Introduction: Suicidal ideation is an emergent problem in the Emergency Department (ED) that often complicates patient disposition and discharge. It has been shown that ketamine possesses fast acting antidepressant and anti-suicidal effects. This study was conducted to examine the effects of a single intravenous bolus of ketamine on patients with suicidal ideations in ED. Methods: Forty-nine subjects with suicidal ideations with or without an unsuccessful suicide attempt, received 0.2 mg/kg of ketamine. Scale for suicidal ideation (SSI) and Montgomery-Abserg depression rating scale (MADRS) were evaluated before and 40, 80 and 120 minutes after drug intervention. The results were compared using the paired t-test and patients were followed up 10 days after ED admission for remnant suicide ideation. Results: SSI (df: 3, 46; F=80.7; p&lt;0.001) and MADRS (df: 3, 46; F=87.2; p&lt;0.001) scores significantly dropped after ketamine injection; the SSI score before and after 20, 40, and 80 minutes of ketamine injection were 23.0±6.7, 16.2±5.2, 14.3±4.3, and 13.6±4.0 respectively. The MADRS scores were 38.2±9.3, 25.6±7.1, 22.7±6.3, and 22.1±5.95 at the same time intervals. 25.5% of patients were hospitalized, 63.3% received medications and 12.2% discharged. 6.2% of patients had suicidal ideations ten days after ED disposition.  Conclusion: It seems that Ketamine couldn't be a good choice for fast reduction of suicidal ideations in ED patients. Further studies are needed to determine the optimal dose of ketamine for different patients

