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10: Ketamine Infusion

Risk Management and Treatment » Pharmacologic Treatments
10: Ketamine Infusion

In patients with the presence of suicidal ideation and major depressive disorder, we suggest offering ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation.

Strength:

Weak for

Category:

ReviewedNew-added

Grades and Definitions

Strong for
or "We recommend offering this option …"
Weak for
or "We suggest offering this option …"
No recommendation
or "There is insufficient evidence …"
Weak against
or "We suggest not offering this option …"
Strong against
or "We recommend against offering this option …"

Categories and Definitions

Evidence Reviewed* Recommendation Category* Definition*
Reviewed New-added New recommendation following review of the evidence
New-replaced Recommendation from previous CPG that has been carried over to the updated CPG that has been changed following review of the evidence
Not changed Recommendation from previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed but the recommendation is not changed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed based on review of the evidence
Not reviewed Not changed Recommendation from previous CPG that has been carried forward to the updated CPG, but for which the evidence has not been reviewed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has not been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed because it was deemed out of scope for the updated CPG
*Adapted from the NICE guideline manual (2012): The guidelines manual. London: National Institute for Health and Care Excellence;2012. and Martinez Garcia L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated recommendations: An assessment of NICE clinical guidelines. Implement Sci. 2014;9:72.

Recommendation Resources

Ketamine is a rapid-acting general anesthetic that can be used as an adjunctive treatment for patients with suicidal ideation and major depression disorder. Ketamine infusion as a single small dose has shown moderate evidence for acute symptom improvement of suicidal ideation within 24 hours of treatment. Additionally, this moderate effect continues from one week and even up to six weeks. Considering the potential risk of addiction, continued repeat administration of ketamine is not recommended. Additionally, there is no evidence to support repeated administration for persistent suicidal ideation.

Training Resources

This section includes links to training resources about ketamine infusion as an adjunctive treatment for patients with suicidal ideation and major depression disorder.

Community Ketamine Resources
Spravato REMS materials
  • All of the SPRAVATO™ REMS materials are available here
  • Power Point presentation summarizing the key aspects of the SPRAVATO™ REMS and VHA-specific considerations can be found here
VA Ketamine Resources
OMSHP Ketamine and Esketamine SharePoint (requires access to VA networks)
Somatic Treatment Community of Practice SharePoint (requires access to VA networks)
Academic Detailing Service Depression SharePoint page (requires access to VA networks)
CPG for Management of Major Depressive Disorder (MDD) (2022)
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Manuals

This section includes links to treatment and/or implementation manuals or resources about ketamine infusion as an adjunctive treatment for patients with suicidal ideation and major depression disorder.

2022 National Protocol Guidance: Ketamine Infusion for Treatment Resistant Depression and Severe Suicidal Ideation
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Webinars

This section includes links to webinars that are recommended about ketamine infusion as an adjunctive treatment for patients with suicidal ideation and major depression disorder.

CPG Webinar The Status of VA Ketamine & Esketamine Services and Implications for Suicide Prevention Presented by Dr. Ilse Wiechers
CPG Webinar Ketamine and Esketamine Treatment: Implications for VA Suicide Preventions Presented by Drs. Deborah Yurgelun-Todd & Perry Renshaw
VA TMS Webinar History & Science Behind Ketamine and Esketamine Treatment for MH Conditions Presented by Dr. Gerard Sanacora (VA course TMS #41757)
VA TMS Webinar Evidence of Esketamine Efficacy and Safety Presented by Drs. Gerard Sanacora & Tobias Martin (VA course TMS #41758)
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Articles

This section includes links to recommended articles about ketamine infusion as an adjunctive treatment for patients with suicidal ideation and major depression disorder.

Fan, W., Yang, H., Sun, Y., Zhang, J., Li, G., Zheng, Y., & Liu, Y. (2017). Ketamine rapidly relieves acute suicidal ideation in cancer patients: a randomized controlled clinical trial. Oncotarget, 8(2), 2356-2360. https://doi.org/10.18632/oncotarget.13743
Grunebaum, M. F., Galfalvy, H. C., Choo, T. H., Keilp, J. G., Moitra, V. K., Parris, M. S., Marver, J. E., Burke, A. K., Milak, M. S., Sublette, M. E., Oquendo, M. A., & Mann, J. J. (2018). Ketamine for Rapid Reduction of Suicidal Thoughts in Major Depression: A Midazolam-Controlled Randomized Clinical Trial. The American journal of psychiatry, 175(4), 327-335. https://doi.org/10.1176/appi.ajp.2017.17060647
Wilkinson, S. T., Ballard, E. D., Bloch, M. H., Mathew, S. J., Murrough, J. W., Feder, A., Sos, P., Wang, G., Zarate, C. A., Jr, & Sanacora, G. (2018). The Effect of a Single Dose of Intravenous Ketamine on Suicidal Ideation: A Systematic Review and Individual Participant Data Meta-Analysis. The American journal of psychiatry, 175(2), 150-158. https://doi.org/10.1176/appi.ajp.2017.17040472
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Podcasts

This section includes links to recommended podcasts that are relevant to ketamine infusion as an adjunctive treatment for patients with suicidal ideation and major depression disorder.

Episode 45: Ketamine for suicidal ideation

Office of the Chief Medical Officer of the City of Austin, Texas (wordpress.com)

Podcast 584: Ketamine for Depression and Suicidality

by Emergency Medical Minute | Podchaser

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