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17: Brief Contact Interventions

Risk Management and Treatment » Pharmacologic and other Somatic Treatments
12 & 13: Ketamine Infusion to Reduce Suicide Ideation & Ketamine or Esketamine to Reduce Suicide or Suicide Attempts

12

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

Strength:

Weak for

Category:

ReviewedNot-changed

13

There is insufficient evidence to recommend for or against ketamine infusions or esketamine to reduce the risk of suicide or suicide attempts.

Strength:

Neither for nor against

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 short-term reduction in suicidal ideation in patients with the presence of suicidal ideation and major depressive 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 and Clinical Resources

This section includes recommended trainings and/or clinical resources about ketamine.

VA Ketamine Resources
OMSHP Ketamine and Esketamine SharePoint (requires access to VA networks)
Somatic Treatment Community of Practice SharePoint (requires access to VA networks)
CPG for Management of Major Depressive Disorder (MDD) (2022)
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Manuals

This section includes recommended implementation manuals about ketamine.

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

This section includes recommended webinars about ketamine.

VA TMS Webinar Evidence of Esketamine Efficacy and Safety Presented by Drs. Gerard Sanacora & Tobias Martin
VA TMS WebinarThe History & Science Behind Ketamine and Esketamine Treatment for Mental Health Conditions Presented by Dr. Gerard Sanacora
CPG Webinar Ketamine and Esketamine Treatment: Implications for VA Suicide Preventions Presented by Drs. Deborah Yurgelun-Todd & Perry Renshaw
CPG Webinar Ketamine for Depression and Suicide Prevention in VA Presented by Dr. Eric Hermes
CPG Webinar The Status of VA Ketamine & Esketamine Services and Implications for Suicide Prevention Presented by Dr. Ilse Wiechers
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Podcasts

This section includes podcasts about ketamine.

Podcast Icon Episode 45: Ketamine for suicidal ideation Office of the Chief Medical Officer of the City of Austin, Texas (wordpress.com)
Podcast Icon Podcast 584: Ketamine for Depression and Suicidality by Emergency Medical Minute | Podchaser
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Articles

This section includes recommended articles about ketamine.

Abbar, M., Demattei, C., El-Hage, W., Llorca, P. M., Samalin, L., Demaricourt, P., Gaillard, R., Courtet, P., Vaiva, G., Gorwood, P., Fabbro, P., & Jollant, F. (2022). Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial. BMJ (Clinical research ed.), 376. e067194. https://doi.org/10.1136/bmj-2021-067194
Dean, R. L., Hurducas, C., Hawton, K., Spyridi, S., Cowen, P. J., Hollingsworth, S.,Marquardt, T., Barnes, A., Smith, R., McShane, R., Turner, E. H., & Cipriani, A. (2021). Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder. The Cochrane database of systematic reviews, 9(9). CD011612. https://doi.org/10.1002/14651858.CD011612.pub3
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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