Amini, Afshin

Hatamabadi, Hamid Reza

Heidari, Kamran

Kashani, Parvin

Younesian, Somaie

Yousefian, Shiva

English

PubMed

Journals Portal, Shahid Beheshti University of Medical Sciences

   This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  36 Emergency (2014); 2 (1): 36-39  ORIGINAL RESEARCH   The Effect of Intravenous Ketamine in Suicidal Ideation of Emergency  Department Patients  Parvin Kashani1, Shiva Yousefian1, Afshin Amini1, Kamran Heidari1, Somaie Younesian1,  Hamid Reza Hatamabadi1, 2* 1. Department of Emergency, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2. Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran  Abstract Introduction: Suicidal ideation is an emergent problem in the Emergency Department (ED) that often compli-cates patient disposition and discharge. It has been shown that ketamine possesses fast acting antidepressant and anti-suicidal effects. This study was conducted to examine the effects of a single intravenous bolus of ketamine on patients with suicidal ideations in ED. Methods: Forty-nine subjects with suicidal ideations with or without an unsuccessful suicide attempt, received 0.2 mg/kg of ketamine. Scale for suicidal ideation (SSI) and Montgomery-Abserg depression-rating scale (MADRS) were evaluated before and 40, 80 and 120 minutes after drug interven-tion. The results were compared using the paired t-test and patients were followed up 10 days after ED admission for remnant suicide ideation. Results: SSI (df: 3, 46; F=80.7; p<0.001) and MADRS (df: 3, 46; F=87.2; p<0.001) scores significantly dropped after ketamine injection; the SSI score before and after 20, 40, and 80 minutes of ket-amine injection were 23.0±6.7, 16.2±5.2, 14.3±4.3, and 13.6±4.0 respectively. The MADRS scores were 38.2±9.3, 25.6±7.1, 22.7±6.3, and 22.1±5.95 at the same time intervals. 25.5% of patients were hospitalized, 63.3% received medications and 12.2% discharged. 6.2% of patients had suicidal ideations ten days after ED disposition.  Conclu-sion: It seems that Ketamine could not be a good choice for fast reduction of suicidal ideations in ED patients. Further studies are needed to determine the optimal dose of ketamine for different patients. Key words: Ketamine; suicide; suicidal ideation; emergency  Cite this article as: Kashani P, Yousefian S, Amini A, Heidari K, Younesian S, Hatamabadi HR. The effect of intravenous ketamine in suicidal ideation of emergency department patients. Emergency. 2014;2(1):36-9.  Introduction: 1 uicidal ideation is an emergent condition that de-mands immediate attention. It has been shown that the time between decision and attempt in pa-tients with suicidal ideations is about ten minutes (1). Various therapeutic interventions to decrease suicide risk have been proposed in serious psychiatric disor-ders for long-term suicide prevention (2, 3). While the recognition of risk factors is very important for pre-venting suicide, they fail to clarify the timing of a sus-pected suicidal behavior. It has been shown that sub-jects with mood disorders are at greater risk of suicide in the first two years after discharge (4).  On the other hand it is known that during admission in emergency department (ED), immediately after dis-charge from ED, and after starting antidepressants are the time points which the subjects are very vulnerable to suicidal ideations (5-9). Therefore, it is crucial to quickly intervene and prevent suicidal behavior in such conditions. It has also been shown that 43% of suicides                                                           *Corresponding Author: Hamid Reza Hatamabadi; Associate Professor of Emergeny Medicine Department, Imam Hossein Educational Hospital, Shahid Madani Ave, Emam Husain Sq, Tehran- Iran. Tel+98 2173432380  Fax: +98 2177557069; Email: hhatamabadi@yahoo.com Received: 29 January 2014; Accepted: 17 February 2014 occur in the first month after discharge (5). This often complicates the disposition discharge of patient in the ED. A patient with significant suicide ideation cannot be safely discharged or admitted to general wards, regard-less of the underlying medical condition.  Different interventions for decreasing the possibility of suicidal risks are effective in long term. For example, lithium, clozapine, and risperidone are used for such a condition in EDs (10-12). However, the acute pharma-cological management of suicidal risk remains compar-atively under investigation (13). Considering the crowdedness of the majority of EDs, it is often impossi-ble to offer standard care to patients with suicidal idea-tion. In such settings, use of pharmaceutical interven-tions can play an important role with a rapid effect on diminishing suicidal ideation.  Numerous studies have shown the effect of single dose of intravenous (IV) ketamine on reducing depressive symptoms in approximately 70% of major depressive disorder (MDD) patients  in 24 hours after infusion (14-18). The effects of Ketamine on reducing suicidal idea-tion in severely depressed patients have been support-ed by preliminary studies (19). Furthermore, a recent naturalistic study proved that a low-dose ketamine is S       This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  37 Kashani et al effective on reducing the suicide ideation in patients refer to the ED (20) and those who have terminal ill-ness(21).  Considering to other studies, Ketamine is a favorable choice for emergency physicians because of many rea-sons; its rapid effect as an anti-suicidal ideation causes that the patient can be discharged from the ED with early outpatient follow up. This is especially applicable in situations when an on call psychiatrist is not availa-ble. Therefore, this study was performed to reaffirm the ketamine effect on patients with suicidal ideation in the ED. Methods: Study design and setting This single-blind clinical trial was done in Emergency Department of Imam Hossein hospital from October to September 2012. Participation in the study was volun-tary and the consent form was obtained from their companions. Patients’ files were completed by the emergency physician and the information was kept strictly confidential. This research was confirmed by ethical committee of Imam Hossein hospital. Participants The patients (age over 16 years) were included in the study based on subjective expression of suicidal idea-tions or recent suicidal actions at the time of admission to the department. Subjects were excluded if a diagnosis of alcohol or substance and drug abuse was made in the past three month or if they had received any medication for two weeks before ED admission.  