Ketamine for Depression, 6: Effects on Suicidal Ideation and Possible Use as Crisis Intervention in Patients at Suicide Risk

Abstract

A growing body of literature suggests that ketamine, administered in subanesthetic doses, has early-onset antidepressant action in patients with severe and even treatment-refractory depression. Many case reports, open-label studies, and randomized controlled trials (RCTs) suggest that ketamine may have dramatic antisuicidal effects, as well. This article examines the benefits of ketamine in patients with suicidal ideation with particular focus on the findings of recent RCTs and meta-analyses. Important findings are that a single dose of ketamine is associated with antisuicidal benefits that emerge within an hour of administration and persist for up to a week. The benefits are seen in patients with mild as well as clinically significant suicidal ideation. The benefits are observed in midazolam- as well as saline-controlled trials. Effect sizes are medium to large. The improvement in suicidal ideation is only partly explained by improvement in depression severity. It is concluded that there is consistent evidence that a single dose of ketamine has dramatic antisuicidal action that emerges almost immediately after dosing and persists for at least a week. The short- and intermediate-term safety and efficacy of ketamine as a crisis intervention treatment for suicidal patients merit study. Areas that need research are outlined.

Suicide Risk in Bipolar Disorder: A Brief Review

“…Similarly, until now, the antisuicidal activity of ketamine was assessed mainly in MDD patients and only a small number of investigations have been conducted in BD patients. These have mainly positive outcomes, but further studies are needed to reveal whether ketamin has a similar antisuicidal effect in BD than in MDD [45,46,47,48,49,50,51].…”

Oral esketamine for treatment-resistant depression: rationale and design of a randomized controlled trial

“…The SHAPS assesses hedonic capacity separately from other depressive symptoms, as anhedonia represents a central construct in MDD with multiple aspects, that is often undervalued in current MDD severity measurements [46]. The Beck Scale for Suicide Ideation (BSS) is a 21-item self-report questionnaire that is used to assess the severity of suicidal ideation [47] – separately from other depressive symptoms, as ketamine might reduce suicidal ideation partly independent from its effect on MDD in general [48, 49]. Cognitive functioning is measured by the Autobiographical Memory Test (AMT), involving the presentation of 10 cue words varying in emotional valence.…”

Eradicating Suicide at Its Roots: Preclinical Bases and Clinical Evidence of the Efficacy of Ketamine in the Treatment of Suicidal Behaviors

“…However, despite the potential benefits of ketamine as a “crisis” treatment for subjects with high suicide risk [ 136 , 137 ], there are still several concerns on its use as pointed out by Nemeroff [ 138 ] in a recent Editorial published on the American Journal of Psychiatry.…”

“…However, despite the potential benefits of ketamine as a “crisis” treatment of a subjects with high suicide risk, there are still several concerns on its use and the main may be the potential abuse of this compound and the lacking of multiple large-scale trials to determine the durability and safety of long-term ketamine treatment [ 136 , 141 ].…”