Category: Federal Forum Posters
Purpose: Intravenous, subanesthetic-dose ketamine is a unique and potentially groundbreaking option for patients with treatment-resistant mood disorders. Rapid improvements in depression symptoms may be observed after ketamine is infused; however, patients often return to their baseline depression symptoms within days after a single ketamine infusion. Trials have shown that benefit of ketamine may be extended with continued infusions, but much remains unknown about the benefits and risks of continued therapy. The primary objective of this MUE was to evaluate the use and effectiveness of ketamine for the management of mood disorders at a Veterans Affairs medical center.
Methods: A patient lists was generated using different methods to gather a complete cohort of patients who received ketamine for a mood disorder. Data was collected from the first ever ketamine infusion through July 13, 2018 via chart review from patient electronic medical records. Baseline data was collected for each patient prior to their first ketamine infusion. Medication history was reviewed to determine if patients were receiving ketamine for a treatment-resistant disorder. Data was collected on ketamine dose and monitoring during infusions. Baseline monitoring was considered appropriate if a depression rating scale was used and documented within two weeks of the first ketamine infusion. Follow-up monitoring was considered appropriate if completed within two weeks after the first ketamine infusion. A response to therapy was defined as greater than or equal to a fifty percent improvement from baseline on a depression rating scale. Progress notes were reviewed to evaluate safety and effectiveness of ketamine.
Results: A total of 30 veterans were identified who received ketamine infusions for a mood disorder. The primary diagnosis was major depressive disorder in 22 patients, bipolar disorder in 7 patients, and schizoaffective disorder in 1 patient. The majority of patients (96.6) percent of patients were determined to have received ketamine for a treatment-resistant disorder. A Montgomery-Asberg Depression Rating Scale (MADRS) was documented in 73.3 percent of patients at baseline. Patients had a median MADRS score of 36 (interquartile range 29 to 40.5) representing severe depression at baseline. An initial dosing regimen of 0.5 mg per kilogram twice weekly was used in 96.6 percent of patients. Patients received a median number of 5 ketamine infusions (range 2 to 50). Only 4 patients had a MADRS score documented at baseline and on follow-up within the pre-specified time frame. Objective response to therapy was unable to be evaluated in 86.6 percent of patients. A subjective benefit from therapy was documented in 70 percent of patients. The majority of patients (60 percent) had no adverse effects reported related to ketamine; however, 23.3 percent of patients experienced dissociative side effects.
Conclusion: Ketamine treatment resulted in subjective improvement for a majority of patients with treatment-resistant mood disorders. Significant improvements are needed in documentation and administration of objective depression rating scales. Consistent use of validated rating scales may allow for a better assessment of patient response to ketamine infusions. A process improvement project is currently underway based on the findings of this medication use evaluation.
Christopher Wilson– Pharmacy Resident, Sheridan VA Medical Center, Sheridan, WY