"Remote Monitoring of Intranasal Ketamine Self-Administration as Maintenance Therapy in Treatment-Resistant Depression (TRD): A Novel Strategy for Vulnerable and At-Risk Populations to COVID-19?"

To the editor:

On March 11, 2020, the World Health Organization (WHO) declared the new coronavirus disease (COVID-19) as a pandemic. This disease is particularly dangerous for the elderly, with older age associated with increased morbidity and mortality. To limit its transmission, psychiatric authorities around the world have used different strategies to transform their services, such as a massive scale-up of telemedicine.

A 61-year-old patient with treatment-resistant depression (TRD) suffering from multiple medical comorbidities was referred to our clinic for ketamine intravenous treatment. The patient underwent an acute treatment protocol with three intravenous infusions of ketamine every other day over 1 week. As the COVID-19 prevalence increased, strategies to prevent outpatient visits were necessary. For the maintenance phase, we modified our route of administration to intranasal. The patient first self-administered the drug in the office and was monitored for 2 hours by clinicians. We supervise the next session in a at-home self-administered treatment via telemedicine. Potential risks and benefits were discussed and agreed with the patient. The spouse acted as the onsite caregiver and was instructed every step remotely by our registered nurse. After the at-home session, both patient and spouse describe a positive experience.

As medical care centers are rapidly populated by COVID-19 infected patients, high number of patients that travel to a treatment site might facilitate transmission of the disease. Regular outpatient treatment for TRD such as repetitive transcranial magnetic stimulation and ketamine can constitute an important risk for contagion and morbidity in older patients. This problem might be averted by massive deployment of outreach services. In the pandemic context, geriatric mental health specialists must be creative to treat their patients safely. Ketamine has been shown to be a promising and safe treatment for TRD in elderly patients. Furthermore, intranasal ketamine has also been demonstrated safe in ambulatory patients. However, ketamine and esketamine treatment are normally offered through some sort of Risk and Mitigation Strategy program. This requirement is designed to make sure patients are monitored during the period when side effects of the drug are most likely to occur. Ketamine has some short-term adverse effects including dissociation, psychotomimetic effects, and cardiovascular changes. However, these side effects often resolve quickly, and patients who responded well to multiple ketamine treatments normally continue to respond well to subsequent treatments. Because ketamine is liable to abuse, these programs are also designed to prevent misuse and diversion. In the context of the COVID-19 pandemic, we believe that patients who had many successful acute treatments without important side effects and that have low risk of addiction can be treated safely at home. We believe the potential risks should not undermine the numerous potential benefits. Rather, the aim is to establish a framework and care plan that reduce these risks, which telemedicine permits. With this pandemic, our usual mode of care delivery is challenged and paradigm shifts are urgently needed. Further study that use this type of outreach approach for monitoring ketamine treatment might be particularly useful to treat elderly patient with TRD.

AUTHOR CONTRIBUTIONS

Dr. Christophe Longpré-Poirier, Dre Veronique Desbeaumes Jodoin and Dr. Jean-Philippe Miron collected the data and provided substantial contributions to the conception of the work. They were involved in the design and in drafting the work. Dr. Paul Lesperance revised it critically for intellectual content and made the final approval of the version to be published.