Treatment of Suicidal Depression with Ketamine in Rapid Cycling Bipolar Disorder

Despite rapid advances in understanding the neuro­biology of bipolar disorders, rapid cycling states con­tinue to be the Achilles heel for psychiatrists. This is due to their elusive presentation, poor treatment response, frequent recurrences, high suicidality and overall poor prognosis (Wu and Dunner, 1993; Coryell et al., 2003; Nierenberg eta!., 2010). The management of rapid cyclers, especially in the acute depressive phase with antidepressants remains a challenge, due to antidepres­sant induced mood switches (hypomanic, manic and mixed) and fear of worsening the overall course of illness (Ghaemi eta/., 2003). The scenario becomes more complicated in the setting of severe depression with suicidality, where electroconvulsive therapy is the only recommended treatment (Srisurapanont et al., 1995).

However, non availability, prohibitive costs, negative public perceptions and stigma limit the utility of electroconvulsive therapy (ECT) in clinical settings (Rose et al., 2003).

Ketamine, a widely used anaesthetic agent and N-methyl-D-aspartate receptor (NMDA) antagonist offers a way out of this conundrum with its rapid antidepressant and antisuicidal effects with better efficacy and tolerability. We present a case of a 19-year­old female with rapid cycling bipolar depression admit­ted aft.er a suicide attempt, successfully treated with ketamine when she failed to improve with standard treatment.