Ketamine Infusion After Suicide Attempt: New Frontiers in Treating Acute Suicidality in a "real world" Medical Setting

Friday, November 12, 2021

4:00 PM – 5:00 PM US Eastern Time

Background/Significance: Suicide is a devastating public health crisis with few available treatments which quickly reduce the intensity of suicidality. In controlled, outpatient research settings, ketamine rapidly reduces suicidal thoughts as early as 2-24 hours after a single infusion in patients with high suicide risk (Price 2014) ( Murrough 2015). In this IRB approved pilot study, we investigated ketamine’s effects on suicidality in a real-world sample of recent suicide attempters at imminent risk of suicide on a tertiary-care Consultation-Liaison (CL) psychiatry service. Through administration of a “pre-treatment” prior to psychiatric hospital transfer, we hypothesized ketamine would rapidly impact suicidal ideation in patients who attempted suicide and synergistically confer enduring benefits to behavioral therapies.

Methods: In an open-label design, we recruited 16 transdiagnostic patients,18-65 years old to receive a single dose of intravenous ketamine (0.5 mg/kg) in the acute medical setting, after CL consultation and informed consent. All were psychiatrically hospitalized post-infusion. Baseline suicidality and depression measures [Columbia Suicide Severity Rating Scale, Montgomery-Asberg Depression Rating Scale, Adult Suicide Ideation Questionnaire, hopelessness (via Cognitive Triad Inventory)] were compared to 24-hours, 5-days, 12-days, and 1- and 3-months post-infusion using paired t-tests.

Results: Across all measures, rapid, statistically significant decreases (p’s< .001) were observed with large to very large effect sizes (Cohen’s d’s: 1.7-8.8) at acute timepoints (24-hour; 5-day). These large gains were also uniformly maintained during follow-up, continuously out to 3-months post-infusion.

Discussion: Ketamine rapidly and robustly reduced suicidal symptoms in an ultra-high-risk, heterogeneous, “real world” sample. Combined with standard care, ketamine might also synergistically enhance the durability of benefit observed following discharge, consistent with a growing literature examining ketamine as a pre-treatment to behavioral therapies ( Dakwar 2020). In forthcoming analyses, we will compare 6- and 12-month rates of suicide re-attempt and re-hospitalization in ketamine-treated patients to a matched case-control sample of suicide attempters who did not receive ketamine pre-treatment.

Conclusion/Implications: Ketamine infusion is a safe, feasible, and viable method to rapidly reduce suicidality among patients admitted to the medical hospital after suicide attempt, and could also have enduring benefits. By advancing knowledge of novel treatment methods in real-world clinical services through completion of further studies, ketamine could become an important and novel tool in the treatment of high-risk CL patients.

References:

Murrough, J. W. et al. (2015). Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med, 45(16), 3571-3580.

Price, R. B. et al. (2014). Effects of ketamine on explicit and implicit suicidal cognition: a randomized controlled trial in treatment-resistant depression. Depress Anxiety, 31(4), 335-343.

Dakwar E. et al. (2020). A single ketamine infusion combined with motivational enhancement therapy for alcohol use disorder: A randomized, midazolam-controlled pilot trial. Am J Psychiatry, 177(2),125-133.

Learning Objectives:

Consider limitations of conventional treatments for high-risk suicidal patients on a consultation liaison psychiatry service
Navigate challenges of conducting a research study in a "real world" medical setting
Understand the role of ketamine as a novel treatment for depression and suicidal ideation

Presenting Author(s)

Sharvari Shivanekar, M.D.

Assistant Professor of Psychiatry
University of Pittsburgh
Pittsburgh, Pennsylvania, United States

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Co-Author(s)

Priya Gopalan, MD, FACLP

Associate Professor of Psychiatry
University of Pittsburgh Medical Center, Western Psychiatric Hospital
Pittsburgh, Pennsylvania, United States
Shelly Kucherer, MD

Assistant Professor of Psychiatry
University of Pittsburgh School of Medicine, Western Psychiatric Hospital
Pittsburgh, Pennsylvania, United States
AI

Alex Israel, MD

Assistant Professor of Psychiatry
UPMC Western Psychiatric Hospital
Pittsburgh, Pennsylvania, United States
CS

Crystal Spotts, MEd

Study Coordinator
Western Psychiatric Hospital
Pittsburgh, Pennsylvania, United States
BP

Benjamin Panny, BS

RA
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, United States
AG

Angela Griffo

Research Specialist
University of Pittsburgh
Pittsburgj, Pennsylvania, United States
NC

Nicolas Cruz, EdM

Senior Research Associate
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, United States
ML

Michael Lightfoot, MA

Senior Clinician
University of PIttsburgh
Pittsburgh, Pennsylvania, United States
RR

Rebecca Rohac

Research Specialist
University of Pittsburgh
Pittsburgh, Pennsylvania, United States
AB

Andrew Baumeister

Research Specialist
University of Pittsburgh
Pittsburgh, Pennsylvania, United States
Manivel Rengasamy, MD

Postdoctoral Fellow
University of PIttsburgh
Pittsburgh, Pennsylvania, United States
Anthony Pizon, MD

Chief of Medical Toxicology, Professor of Emergency Medicine
University of Pittsburgh Medical Center
PITTSBURGH, Pennsylvania, United States
RP

Rebecca Price, PhD

Associate Professor of Psychiatry and Psychology
University of Pittsburgh
Pittsburgh, Pennsylvania, United States