S.B. was a 64-year-old divorced caucasian woman with hospice diagnoses of both respiratory failure and chronic obstructive pulmonary disease. She was oxygen dependent and her prognosis was weeks to months. Over several months prior to psychiatric consultation, she had developed severe depressive symptoms, which included low mood, low energy, hypersomnia, decreased appetite with unintentional weight loss, hopelessness, and excessive feelings of guilt, especially regarding feeling like a burden on her roommate, who was also her close friend and primary caregiver. She was preoccupied with thoughts of wanting to die. She did not plan or intend to end her life, stating “I'm too chicken to die.” Prior to the onset of her depressive symptoms, she greatly enjoyed reading books and socializing with friends; however, she had stopped these activities for at least 2 months. A large pile of bills was noted on the coffee table, which she had been avoiding for weeks.
Additionally, S.B. had severe anxiety symptoms related to shortness of breath. She reported one to three panic attacks per day. She was noticeably anxious during the initial interview, shifting in her seat, picking at her lips, and playing with her toes. She also reported feeling irritable, which was confirmed by her caregiver/roommate. She would shout and appear extremely irritated when the phone rang or the dog would bark. She also exhibited a somatic focus, not only on pain, but her perception of pain and shortness of breath. There was no evidence of cognitive impairment.
Scheduled medications included duloxetine 60
mg daily, morphine sulfate extended release 90
mg daily, prednisone 10
mg daily, aspirin, albuterol sulfate, tiotropium bromide, fluticasone-salmeterol, risedronate sodium, docusate, and a lidoderm patch. As needed medications available (but not necessarily used) included morphine 10
mg hourly, oxycodone/acetaminophen 5/325
mg every 4 hours, diazepam 5
mg every 6 hours, trazodone 50
mg at night, naproxen 220
mg daily, tizanidine up to 4
mg every 8 hours, oxygen, and lactulose. No changes in psychotropic medications (antidepressants, anxiolytics, and opiates) had occurred for at least 8 weeks prior to ketamine dosing. During the study, no scheduled or as needed medication changes occurred until day 14, when her prednisone was increased for worsening shortness of breath.
After informed consent and completion of validated scales for evaluating psychiatric symptoms and adverse events (), S.B. was given a dose of 27.5
mg of ketamine (0.5
mg/kg) orally at home. Subsequently, her mood was greatly improved as indicated by a 45% drop in her 17-item Hamilton Rating Scale for Depression (HRSD17
) score just 60 minutes after the dose. By day 15, there was a 66% improvement. The depression subscale of the Hospital Anxiety and Depression Scale (HADS) showed a similar trend, with a 66% reduction in score just 120 minutes after the dose and a 50% reduction at day 15. Surprisingly, the anxiety subscale of the HADS also dramatically improved, with an 83% reduction in score just 120 minutes after the dose and a 50% reduction at day 15. Either improvements or no changes were also found on scales of adverse effects and cognitive status, including the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS), and the Mini-Mental State Exam (MMSE). Fewer somatic symptoms were recorded after dosing with ketamine, and pain scores improved (, ).
FIG. 1. Rating Scales for Case 1: (A) 17-item Hamilton Rating Scale for Depression and Hospital Anxiety and Depression Scale scores indicating a decrease in depressive and anxiety symptoms and (B) Adverse Symptom Checklist and Brief Psychiatric Rating Scale scores (more ...)
Her clinical picture matched her improvement on the scales. By 120 minutes after ketamine dosing, she no longer had suicidal thoughts and noted a significant improvement in her depression and anxiety. S.B. expressed hope for the future and no longer felt irritable. She became much more engaging, desiring to talk about television shows and soap operas. Over the ensuing week, her appetite had improved dramatically. Her affect remained euthymic and she stated “I feel relaxed.” The overt signs of anxiety and irritability she displayed prior to ketamine dosing were absent. She had paid and filed away her entire pile of bills. Her caregiver reported that S.B. was much more alert and no longer “nodded off” throughout the day. Her pain and shortness of breath had also improved. S.B. did report trouble sitting still, but explained “I want to get out and do things now.” She had become less preoccupied with feeling like a burden to her roommate. Additionally, she had begun to read books again, and her caregiver noted that this was a “striking change.” Lastly, she started to call her friends and initiated planning social gatherings. Her mood and anxiety showed further improvement over the subsequent week. Her caregiver commented to the research team “thank you for giving me my friend back.”
S.B. was followed clinically for several months. After a month, significant depressive symptoms returned, but not as severe as prior to ketamine dosing. Both S.B. and her caregiver requested a repeat dose. Her clinical picture at this time was complicated by delirium likely secondary to pain medication adjustments; however, she was given a repeat dose of ketamine to which she did not respond. Her mood and anxiety were eventually stabilized with bupropion XL, gabapentin, and a stable pain medication regimen.