Intervention A single dose of ketamine hydrochloride infusion (0.2 mg/kg, over one minute) was administered to the se-lected subjects. This is the lowest dose of ketamine which has been described as effective in diminishing suicide ideation in previous studies (20, 21). Patients’ suicidal ideations were assessed by using Montgomery-Asberg Depression Rating Scale (MADRS) and Scale for Suicidal Ideation (SSI). MADRS and SSI scales were completed for all of the patients in different times as follow: before injection and 40, 80, 120 minutes after infusion. The patients’ treatment followed standard ED protocols regardless of the study results; the outcome was followed up ten days after admission by a tele-phone contact. Statistical analysis Descriptive analyses were performed by statistical software SPSS version 21.0 and graphs drawn by Excel 2013. The SSI≥4 was considered as significant suicidal ideations and SSI<4 without significant suicidal idea-tions. SSIs were compared before and after ketamine injection by paired t-test and repeated measures analy-sis of variance. The p<0.05 was considered statistically significant. Results: Forty-nine patients were included in this study. Fifty one percent of patients were female (n=25) and 49% were male (n=24). The mean age of patients was 32±10.8 years. Thirty-eight percent of patients (n=19) had a history of mental illness (bipolar and major de-pression), 30% (n=15) previous suicidal ideations, 12 % (n=6) psychiatric hospitalization, and 34% (n=17) self-injury. Table 1 shows the mean and SD of patients’ vital signs before and after injection of ketamine. Significant de-crease was observed in the values of PR (89.8±8.8 vs. 87.8±7.5; p<0.001) and RR (18.5±5.0 vs. 17.4.0±2.0 re-spectively, p=0.04) ten minutes after ketamine injec-tion. No significant difference was seen in the levels of BP (14.9±2.01 vs. 12.6±1.9; p=0.32) and O2SAT before and after ketamine injection (96.4±1.1 vs. 95.1±1.5; p=0.35). Mean and standard deviation of SSI scores before injec-tion and at 40, 80 and 120 min after ketamine injection were respectively, 23.0±6.7, 16.2±5.2, 14.3±4.3 and 13.6±4.0. The repeated measures analysis showed that the SSI scores decreased over time significantly. The most significant reduction was seen in the first 40 minutes after injection (p<0.001) but, the score main-tained a decreasing trend until 120 minutes (df: 3, 46; F=80.7; p<0.001). Mean and standard deviation of MADRS rating scales as well indicated a significant re-duction in SSI scores at the times after injection (df: 3, 46; F=87.2; p<0.001). MADRS rating scales before injec-tion of ketamine was 38.2±9.3 and at the time of 40, 80 and 120 minutes after injection were respectively 25.6±7.1, 22.7±6.3 and 22.1±5.95. Once again the high-est rate of reduction was at 40 min after the injection (p<0.001). 25.5% of patients (n=12) were hospitalized, 63.3% (n=31) received medication, and 12.2% (n=6) dis-charged. Follow-up 10 days after admission in ED showed that 85.7% of patients (n=44) did not have any suicidal thoughts, 8.2% (n=4) had hospitalized and Table 1: Vital signs measures before and after ketamine infusion  Vital signs Time of injection p Before After 10 minute Pulse rate 89.8±8.8 87.8±7.5 <0.001 Respiratory rate 18.5±5.0 17.4±2.0 0.04 Blood pressure (Systolic/Diastolic) 12.6/8.1 12.6/8.2 0.32 O2 saturation 96.4±1.1 95.1±1.5 0.35      This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  38 Emergency (2014); 2 (1): 36-39 6.1% (n=3) still had suicidal thoughts. Discussion: Suicide is one of the leading causes of death among young people especially those who have psychiatric disorders. In the past decade, many efforts have been done to prevent suicide attempts that the most im-portant one was evaluating the risk factors of suicide and ways to prevent this problem (22). Suicidal idea-tion is a medical emergency that requires immediate attention and treatment. Unfortunately, therapeutics used now for the rapid decrease in suicidal thoughts is often followed up with unpleasant consequences (23). In this study, the effect of ketamine was evaluated on 49 patients admitted in ED with suicidal ideations and ac-tions. Although suicidal ideation did not remove after ketamine injection, evaluation at 40, 80 and 120 min after infusion showed a significant reduction in SSI and MADRS scores (Figure 1 and 2). Previous studies have assessed the effect of ketamine infusion in patients with treatment-resistant depressive disorder and demon-strated rapid beneficial effects on suicidal ideation (18, 19). The results like previous studies show that keta-mine is effective in reducing suicidal ideations. Yet in our study, the SSI score 40 minutes after the injection of ketamine dropped from 23±6 to 16±5, which although is significant, still above the previously set limit of 4. This might be due to the lower dose of ketamine used in our study compared to prior ones (0.5mg/kg) (19). It means that injection of 0.2mg/kg to patients was unable to eliminate suicidal ideation.  A significant reduction was observed in the amount of RR and PR but all of the indices remained in normal limits and no danger threatened patients after injection of ketamine. The follow up of patients after ten days showed that some of them had still suicidal ideations (6.1%). This may reflect a shorter time of action for ketamine at the low dose of ketamine infusion (0.2 mg/kg) used in this study. Therefore, if such a dose were used, adjunct treatments or repeated dose maybe also needed.  It is clear that the results of current studies should be interpreted with more caution due to the small size of the population. The findings of this study showed that ketamine, as a modulating of glutaminergic system, could not be a good candidate for the quick treatment of suicidal ideations in the ED.  However, further studies should be done to confirm the findings of this and previous studies; so that the optimal dose of ketamine for different patients and its lasting impact could be determined. Limitations The main limitation of present study is the small sample size. Another limitation of this study is the lack of a con-trol group. However, because ketamine does not have any effect on suicidal ideations, this limitation did not affect the findings. Conclusion: It seems that Ketamine could not be a good choice for fast decrease of suicidal ideations in ED patients. Fur-ther studies are needed to determine the optimal dose of ketamine for different patients. Acknowledgments: We would like to thanks from emergency ward staffs of Shohadaye Hafte Tir Hospital. Conflict of interest: None Funding support: None Authors’ contributions: Parvin Kashani and Hamid Reza Hatamabadi designed the study. Shiva Yousefian and Somaie Younesian par-ticipated in data gathering. Kamran heidari analized the                 Figure 1: Scale for Suicidal Ideation (SSI) scores before and after ketamine infusion.   Figure 2: Montgomery-Abserg Depression Rating Scale (MARDS) scores before and after ketamine infusion.               This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  39 Kashani et al data. Afshin Amini followed the patients and wrote the first draft of article. All authors approved the final ver-sion of manuscript. References:  1. Deisenhammer EA, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009; 70(1):19-24. 2. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-66. 3. Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5): 563-70. 4. Gausset M, Casadebaig F, Guillaud-Bataille J, Quemada N, Terra J. [Mortality of mentally ill patients. Review of the literature]. L'Encephale. 1991;18(1):93-100. 5. Hunt IM, Kapur N, Webb R, et al. Suicide in recently disch-arged psychiatric patients: a case-control study. Psychol Med. 2009;39(3):443-9. 6. Janofsky JS. Reducing inpatient suicide risk: Using human factors analysis to improve observation practices. J Am Acad Psychiatry Law. 2009;37(1):15-24. 7. Mills PD, DeRosier JM, Ballot BA, Shepherd M, Bagian JP. Inpatient suicide and suicide attempts in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf. 2008;34(8):482-8. 8. Yeager KR, Saveanu R, Roberts AR, et al. Measured response to identified suicide risk and violence: What you need to know about psychiatric patient safety. Brief Treat Crisis Interv. 2005;5(2):121-8. 9. Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suici-dal behaviors. JAMA. 2004;292(3):338-43. 10. Baldessarini RJ, Tondo L, Davis P, Pompili M, Goodwin FK, Hennen J. Decreased risk of suicides and attempts during long‐term lithium treatment: a meta‐analytic review. Bipolar disord. 2006;8:625-39. 11. Meltzer HY, Alphs L, Green AI, et al. Clozapine treatment for suicidality in schizophrenia: international suicide preven-tion trial (InterSePT). 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The Effect of Intravenous Ketamine in Suicidal Ideation of Emergency  Department Patients

