History & Physicals:
Journal Article Summary:
Ketamine for the acute treatment of severe suicidal ideation: double blind, randomized placebo-controlled trial
Treating suicidal ideation in bipolar disorder poses a challenge since the traditional first line agents SSRIs and SNRIs can induce mania which is why their use is not recommended in this population. These medications also take several weeks to a month before the beneficial effects are observed which makes them ineffective during an acute suicidal crisis. The same delayed effect has been observed for mood stabilizers and antipsychotics such as lithium and clozapine in mood disorders. Psychotherapy also takes several sessions to be efficient and the evidence for ECT is weak. Overall, there is limited evidence-based options to treat suicidal crises in general which makes this an important area of research.
The objective of this study was to examine full remission of suicidal ideation 72 hours after two infusions of ketamine vs placebo. There were three experiment groups: those with bipolar disorder, depression, or another main diagnosis. The secondary objectives were to determine if ketamine acted on suicidal ideas through an analgesic effect on mental pain and if the effect of ketamine persisted at six weeks. There were 156 participants with 83 in the placebo group and 73 in the ketamine group. Two 40 minute IV infusions of 0.5mg/kg of ketamine were given or placebo which was normal saline at baseline then 24 hours later.
The results showed that more participants receiving ketamine had full remission of suicidal ideation at day three than those receiving placebo. Full remission was found in 63% of the ketamine arm vs 31.6% of the placebo arm. At 6 weeks post treatment the remission of ketamine remained high, but it was non-significant to placebo.
Site Visit Summary:
During my first site evaluation, I presented one case which was about a 54 year old caucasian female with a past psychiatric history of major depressive disorder, anxiety, and polysubstance abuse including cocaine, marijuana, and benzodiazepines. She was exhibiting paranoid delusions so my differential was focused on sorting out if the cause was organic or not. Substance abuse needed to be weighed against other psychiatric diagnosis. My site evaluator brought up the legalities of the case and we discussed the legal framework for admitting somebody involuntary and which grounds we had to do that for this particular case. It was an interesting perspective because I had be so focused on the medical aspects I had not previously given enough thought to the other parts of the case that needed consideration.
The second evaluation I presented two more cases along with pharmacy cards and a research article. The main objective of the article I selected was to evaluate ketamine as a treatment for severe suicidal ideation. I explain the outcomes of this trial in my journal article summary section. My last case presentation which was about an adult patient with autism spectrum disorder and mild cognitive impairment brought up the legal question of if the patient had capacity to chose their medical decisions and how we assess that as providers followed up the legal proceedings. Overall, each site visit taught me more about the medico-legal aspects of the profession.
Typhon Case Logs:
This past psychiatry rotation taught me so much about teamwork. Working in the same physical space as the social workers, PCA’s, and nurses gave me the opportunity to see all that goes into a patient’s care outside of my history and physical with them. The management for most psychiatry conditions I saw had large social components to them. While I would recommend “prescribing” a pharmacologic agent, I saw how social workers “prescribe” their own part of the treatment plan such as connecting the patient with housing, food, and other social services. The team also functioned as a unit when it came to practicing safety measures and working together which was subsequently reflected into enhanced patient care.
I have always wanted to practice medicine at a community-based level and as I move through my rotations, I find this to still hold true. I enjoyed that my psychiatric rotation was at a NYC-HHC community hospital where I could provide services in this type of setting. I was able to provide care for many incarcerated individuals as well that were transferred to the medical site for treatment. Through this experience I have become interested in working with this population and am further looking into pursuing a role where I could provide medical treatment at state or local detention center.
One area of improvement I want to continue to work on is my presentation to patients. I have found that in psychiatry it is especially important to gain the trust of the patient to gather a proper history and start them on a treatment plan they will be compliant with. I have learned that building a rapport cannot always be built during the first encounter but in a hospital setting we can speak to the patient several times during their stay which can slowly help build the patient-provider relationship.
One thing I would want my preceptor and colleagues to notice about my performance was my ability to de-escalate patient conflicts. There were several instances where I was able to calmly help reduce a patient’s agitated which prevented them from needing a stat medication such as Haldol or Ativan and prevented them from needing restraints. While this was not always possible, for the instances that it worked it was beneficial to both the patients and medical staff.
Overall, I very much enjoyed my psychiatric rotation and believe this may be a specialty I would like to enter. As of right now, OB/GYN and Psychiatry are the top two specialties I am hoping to practice in after graduation.