Magazine article Clinical Psychiatry News

Use MADRS to Dose Ketamine for Depression

Magazine article Clinical Psychiatry News

Use MADRS to Dose Ketamine for Depression

Article excerpt

NEW ORLEANS -- Ketamine infusions are becoming more and more routine for refractory depression, but the literature is just not clear about the optimal treatment regimen.

Studies have run the gamut from daily, to weekly, to monthly infusions, with scant information on how to predict who will respond and how to maintain response.

Investigators from the ChathamKent Clinical Trials Research Centre in Chatham, Ont., have found a solution. They dose ketamine based on Montgomery-Asberg Depression Rating Scale (MADRS) scores. The approach has led to marked improvements in 19 of 44 patients (43%), with remissions sustained for up to 74 weeks and counting, according to a report at the American Psychiatric Association's Institute on Psychiatric Services.

"Almost everybody feels significantly better an hour after the infusion. The question is how long will they continue to feel better, and how to find the ones who will stay well. That's what we've tried to answer here," said principal investigator and psychiatrist Ranjith Chandrasena, MD, the research center's scientific director.

Ketamine is dosed at 0.5 mg/kg IV over 45 minutes, delivered in an ambulatory care center under the supervision of a respiratory therapist and a physician assistant, with vital signs monitored every 10 minutes. Patients are cleared ahead of time for anesthesia, since ketamine at higher doses is an anesthetic.

In the induction phase, patients are offered up to three ketamine infusions weekly; if MADRS scores don't remain below 16 points a month after the last induction dose, ketamine is judged to be ineffective, and the patient is taken off the protocol. A score below 16 "pretty much translates to normal functioning," Dr. Chandrasena said.

Patients who remain below 16 points a month after their last induction dose are moved onto maintenance and qualify for repeat infusions when their MADRS creeps above 16 points, so long as it's stayed below 16 for a month or more in the interim. …

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