Nebulized ketamine as a treatment protocol for treatment of depression in high functioning autism spectrum disorder in emergency room: A case report

Avinash. S1, Yamini kannapan2, Vidya saketharaman3

1First year MEM, Kauvery Hospital, Alwarpet, Chennai

2Consultant-Psychiatrist, Kauvery Hospital, Alwarpet, Chennai

3Emergency Physician, Kauvery Hospital, Alwarpet, Chennai

Abstract

Background

depression in individuals with autism spectrum disorder (ASD) poses unique challenges due to communication difficulties and atypical presentation of depressive symptoms. This case report details the novel use of nebulized ketamine as a treatment protocol for depression in an 18-year-old female with high functioning asd in emergency room for better monitoring and observation.

Nebulized ketamine was administered at a dose of 2mg/kg over 20 min. Following treatment, patient exhibited a marked improvement in mood and social interaction. Nebulized ketamine appears to be a promising treatment for depression in individuals with high functioning asd, facilitating rapid improvements in both mood and social engagement. Further studies are required to confirm these findings and to develop standardized treatment protocols.

Keywords: nebulized ketamine; high functioning autism spectrum disorder; depression; emergency medicine; rapid treatment; case report

Case presentation

An 18-year-old female, studying first-year under graduate degree at Chennai. Presenting with a complaint of difficulty concentrating, incomplete assignments, socialization issues, low self-esteem.

History of deliberate self-harm (DSH) since age 13, significant anxiety, and low mood.

Clinical findings: Initially non-communicative, improved eye contact and engagement over sessions reduced suicidal ideation, and pessimistic thoughts.

Diagnostic assessment: No family history of psychiatric illness. No major medical comorbidities.

  • Various psychological assessments administered:
  • Millon Clinical Multiaxial Inventory–iii (MCMI-iii),
  • International Personality Disorder Examination (IPDE),
  • Beck Depression Inventory (BDI-ii),
  •  Thematic Apperception Test (TAT)
  • Adult Asperger Assessment (AAA).

Examination

During the assessment, the patient displayed poor eye contact, social anxiety, and avoided communication with strangers or hospital employees and euthymic affect. She cooperated with assessments but provided brief answers. Test findings revealed elevated scores suggesting severe personality pathology, traits of emotionally unstable personality, and features consistent with autism spectrum disorder (ASD).

Findings

The patient exhibited characteristics of borderline personality pathology, emotionally unstable traits, and asd features. She displayed impairment in social interaction, lack of empathy, and rigid adherence to routines. Additionally, she demonstrated repetitive behaviors and sensory sensitivities consistent with ASD.

Treatment

The traditional treatment includes a multidisciplinary approach.

  • Pharmacotherapy
  • Dialectical behavioral therapy
  • Social skill training

In this patient the severity of the depression and acute risk of suicide has been assessed. A decision for nebulization of ketamine as an off label intervention  was made . We used MADRS scoring for monitoring the effects of nebulised ketamine

Who can be given ketamine therapy?

  • Treatment resistant depression
  • Depression with high risk of suicide
  • Obsessive compulsive disorder
  • Bipolar affective disorder
  • Post traumatic stress disorder
  • Migraine

Who has to avoid ketamine therapy?

  • Uncontrolled hypertension
  • Pregnancy
  • Untreated hyperthyroidism
  • Lactating mothers
  • History of substance abuse and history of psychosis

Treatment protocol for nebulized ketamine

  • Patient should be accompanied by a person for the whole day.
  • Post nebulization, patient should undergo MADRS scoring and document the results for 5 alternate day cycles.
  • Complications To Be Monitored: Tachycardia ,Nausea, Bitter Taste In The Mouth, Dizziness

Results

MADRS Scoring Pre nebulization Post nebulization
Day 12918
Day 3136
Day 5215
Day 7273
Day 9119

MADRS Scoring

  • Normal range: 0–6
  • Mild Depression: 7–19
  • Moderate Depression: 20–34
  • Severe Depression: More than 35

Discussion

Pathophysiology of nebulized ketamine in treating depression in high functioning autism spectrum disorder (ASD) with comorbid depression;

 

Review of literature

Depression and ketamine

Depression is a complex and multifactorial disorder with genetic, biochemical, and environmental components. Traditional antidepressants, such as SSRIS and SNRIS that target monoamine neurotransmitters can take weeks to become effective. In contrast, ketamine, an NMDA receptor antagonist, offers a novel mechanism of action by enhancing synaptic plasticity and connectivity, which can lead to rapid antidepressant effects [8]. This rapid response is particularly valuable in acute settings where traditional treatments may fall short.

Comparison with other case reports

The use of ketamine for depression has been increasingly documented, primarily through intravenous administration. Research, including a study by Lapidus et al. (2014), demonstrated rapid antidepressant effects with intranasal ketamine in treatment-resistant depression, providing a precedent for alternative routes of administration [7]. Our case aligns with these findings, suggesting that nebulized ketamine can also provide rapid relief, with the added benefits of ease of administration and reduced invasiveness.

Treatment options for depression

  • Traditional treatments
  • Pharmacotherapy with SSRIS, serotonin-norepinephrine reuptake inhibitors (SNRIS)
  • Psychotherapy such as CBT.
  • For treatment-resistant depression, options are more limited, and interventions like electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS) are considered.
  • Ketamine, particularly in sub-anesthetic doses, has emerged as a promising alternative for these patients. While intravenous and intranasal routes are more commonly studied, nebulized ketamine provides a less invasive and potentially more accessible option, particularly useful in the ED where rapid and effective intervention is required [10]

Morbidity and mortality

Depression carries a significant risk of morbidity and mortality, primarily due to suicide. Rapid intervention is crucial to mitigate this risk. Ketamine’s fast-acting properties can bridge the gap until traditional antidepressants take effect, potentially reducing the risk of suicide in acute settings. Studies have shown that ketamine can provide significant symptom relief within hours, which is critical in preventing suicide and stabilizing patients [11]

Acknowledgement

We extend our sincere appreciation to dr. Yamini kannapan, mbbs dpm dnb, and dr. Vidya saketharaman, consultant mem/mrcem,dr aslesha hod of emergency medicine, kauvery hospital.for their invaluable contributions and guidance to this case report.

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Dr. Yamini Kannappan

Dr. Yamini Kannappan
Consultant Psychiatrist

Dr.Vidya

Dr. Vidya Saketharaman
Consultant – Emergency Physician

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