Ketamine infusion combined with accelerated sequential theta burst stimulation in multi-therapy-resistant bipolar depression: A case report.

In a 69-year-old man with chronic multi-therapy resistant bipolar depression, combining intravenous ketamine three times per week with sequential theta burst stimulation led to complete remission that persisted at a two-year follow-up. The patient had previously failed numerous antidepressants, mood stabilizers, electroconvulsive therapy, and standalone brain stimulation. Clinical improvement was measured by a drop in the Hamilton Depression Rating Scale from 15 to 8 and eventually to remission. Electroencephalography showed corrected dysregulated brain activity patterns, suggesting changes in short-term adaptive plasticity. This combination may offer a treatment path for patients who do not respond to standard therapies.

Study at a glance

Abstract

Treatment resistance in bipolar depression is one of the most challenging clinical conditions to treat in psychiatry. We present a case of an elderly gentleman with chronic Multi-Therapy Resistant Bipolar Depression (MTRBD), where ketamine, a preferential NMDAR blocker on cortical GABAergic interneurons, is used adjunctively with sequential theta burst stimulation (sTBS) to achieve remission. Intravenous ketamine thrice a week was administered with sequential bilateral intermittent- and continuous-Theta Burst Stimulation (iTBS and cTBS) in 69-year-old man, with 2 years of bipolar depressive episode with multiple comorbidities, resistant to numerous antidepressants, anticonvulsants and antipsychotic mood stabilizers, individualised psychotherapies, trial of electroconvulsive therapy and sTBS. Roving mismatch negativity (rMMN), a robust passive EEG-ERP paradigm measuring neuroplasticity, was evaluated before and after this treatment protocol RESULT: A significant clinical improvement with Hamilton depression rating scale (HDRS 17) score improving from 15 to 8 with progressive improvement to achieve complete remission that persisted even at the latest 2-year follow-up on stable medications. A pronounced correction of dysregulated repetitive positivity, partial correction of deviant negativity was noted in rMMN after the treatment. The novel combination of ketamine has resulted in sustained clinical remission in a patient with MTRBD. Earlier failure of sTBS and ECT underlines the importance of this combination. The rMMN findings were consistent with changes in short-term adaptive plasticity and may represent a potential neurophysiological correlate of treatment response. Combining Ketamine.