Although some authors1,6 advise caution with widespread ketamine use, patients with TRD want effective treatments and may discount these warnings. Even though longer-term studies are needed, ketamine “infusion clinics” are already being established. Before referring patients to such clinics, it is important to understand the current clinical and safety limitations and requirements for ketamine in TRD and to consider and discuss the risks and benefits carefully.
CASE CONTINUED
Because Ms. B has tried several antidepressants and adjunctive therapies without success, and her depression is severe enough to affect her functioning in several domains, it might be reasonable to discuss a trial of ketamine. However, Ms. B also should be presented non-ketamine alternatives, such as other adjunctive strategies (liothyronine, buspirone, cognitive-behavioral therapy) or a trial of nortriptyline or a monoamine oxidase inhibitor.
If ketamine is thought to be the best option for Ms. B, her provider needs to establish a clear expectation that the effects likely will be temporary. Monitoring should include applying a rating scale to assess depressive symptoms, suicidality, and psychotomimetic symptoms. During and shortly after infusion, anesthesia support should be provided and blood pressure and other vital signs should be monitored. Additional monitoring, such as telemetry, might be indicated.