In the end, they tried intranasal ketamine. The response was, just as you described, robust. Her self-injurious behavior dropped in a very pronounced way within a day or two. But she then did require administrations a couple of times a week in order to keep that suicidality at bay.
Based on that example, I’m wondering whether there is an application here for people who are suicidal yet who may not have features of major depression or bipolar depression.
Dr. Mann: It’s a very interesting suggestion for which we have no data-based answer. However, we have a clue from the study that we published in the American Journal of Psychiatry and have since published further analyses on.
The reasons that people die by suicide, or make suicide attempts, are not entirely attributable to the fact that they suffer from a mood disorder.
Dr. Sederer: Yes, because only a minority of individuals with a mood disorder ever make suicide attempts. But there is a subgroup at risk.
Dr. Mann: Here at Columbia, we’ve promulgated the stress-diathesis model for suicidal behavior. A stressor could be external life events, but the internal stressor would be something like an acute episode of depression.
But predisposition also plays an important role, which has several elements to it. One is decision-making. These are patients with a propensity to go for a short-term, quick relief. In other words, a patient would be seeking immediate relief rather than waiting for the delayed improvement from an antidepressant. They’re more prone to act on the pain of the depression and terminate their lives – to try to end their pain – rather than wait and hope that, in time, there’s a chance that the antidepressant will work.
Dr. Sederer: What else do you want to share with our viewers about this medication and how it’s used?
Dr. Mann: My goal in treating patients is to try to use the least amount of medication possible. We do not really know yet the long-term safety of ketamine treatment.
It’s been used for many decades in anesthesia, but people don’t get repeated anesthetic doses of ketamine. And higher doses of ketamine given repeatedly have been shown in preclinical studies to produce little lesions in the brain, which is not good. But we’re using much lower doses.
As we potentially move into a time when we could be giving multiple doses of ketamine to patients, we should remember that we need to be cautious about that. If we don’t need to give them more doses, we shouldn’t. We should know that there is a potential downside that we don’t fully understand yet to giving ketamine repeatedly.
And that’s aside from its abuse potential. We know that people have employed ketamine for physical and emotional pain, and when they administer it themselves, they tend to get dependent on it. In a clinic setting it’s given in a very formal and structured fashion, a bit like the administration of opioids. In that setting, it is much safer and the risk for abuse and diversion is minimized. But we need to remember that this drug does have abuse potential and perhaps not yet fully measurable neurotoxic effects.
Dr. Sederer: If physicians, nurses, and other professional clinicians want to learn more about this medication, what are the accurate, reliable sources of information to which you suggest they turn?
Dr. Mann: The National Institute of Mental Health’s website offers good and reliable information for patients and their families. It is an unbiased, scientific, and thoughtful source of information, and better than just trolling the Internet for information.
People are much more sophisticated now than they were 20 years ago in these matters, and scientific papers are much more accessible to the public. Reading papers in recognized journals is also a useful way to gain information.
For example, one of the major papers that we published in the American Journal of Psychiatry is available to anybody on the Internet to read. So, I encourage people to make their own inquiries and talk to more than one doctor. Informed patients and families are the best partners a doctor can ever have. We encourage that in all of our patients.
Dr. Sederer: I want to thank you very much, Dr. Mann, for your work in this area and for joining us here at Medscape and Columbia Psychiatry to teach us so much about what is truly a novel psychopharmacologic agent, yet one where we still have a lot more to learn.
A version of this article originally appeared on Medscape.com.