Ketamine Self-Medication in a Patient with Autism Spectrum Disorder and Comorbid Therapy-Resistant Depression

In this case report, we present an adult male patient with autism spectrum disorder and a comorbid (treatment-resistant) mood disorder with suicidality. He has been treated with numerous psychopharmaceuticals, most recently risperidone and valproic acid. He has been hospitalized several times and has attempted suicide. He displayed limited social functioning, repetitive behaviors, sensory hypersensitivity, anxiety, depressed mood, anhedonia, low energy, and chronic suicidality. Despite intensive treatment, he remained highly symptomatic and unable to work. After repeatedly self-medicating with ketamine, the patient reported that his depression and suicidality disappeared and that his autism spectrum disorder symptoms were reduced. This case study – along with previous clinical studies – suggests that ketamine is likely to be effective against depression and suicidality and potentially effective against (certain) autism spectrum disorder symptoms. However, increasing public awareness of the beneficial effects of ketamine may lead to more unsupervised and thus risky use of ketamine for self-medication

International consensus statement for the screening, diagnosis, and treatment of adolescents with concurrent attention-deficit/hyperactivity disorder and substance use disorder

$\bf Background:$ Childhood attention-deficit/hyperactivity disorder (ADHD) is a risk factor for substance misuse and substance use disorder (SUD) in adolescence and (early) adulthood. ADHD and SUD also frequently co-occur in treatment-seeking adolescents, which complicates diagnosis and treatment and is associated with poor treatment outcomes. Research on the effect of treatment of childhood ADHD on the prevention of adolescent SUD is inconclusive, and studies on the diagnosis and treatment of adolescents with ADHD and SUD are scarce. Thus, the available evidence is generally not sufficient to justify robust treatment recommendations. $\bf Objective:$ The aim of the study was to obtain a consensus statement based on a combination of scientific data and clinical experience. $\bf Method:$ A modified Delphi study to reach consensus based upon the combination of scientific data and clinical experience with a multidisciplinary group of 55 experts from 17 countries. The experts were asked to rate a set of statements on the effect of treatment of childhood ADHD on adolescent SUD and on the screening, diagnosis, and treatment of adolescents with comorbid ADHD and SUD. $\bf Results:$ After 3 iterative rounds of rating and adapting 37 statements, consensus was reached on 36 of these statements representing 6 domains: general ($\it n$ = 4), risk of developing SUD ($\it n$ = 3), screening and diagnosis ($\it n$ = 7), psychosocial treatment ($\it n$ = 5), pharmacological treatment ($\it n$ = 11), and complementary treatments ($\it n$ = 7). Routine screening is recommended for ADHD in adolescent patients in substance abuse treatment and for SUD in adolescent patients with ADHD in mental healthcare settings. Long-acting stimulants are recommended as the first-line treatment of ADHD in adolescents with concurrent ADHD and SUD, and pharmacotherapy should preferably be embedded in psychosocial treatment. The only remaining no-consensus statement concerned the requirement of abstinence before starting pharmacological treatment in adolescents with ADHD and concurrent SUD. In contrast to the majority, some experts required full abstinence before starting any pharmacological treatment, some were against the use of stimulants in the treatment of these patients (independent of abstinence), while some were against the alternative use of bupropion. $\bf Conclusion:$ This international consensus statement can be used by clinicians and patients together in a shared decision-making process to select the best interventions and to reach optimal outcomes in adolescent patients with concurrent ADHD and SUD