Ketamine for the Treatment of Intrusive Negative Thoughts and Suicide

Staggering Statistics in the US About Suicide

• Last year, nearly 50,000 Americans lost their lives to suicide.
• On average, there are 132 suicides per day, or approximately one death every 11 minutes.
• The rate of suicide increased by 40% in the past 20 years and continues to rise.
• Suicide is among the top nine leading cause of death for people ages 10-64.

Current Management for Suicidal Patients in the Emergency Department

The management of individuals at risk of suicide involves several key components:

1. Medical stabilization and initial medical assessment: The foremost priority for individuals who have attempted suicide is to stabilize their medical condition, addressing any physical injuries or drug ingestion. Medical interventions may involve decontamination and the administration of antidotes. A "focused medical assessment," often conducted by an emergency department (ED) physician, includes a history and physical examination, and may encompass tests such as toxicologic screening.
2. Assessment and reduction of immediate risk: A risk assessment is carried out to determine the level of care needed. Typically, individuals with recent suicidal behavior or an imminent high risk of suicide are recommended for inpatient hospitalization, sometimes involving involuntary admission.
3. Pharmacotherapy: Sedative medications like Haldol, lithium and specific antidepressants may be administered to promptly reduce the risk of suicide.
4. Comprehensive Assessment and Discharge Planning: More comprehensive psychiatric assessments are typically conducted by mental health consultants, such as psychiatrists, psychologists, or social workers. The patient's disposition is determined, and plans for outpatient referrals to ensure ongoing care are put in place.

While the aforementioned represents the standard approach for addressing acute suicidal crises in the emergency department, I have personally witnessed the less-than-ideal reality. Patients are placed on a "psychiatric hold" in a section of the emergency department alongside individuals facing various psychiatric emergencies, including acute psychosis. This environment can be chaotic, marked by confrontations, noise, fluorescent bright lights, and other disturbances—far from the tranquil setting conducive to easing someone out of an acute suicidal state.

Subsequently, patients are sedated, often in conjunction with other antidepressants that have a delayed onset of action. Upon awakening, they may be offered unappetizing food like a bologna sandwich while awaiting a more in-depth psychiatric evaluation by the on-call psychiatrist. It's important to note that this awaited relief is far from expedited, with patients frequently enduring waits sometimes as long as 24 hours. Understandably, this prolonged waiting period can leave patients feeling hopeless, frustrated, and occasionally reclassified as "low risk," which allows them to leave, potentially prematurely. In other instances, they simply choose to leave against medical advice—a decision that can be difficult to fault given the circumstances.

The Efficacy of Ketamine in Addressing Suicidal Ideation

Intravenous ketamine has shown promise as a rapid and effective treatment for suicidal ideation. Clinical studies have shown that a single ketamine infusion can reduce suicidal thoughts within just one hour. Those receiving ketamine achieved full remission of suicidal ideas at a rate of 63% by day three, and remission rates remained high (70%) at week six.  It is worth noting that the nasal form of ketamine, Esketamine, is FDA-approved for unipolar major depression that includes acute suicidal ideation or behavior. However, it is important to highlight that there is a lack of high-quality studies demonstrating Esketamine's ability to prevent suicide or suicidal behavior, and the evidence supporting its effectiveness in improving suicidal ideation is limited. Intravenous ketamine allows for a more consistent and rapid response and is thus the preferred from of ketamine for suicidal ideation.

One of the notable aspects of ketamine's effectiveness is its speed of action. Unlike traditional antidepressants that can take weeks to start working, ketamine can often produce a rapid reduction in suicidal thoughts within hours or even minutes after administration. This quick onset of action can be crucial in emergency situations where immediate relief is needed to prevent self-harm or suicide attempts.

Real-World Examples of Ketamine for Negative Thoughts

It never ceases to amaze me how ketamine's immediate effects can eliminate negative self-talk in my patients. Ketamine's impact is so strikingly evident that one can't help but feel immense hope and appreciation for, what I believe, is a gift in the field of mental health. A recurring experience after a ketamine infusion includes a feeling of hope and self-love. Witnessing the ‘dark cloud’ lift from my patients is an experience I hold dear. As one former patient put it best,

"Love is everything. I'm back! I'm going to be okay, no, I'm going to be more than just okay."

What I often observe with my patients after their initial evaluation is that they are often well-informed about what they "should do" to feel better, yet they lack the energy, motivation, and willpower to help themselves. They feel stuck and need something to trigger a significant shift in their thought processes regarding their current situation and outlook on life. Ketamine offers them that stark change in perception and a gleaming glimmer of hope that they will be more than "just okay."

Exploring the Future of Ketamine

My hope is that ketamine will be offered as an initial treatment approach during acute suicidal crises, as witnessed on the frontlines in the emergency department. I envision a future where suicidal patients receive ketamine infusions instead of being held against their will and sedated as a form of ‘help’.

Secondly, I hope for a future where ketamine is accessible to more than just those who can afford it in the outpatient setting. People in lower socioeconomic statuses suffer just as much, if not more, than those with expendable income. We need to think on a larger scale and consider how improvements in mental health for the masses will have a positive impact on humanity.

Final Thoughts

As we approach the end of the year, let's take a closer look at ketamine as a valuable tool for tackling this affliction that affects millions. Ketamine provides a rapid and effective means to eliminate negative self-talk and thoughts of self-harm. However, it is crucial for individuals experiencing such thoughts to seek comprehensive care from mental health professionals who can assess their unique needs and provide appropriate interventions. Please consider Innerbloom and our team as a source of hope for a brighter future filled with self-love.