Reversal of Non-Suppression of Cortisol Levels in a Patient With Refractory Depression Receiving Ketamine
“Mr. J,” a 46-year-old man with treatment-resistant depression, was hospitalized following a serious suicide attempt. He had failed trials of selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotics, lithium, lamotrigine, riluzole, and ECT. In preparation for a trial of tranylcypromine, we discontinued the patient’s current medications and initiated intravenous ketamine infusions at 0.5 mg/kg over the course of 40 minutes each. Prior to the patient’s first ketamine infusion, his DST showed nonsuppression, with an 8:00 a.m. cortisol level of 1.7 mcg/ml and a 4:00 p.m. cortisol level of 7.4mcg/ml. After three alternate-day infusions of ketamine, his mood improved dramatically, with a 50% reduction in his Hamilton Depression Rating Scale score. Repeat DST showed suppression with 8:00 a.m. and 4:00 p.m. cortisol levels of 1.1 and 1.0, respectively (normalized). One week after discontinuation of ketamine, the patient’s symptoms returned. Prior to starting the monoamine oxidase inhibitor, and upon re-emergence of symptoms, his cortisol levels were once again nonsuppressed, with levels of 7.7 mcg/ml and 14.5 mcg/ml, respectively.
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