to many antidepressant treatments, including electroconvulsive therapy (ECT) and ketamine alone, was given a combination of ECT (up to 150% bilateral stimulation) 2–3 times per week and intravenous racemic ketamine (up to 75 mg per infusion) on ECT-free days. Robust anti-suicidal and antidepressant effects appeared during the first week. After 9 ECT treatments and 7 ketamine infusions, the patient achieved a stable state and was discharged. A maintenance plan of monthly ECT with two ketamine infusions (up to 100 mg) around each ECT prevented relapse. The alternating regimen proved safe and long-term effective in this case.

Study at a glance

Abstract

IntroductionTreatment resistant depression (TRD) affecting approximately 10–30% of all depressed patients often remains misdiagnosed and undertreated, leading to a higher risk of relapse and suicide. Electroconvulsive therapy (ECT) and sub-anesthetic ketamine have repeatedly shown to be effective in the TRD population. Administering ketamine as an anesthetic component to augment antidepressant efficacy of ECT has been proven inconclusive, while a combination of alternating ECT and ketamine has not been investigated yet.Case reportWe present a severely depressed and chronically suicidal female inpatient who failed multiple antidepressant treatment attempts, requiring frequent psychiatric admissions. Since available conventional as well as non-conventional antidepressant treatment strategies were nearly exhausted, we employed a combination of ECT (bilateral stimulation up to 150%) 2–3 times/week, while intravenous racemic ketamine (up to 75 mg per infusion) was administered on ECT free days 2–3 times/week. Consequently, robust anti-suicidal and antidepressant effects could be observed already during the first treatment week. The temporarily occurring subjective forgetfulness disappeared after the last ECT. Summarizing, we employed 9 ECT treatments and 7 ketamine infusions leading to a stable psychopathological state even after discharge from psychiatric inpatient care. In order to prevent relapse a maintenance-therapy comprising ECT once monthly and 2 ketamine infusions (up to 100 mg per infusion) administered on the day before and after ECT was established.ConclusionsIn our patient alternating ECT and intravenous racemic ketamine were proven safe and long-term effective after numerous failed antidepressant trials including ECT and ketamine alone. We may hence encourage clinicians to widen their therapeutic armamentarium in severe TRD.Disclosure of interestThe authors have not supplied their declaration of competing interest.