According to a retrospective review from a single private practice, intranasal ketamine (InK) is both safe and effective as maintenance treatment for patients with Fear of Harm (FOH), a phenotype of bipolar disorder (BD).

BD-FOH typically has a pediatric onset and is characterized by “BD plus treatment resistance, separation anxiety, aggressive obsessions, parasomnias, and thermal dysregulation,” the study authors explained.  

During the study, 45 patients who received treatment with InK from 3 months to 6.5 years completed a survey assessing clinical effectiveness and safety of InK. The authors stated that InK was administered every 3 to 4 days and peak doses ranged from 20 to 360mg. “Effectiveness was assessed from analysis of responses to 49 questions on symptomatology plus qualitative content analyses of written reports and chart review,” the authors write.  Additionally, adverse events (AEs) were evaluated based on frequency, duration, as well as severity. 

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Findings showed that almost all patients were ‘much’ to ‘very much’ improved clinically and in ratings of social function and academic performance. Additionally, significant reductions were observed in each symptom category. A total of 13 persistent AEs were reported, however none of these resulted in treatment discontinuation. Although acute emergence reactions were sporadically seen in up to 75% of patients, they were considered mild in severity as well as brief in duration.

InK appears to be safe and effective for the treatment of BD-FOH and should be considered a tertiary alternative treatment in refractory cases. The study authors noted that limitations of the review included the potential for both response and recall bias, retrospective review from a single practice, as well as a lack of placebo control.  “Randomized control trials are warranted,” the authors conclude. 

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