A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience
Issue link: http://innovationscns.epubxp.com/i/796206
[ V O L U M E 1 4 , N U M B E R 1 – 2 , J A N U A R Y – F E B R U A R Y 2 0 1 7 ] Innovations in CLINICAL NEUROSCIENCE 57 and neurologic deterioration, following E CT are still unclear. 4 ,5,7,8 Ketamine, a N-methyl-D-aspartate (NMDA) receptor antagonist emerged as a potential treatment of mood disorders with rapid and sustained a ntidepressant effect. 9 A t low doses for antidepressant treatment, side effects associated with ketamine include perceptual disturbances, confusion, blood pressure elevation, euphoria, dizziness, and increased libido, but these symptoms usually resolve within 80 minutes after ketamine infusion. 10 We present a case of a patient with MS and TRD. She was initially considered for ECT after not responding to oral antidepressants, but her depression was successfully treated with intravenous ketamine. Shehad maintenance of the recovery from depression over two years with significant reduction of her depressive symptoms. This observation suggests a potential alternative to ECT in treating TRD in a patient with MS. CASE REPORT In September 2007, a 45-year-old woman was referred to psychiatry for worsening depressive symptoms. She had been diagnosed with MS in 2004, presenting with initial symptoms of left arm and hand numbness. Her magnetic resonance imaging (MRI) scan revealed 4 to 5 periventricular white matter lesions and an anterior cervical involvement at C5. She had two exacerbations of her symptoms during the following three months, fulfilling the diagnosis criteria of relapsing remitting MS, and was enrolled in the Beyond medication trial (ID: NCT00099502), using betaseron, in January 2005. The Beck Depression Inventory (BDI) was used for evaluating her level of depression. At screening for the trial ,the patient's BDI score was 18, corresponding to borderline clinical depression. She worsened to moderate depression (23 on BDI) by May 2005, but continued her participation in the trial until fall of 2006, when she was diagnosed with MDD. Prior to referral to psychiatry, she was treated with paroxetine, but it did not improve her mood. From the end of her participation in the Beyond trial to her time of presentation, she did not have any relapses in her MS symptoms, and her MRI and neurologic examinations were stable. Her depression, however, continued to worsen. Between 2007 and 2014, she received courses of five different oral antidepressants (desipramine, venlafaxine, mirtazapine, paroxetine, and buproprion). She had augmentation of the antidepressants without benefit. In January 2014, she requested ECT from psychiatry due to apparent TRD. Due to concern for her neurologic condition and potential risk of worsening her MS symptoms, ketamine treatment was discussed and initiated as an alternative to ECT. Our clinic has more than eight years of experience in treating TRD with ketamine. 11,12 The treatment protocol includes an initial series of six treatments administered every other day, followed by a maintenance schedule starting with a weekly treatment and tapering to one treatment every three weeks. 11 Ketamine is administered intravenously at 0.5mg/kg of ideal body weight over 40 minutes. The longitudinal observation of depression symptoms (measured by BDI) in response to ketamine treatments in this patient is shown in the Figure 1. She received her first treatment in January 2014, and was followed for two years using our established protocol. Her BDI score before initiation of the treatment was 38, corresponding to severe depression. Response to treatment, defined as 50-percent reduction in BDI scores, was observed after the fifth treatment (Day 10) with a BDI score of 19, corresponding to borderline clinical depression. The calibration of treatment frequency for maintenance schedule began two weeks after ketamine treatment initiation. For this patient ,the maintenance schedule ranged from one weekly treatment to one treatment every three weeks. During the maintenance period, the BDI scores ranged between 5 and 16, corresponding to non-depressed state. FIGURE 1. This figure illustrates the longitudinal observation of depression symptoms using Beck Depression Inventory (BDI) in response to ketamine treatment in one patient with multiple sclerosis and treatment-resistant depression. The horizontal dashed line represents BDI score consistent with clinical depression (BDI score=18). Vertical hash marks indicate treatment days. The shaded area shows BDI scores consistent with none-depressed state.