Navigating Complex Ketamine Treatment: A Case Study on Ketamine Therapy and Bipolar Diagnosis in Psychiatric Practice

A clinical case study on how integrated ketamine therapy and psychiatric care at Point Loma Clinic enabled early detection of a shift from depression to bipolar disorder.

Patient Background: Treatment-Resistant Depression and a History of Mood Instability

Joe is in his mid-fifties, an accomplished attorney who has been suffering from recurrent depression since his early adulthood. The depression was difficult to treat; many different medications have been tried, including mood stabilizers (medications for bipolar disorder), but those were prescribed such a long time ago that Joe had a hard time remembering how he was feeling when they were prescribed. All he knew was that for at least the last ten years he had been depressed, sometimes more, sometimes less, but never free from it.

Introduction to Ketamine Treatment: Split Care and the Role of Ketamine Clinics

Joe was one of the first patients treated with ketamine at Point Loma Clinic, originally in a different setting. He was under the care of another psychiatrist who continued to prescribe his 20 mg Trintellix (vortioxetine), the antidepressant Joe had been taking for many years. This “split” treatment is standard practice at the so-called Ketamine Clinics, and is available at PLC as well, as an option.

Improvements and Challenges: Partial Response to Ketamine for Depression

His mood improved partially, more noticeably than during his ten years on the antidepressant alone. It became easier for Joe to complete tasks, which allowed him to increase his activities in business and eventually develop a romantic relationship, but many less important activities, such as fixing broken items at home, remained undone.

He settled into a pattern of monthly ketamine visits at PLC and trimonthly visits with his psychiatrist. At one point, the psychiatrist retired, and Joe elected to consolidate both traditional medication treatment and Ketamine treatment at PLC.

Emerging Complications: Irritability, Hypomania, and Diagnostic Reevaluation

The first sign that something was changing was him beginning to report irritability. He lashed out at meetings at work, which eventually resulted in him losing one of his important clients. He mentioned that this was a problem many years ago, likely before his depression worsened. He admitted that he was having a difficult time controlling these outbursts but initially denied that they constituted a problem.

During subsequent treatments, we spent more and more time discussing this issue. At the second-to-last visit, when it became clear that this behavior continued to worsen, and he started to have some difficulty falling asleep, we embarked on a slow tapering off the Trintellix.

Diagnosis Reevaluation: From Chronic Depression to Bipolar Disorder

At his most recent visit, Joe was taking it every other day, at an effective daily dose of only 10 mg. It was clear, however, that Joe was in a hypomanic state: he was talkative, his mind was racing, he was even more irritable than before, among many other symptoms of that condition.

I informed Joe that ketamine was no longer indicated since he was no longer depressed. He was a bit surprised and disappointed, but he understood the reasoning. He even admitted that he himself knew he had become hypomanic.

At this point, his diagnosis had to be changed from “Chronic Depression, questionable Bipolar Disorder” to “Bipolar Disorder.” His psychiatric treatment at PLC will continue in a more traditional fashion, focused on the new diagnosis. If his depression returns in the future, and it again fails to improve with treatment, ketamine may be indicated again.

Why Integrated Psychiatric Care Matters: Catching Clinical Shifts Early

We at PLC believe that one of the advantages of Ketamine being administered in a general psychiatric practice is that it is easy to catch changes in the clinical presentation, changes that may necessitate reevaluating the feasibility of the Ketamine treatment on the spot. The integration of medication management and ketamine monitoring in a single practice setting is a meaningful patient safety advantage.

Consider how long it would have taken to notice Joe’s shift from depression to hypomania in a setting where he receives ketamine at a Ketamine Clinic, while only seeing a general psychiatrist or perhaps a primary care physician every 3 – 6 months elsewhere. Chances are that it could have taken several visits for something to start looking suspicious. Joe himself was ready to go along with the treatment, having settled into the chair as usual, and only careful discussion revealed that things have become very different.

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Alexander Papp, MD