2015 myresearch Science Internship Program: Nursing Care. Civic Education Office of Government and Community Relations

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1 2015 myresearch Science Internship Program: Nursing Care Civic Education Office of Government and Community Relations

2 Mary Chudy Science Internship Program: Nursing Care

3 Patients with a Deep Brain Stimulator who Received Ketamine for Treatment Resistant Depression: A Case Study Mary Chudy Nora Finnegan, RN, BSN

4 Abstract About 50% of people do not respond to medications and therapy. Deep brain stimulation (DBS) involves sending electrical impulses to the brain. DBS, along with ketamine, are two treatments that help alleviate depressive symptoms. This study looked at 3 patients with TRD who had DBS and were being treated with ketamine. If one has an implanted DBS, ketamine infusions will not successfully treat them.

5 Background In a given year, about 14 million Americans will experience an episode of MDD. Of those that receive treatment (30%) 50% will not respond. Two+ failed treatment attempts lowers likelihood of remission. Consider diagnosis of TRD

6 Background Ketamine is a dissociative anesthetic used in veterinary medicine. In sub-anesthetic doses, it provides relief for patients with TRD. 0.5 mg/kg over 40 minutes with saline bolus following Targets the NMDA receptor complex inhibitory GABA

7 Background Deep Brain Stimulation to certain neuroanatomical sites has also been found to alleviate symptoms. Small electrical impulses trigger increased brain activity.

8 Problem/Purpose Provide clinical evidence on the efficacy of ketamine treatments in patients with DBS Explore the biochemical pathways of both ketamine and DBS in relation to each other Synthesize whether the presence of a DBS indicates or contraindicates ketamine

9 Hypothesis If ketamine patients have a pre-existing functioning deep brain stimulator then they will Respond later than patients normally would (24 hrs) Experience a lessened response to the ketamine infusions Ultimately need to withdraw from the ketamine treatments due to lack of response

10 Methodology Retrospective study medical chart review on 3 patients who fit criteria Receiving/have received a series of ketamine infusions Functional, implanted DBS in use Charts compared to those w/o DBS Indications for ketamine 2 or more failed antidepressants in 2+ classes ECT produced no response No major head trauma or psychosis

11 MADRS Score Data Treatment # Downward trend demonstrates ketamine s efficacy.

12 MADRS Score Data Patient MADRS Scores During Ketamine Treatment # Initial, transient drop in MADRS. No lasting effect.

13 Results A MADRS score of <8 maintained for 3-4 weeks= depression in remission. Pt 1: responder- 9 Pt 2: non-responder Pt 3: non-responder- 21.5

14 Conclusions Hypothesis supported by results If patient with DBS is being treated with ketamine Will experience lessened degree of alleviation Longer than average acute series Transient response Eventual regression to original state

15 Recommendations Larger sample size to further confirm these results Further research on the biochemical mechanism of deep brain stimulation Healthcare organizations educate on the possibility to treat TRD with sub-anesthetic doses of ketamine Further research on the NMDA receptor complex

16 References Bogod, N. (n.d.). Long-Term Neuropsychological Safety of Subgenual Cingulate Gyrus Deep Brain Stimulation for Treatment-Resistant Depression. Retrieved July 13, 2015, from The Journal of Neuropsychiatry website: Deep Brain Stimulation to Reward Circuitry Alleviates Anhedonia in Refractory Major Depression. (n.d.). Neuropsychopharacology. (including photos slide 7, 14). lkennedy, S. (n.d.). Deep Brain Stimulation for Treatment-Resistant Depression: Follow-Up After 3 to 6 Years. Retrieved July 12, 2015, from Long-Term Effects of Nucleus Accumbens Deep Brain Stimulation in Treatment-Resistant Depression: Evidence for Sustained Efficacy. (n.d.). Retrieved from Neuropsychopharmacology website:

17 Special Thanks Nora Finnegan, RN, BSN Roman Dale, MD Lawre Stratton, RN The entire staff of Behavioral Health at Lutheran Hospital Nedra Starling, MA, MPH, ABD/DrPH and the Civic Education Department My amazing peer group and fellow peer mentors

18 Copyright 2015 Cleveland Clinic Foundation