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Ketamine for Bipolar Depression

By Raquel Bennett*, Christian Yavorsky and Gary Bravo

Bipolar disorder (type 1) is a serious and chronic psychiatric illness that can be difficult to treat. Many bipolar patients have refractory depressive episodes.

Racemic ketamine, a glutamate modulator with prominent dissociate and psychedelic properties, has been demonstrated to have rapid acting antidepressant and anti-obsessional effects which may be useful for treating the symptoms of bipolar depression. Most of the existing research literature on unipolar and bipolar depression has looked at racemic ketamine in the sub-psychedelic dose range given by infusion as a stand-alone treatment (without concurrent psychotherapy).

This article expands on the existing research by articulating three different paradigms for ketamine treatment: biochemical, psychotherapeutic, and psychedelic. The authors use composite clinical vignettes to illustrate different ways of working with ketamine to treat bipolar depression, and discuss a variety of clinical considerations for using ketamine with this population, including route, dose, frequency, chemical mitigators, and adverse events.

Note that the conceptual paradigms could be applied to any ketamine treatment, with broad applicability beyond bipolar treatment.

 

Introduction

Bipolar disorder (type 1) is a serious and chronic mood disorder that affects nearly 3% of the population globally (1). It is associated with high rates of disability, suicidal ideation, and completed suicides (2). Conventional treatment for this population typically includes oral antidepressant and mood stabilizing or antipsychotic medication, and possibly anxiolytic or hypnotic medications (3). Even with these medications, many patients with bipolar disorder (type 1) struggle with refractory and recurrent depressive episodes (4). Further, the medications can cause bothersome side effects which interfere with patient compliance. In other words, the medications that are widely used at this time may not sufficiently meet the needs of these individuals (5).

Ketamine treatment may be helpful in addressing…