Introduction: Suicidal ideation is an emergent problem in the Emergency Department (ED) that often complicates patient disposition and discharge. It has been shown that ketamine possesses fast acting antidepressant and anti-suicidal effects. This study was conducted to examine the effects of a single intravenous bolus of ketamine on patients with suicidal ideations in ED. Methods: Forty-nine subjects with suicidal ideations with or without an unsuccessful suicide attempt, received 0.2 mg/kg of ketamine. Scale for suicidal ideation (SSI) and Montgomery-Abserg depression rating scale (MADRS) were evaluated before and 40, 80 and 120 minutes after drug intervention. The results were compared using the paired t-test and patients were followed up 10 days after ED admission for remnant suicide ideation. Results: SSI (df: 3, 46; F=80.7; p&lt;0.001) and MADRS (df: 3, 46; F=87.2; p&lt;0.001) scores significantly dropped after ketamine injection; the SSI score before and after 20, 40, and 80 minutes of ketamine injection were 23.0±6.7, 16.2±5.2, 14.3±4.3, and 13.6±4.0 respectively. The MADRS scores were 38.2±9.3, 25.6±7.1, 22.7±6.3, and 22.1±5.95 at the same time intervals. 25.5% of patients were hospitalized, 63.3% received medications and 12.2% discharged. 6.2% of patients had suicidal ideations ten days after ED disposition.  Conclusion: It seems that Ketamine couldn't be a good choice for fast reduction of suicidal ideations in ED patients. Further studies are needed to determine the optimal dose of ketamine for different patients.</p

The Effect of Intravenous Ketamine in Suicidal Ideation of Emergency Department Patients

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