key: cord-0692822-1sqgigqk
authors: Longpré-Poirier, Christophe; Jodoin, Véronique Desbeaumes; Miron, Jean-Philippe; Lespérance, Paul
title: “Remote monitoring of intranasal ketamine self-administration as maintenance therapy in treatment-resistant depression (TRD): a novel strategy for vulnerable and at-risk populations to COVID-19?”
date: 2020-05-05
journal: Am J Geriatr Psychiatry
DOI: 10.1016/j.jagp.2020.04.024
sha: dfa2e03f46cb0edc91fa5bbae949cf82050d36cc
doc_id: 692822
cord_uid: 1sqgigqk

Abstract This work describes a clinical case in which we used telemedicine to monitor at-home ketamine treatment in TRD. Ketamine has been shown to be a promising and safe treatment for TRD in elderly patients. However, the COVID-19 pandemic is clearly impacting the world and this disease is recognized as being particularly dangerous for the elderly and vulnerable patients. To limit the transmission of the disease, geriatric mental health specialists must be creative and ensure the safety of their patients by limiting human to human contact. This problem might be averted by massive deployment of outreach services and telemedicine strategies.

Title: "Remote monitoring of intranasal ketamine self-administration as maintenance therapy in treatment-resistant depression (TRD): a novel strategy for vulnerable and atrisk populations to COVID-19?" Christophe Longpré-Poirier M.D. 1.2.3d ., Véronique Desbeaumes Jodoin Ph.D. 1 This work describes a clinical case in which we used telemedicine to monitor athome ketamine treatment in TRD. Ketamine has been shown to be a promising and safe treatment for TRD in elderly patients. However, the COVID-19 pandemic is clearly impacting the world and this disease is recognized as being particularly dangerous for the elderly and vulnerable patients. To limit the transmission of the disease, geriatric mental health specialists must be creative and ensure the safety of their patients by limiting human to human contact. This problem might be averted by massive deployment of outreach services and telemedicine strategies.

To the editor:

On March 11, 2020, the World Health Organization (WHO) declared the new coronavirus disease (COVID-19) as a pandemic. This disease is particularly dangerous for the elderly, with older age associated with increased morbidity and mortality (1). To limit its transmission, psychiatric authorities around the world have used different strategies to transform their services, such as a massive scale-up of telemedicine.

A 61-year-old patient with TRD suffering from multiple medical comorbidities was referred to our clinic for ketamine intravenous (IV) treatment. The patient underwent an acute treatment protocol with three IV infusions of ketamine every other day over one

week. As the COVID-19 prevalence increased, strategies to prevent outpatient visits were necessary. For the maintenance phase, we modified our route of administration to intranasal (IN). The patient first self-administered the drug in the office and was monitored for two hours by clinicians. We supervise the next session in an at home selfadministered treatment via telemedicine. Potential risks and benefits were discussed and agreed with the patient. The spouse acted as the onsite caregiver and was instructed every step remotely by our registered nurse. After the at-home session, both patient and spouse describe a positive experience.

As medical care centres are rapidly populated by COVID-19 infected patients, high number of patients that travel to a treatment site might facilitate transmission of the disease. Regular outpatient treatment for TRD such as repetitive transcranial magnetic stimulation (rTMS) and ketamine can constitute an important risk for contagion and morbidity in older patients. This problem might be averted by massive deployment of outreach services (2) . In the pandemic context, geriatric mental health specialists must be creative to treat their patients safely. Ketamine has been shown to be a promising and safe treatment for TRD in elderly patients (3) . Furthermore, IN ketamine has also been demonstrated safe in ambulatory patients (4) . However, ketamine and esketamine treatment are normally offered through some sort of Risk and Mitigation Strategy program. This requirement is designed to make sure patients are monitored during the period when side effects of the drug are most likely to occur. Ketamine has some shortterm adverse effects including dissociation, psychotomimetic effects, and cardiovascular changes (5) . However, these side effects often resolve quickly, and patients who responded well to multiple ketamine treatments normally continue to respond well to subsequent treatments. Because ketamine is liable to abuse, these programs are also designed to prevent misuse and diversion. In the context of the COVID-19 pandemic, we believe that patients who had many successful acute treatments without important side effects and that have low risk of addiction can be treated safely at home. We believe the potential risks should not undermine the numerous potential benefits. Rather, the aim is to establish a framework and care plan that reduce these risks, which telemedicine permits. With this pandemic, our usual mode of care delivery is challenged and paradigm shifts are urgently needed. Further study that use this type of outreach approach for monitoring ketamine treatment might be particularly useful to treat elderly patient with TRD.

The other authors report no funding to disclose or conflicts with any product mentioned or concept discussed in this article

Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy

At the epicenter of the Covid-19 pandemic and humanitarian crises in Italy: Changing perspectives on preparation and mitigation. NEJM Catalyst Innovations in Care Delivery

Use of ketamine in elderly patients with treatment-resistant depression

Safety and efficacy of intranasal ketamine for the treatment of breakthrough pain in patients with chronic pain: a randomized, double-blind, placebo-controlled, crossover study

Side-effects associated with ketamine use in depression: a systematic review