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Induction of Prolonged Mania During Ketamine Therapy for Reflex Sympathetic Dystrophy

Amy K. Ricke, R. Snook, A. Anand

Biological Psychiatry May 6, 2011 DOI: 10.1016/j.biopsych.2011.02.030 (opens in new tab)

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Study at a glance

AI-extracted from the abstract
Characteristics Case study Case report Peer reviewed
Sample size 1
Population 42-year-old woman with chronic pain and reflex sympathetic dystrophy
Intervention IV ketamine
Duration 10 days
Topics Esketamine Ketamine
Citations 34
Key findings Ketamine therapy for chronic pain was associated with the emergence of mania-like symptoms, including pressured speech, emotional lability, and disorganized thinking, in a patient with a history of depression.

Abstract

Ms. M is a 42-year-old Caucasian married woman with a history of chronic left gluteal and left leg pain diagnosed as reflex sympathetic dystrophy. She was disabled by refractory symptoms that had failed a number of interventions and required high-dose opioids. Ms. M was otherwise high functioning and had completed a professional degree. The patient elected to undergo experimental IV ketamine therapy for her symptoms. An admission note documented a history of depression and insomnia, for which the patient had been prescribed duloxetine 20 mg daily, mirtazapine 45 mg qHS, and quetiapine 100 qHS. These medications were held on admission. On Day 1, ketamine was started and titrated from 10 to 20 mg/hour over a period of 5 days in the intensive care unit. The patient immediately reported that her pain was much better and it was a “miracle,” but by Day 2 she again complained of considerable pain. On Day 3, duloxetine 20 mg and mirtazapine 45 mg were restarted. By Day 4, Ms. M reported significant pain relief and continued to get better by Day 5 and Day 6. In these first 6 days, some subtle behavioral changes were seen (e.g., sometimes being too optimistic about the therapy), but nothing extraordinary was documented, and the therapy continued because Ms. M seemed to benefit considerably from it. On Day 7 of the ketamine protocol, Ms. M started exhibiting notable changes in her mental status. She appeared over-sedated and admitted to self-administering opioids from a supply she kept in her purse, but when asked to, she was reluctant to turn these over to her physicians. On Day 8, Ms. M was irritable and emotionally labile and expressed the feeling that the team was withholding pain medications from her. Without any prompting, she detailed a series of past traumas that she had experienced, including the deaths of her parents. Therefore, on Day 8, quetiapine 100 mg qHS was restarted, and duloxetine was increased to 60 mg. However, her mania like symptoms did not get better, and on Day 10 Ms. M demonstrated pressured speech and sent her physicians a lengthy e-mail that was tangential with loosening of associations. The communication included statements like “Dear Doctors and Heroes” and “If we could treat RSD like jazz we could treat individuals according to specific needs at specific times.” Given her symptoms, a decision was made to

Comparable studies

Other case reports and case series on ketamine, most cited first.

Study Year Design Participants
The destruction of the lower urinary tract by ketamine abuse: a new syndrome? Young recreational abusers of street-ketamine in Hong Kong referred to urology units 2008 Retrospective case series n = 59
Electroconvulsive Therapy, Ketamine, and Esketamine in a Patient with Major Depressive Disorder and Multiple Comorbidities: A Case Report over 10-year Treatment from Adolescence to Adulthood. A patient with treatment-resistant depression and comorbid generalized anxiety... 2025 Case report n = 1
Treatment of compulsive behaviour in eating disorders with intermittent ketamine infusions Chronic and treatment-resistant eating disorder patients 1998 Case series n = 15
Oral Administration of the NMDA Receptor Antagonist S-Ketamine as Add-On Therapy of Depression: A Case Series Four depressed patients taking standard antidepressants 2009 Case series n = 4
A longitudinal case series of IM ketamine for patients with severe and enduring eating disorders and comorbid treatment‐resistant depression Patients with enduring eating disorders and treatment-resistant depression 2021 Case series n = 4

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Esketamine Ketamine Depression