Weleff Jeremy, Bryant Kelly, Kovacevich Alexsandra, Barnett Brian S
Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, EC-10 Cleveland Clinic, 9501 Euclid Ave., Cleveland, OH, USA.
Case Rep Psychiatry. 2022 Apr 26;2022:1104668. doi: 10.1155/2022/1104668. eCollection 2022.
Clinical trials have demonstrated that subanesthetic intravenous ketamine exerts antidepressant effects lasting a week or longer postinfusion, as well as antisuicidal effects starting approximately 4 hours postinfusion and lasting 72 hours or longer. These findings have generated considerable enthusiasm within psychiatry. However, reports of treatment-emergent suicide attempts and completed suicides in some patients receiving ketamine or the ketamine enantiomer esketamine have begun to emerge. Here, we contribute to the small literature on suicide-related adverse events and ketamine with an unusual case of a patient who died either by suicide or accidental death via autoerotic asphyxiation approximately four days after a ketamine infusion. . The patient was a 28-year-old man with major depressive disorder, generalized anxiety disorder, panic disorder, obsessive compulsive disorder, autism spectrum disorder without intellectual disability, attention deficit hyperactivity disorder, hypothyroidism, low testosterone, and sleep apnea referred for management of treatment resistant depression. His depression briefly remitted with ketamine, and suicidality briefly disappeared. However, these improvements were short-lived. Four days after his seventh and final scheduled ketamine infusion, the patient was found dead, presumably due to autoerotic asphyxiation. Interestingly, ketamine use has been reported in association with autoerotic asphyxiation. However, given our patient's recent severe suicidality, methods of his past suicide attempts, and family history of suicide, death from suicide seems more likely. . Here we consider the possibility of whether ketamine may have contributed to the patient's possible suicide, either via a direct worsening of his suicidality or psychological withdrawal following cessation of treatment, given recent concerns about psychological withdrawal's potential role insuicides following esketamine treatment.
Though we are uncertain about the patient's cause of death, this case provides an opportunity to highlight important gaps in our understanding of the suicide-related risks of subanesthetic intravenous ketamine treatment for mood disorders and suicidality.
临床试验表明，亚麻醉剂量静脉注射氯胺酮可产生持续一周或更长时间的抗抑郁作用，以及在输注后约4小时开始并持续72小时或更长时间的抗自杀作用。这些发现引起了精神病学界的极大关注。然而，一些接受氯胺酮或氯胺酮对映体艾氯胺酮治疗的患者出现治疗后自杀未遂和自杀死亡的报告已开始出现。在此，我们通过一个不寻常的案例为关于自杀相关不良事件和氯胺酮的少量文献做出贡献，该患者在氯胺酮输注后约四天死于自杀或通过性窒息意外死亡。该患者为一名28岁男性，患有重度抑郁症、广泛性焦虑症、惊恐障碍、强迫症、无智力障碍的自闭症谱系障碍、注意力缺陷多动障碍、甲状腺功能减退、低睾酮血症和睡眠呼吸暂停，因难治性抑郁症的管理前来就诊。他的抑郁症通过氯胺酮短暂缓解，自杀倾向也短暂消失。然而，这些改善是短暂的。在他第七次也是最后一次预定的氯胺酮输注四天后，患者被发现死亡，据推测是由于性窒息。有趣的是，已有氯胺酮使用与性窒息相关的报道。然而，鉴于我们患者近期严重的自杀倾向、他过去的自杀未遂方法以及自杀家族史，自杀死亡似乎更有可能。在此，我们考虑氯胺酮是否可能通过直接加重他的自杀倾向或治疗停止后的心理戒断导致患者可能的自杀，鉴于近期对艾氯胺酮治疗后心理戒断在自杀中潜在作用的担忧。
尽管我们不确定患者的死因，但这个案例提供了一个机会，以突出我们在理解亚麻醉剂量静脉注射氯胺酮治疗情绪障碍和自杀倾向的自杀相关风险方面的重要差距。
