(143) Ketamine Withdrawal-Induced Mania: A Case Report and Review of the Literature

Background/Significance: Ketamine, a derivative of phencyclidine (PCP), has gained popularity in medical and psychiatric practice for its analgesic and antidepressant effects. While anxiety, dysphoria, and tremors are known neuropsychiatric manifestations of withdrawal, no specific ketamine withdrawal syndrome has been described to date (1).

Case: The patient is a 66-year-old male with a history of cardiomyopathy, ventricular tachycardia, strokes, and chronic shoulder pain on daily oral ketamine for 6 months. He presented with a dramatic change in behavior after the abrupt discontinuation of ketamine. The patient exhibited all cardinal symptoms of mania: euphoric and irritable mood, increased goal-directed activity, disinhibition, pressured speech, grandiosity, and insomnia. Lab investigations were all within normal limits, except for a positive COVID-19 PCR test (asymptomatic). Initial CT head without contrast showed age-indeterminate scattered hypodensities. MRI head confirmed these to be most likely indicative of the remote stroke history.

Methods: We queried PubMed regarding all applicable articles published from its inception to March 2024 using a combination of MeSH terms: "ketamine" AND "Substance Withdrawal Syndromes." Items were excluded if they were irrelevant, not in English, or were using animal models only. Given the limited results, the search will be extended to other databases, and results will be updated before the final presentation.

Results: Only two articles were found, describing two case reports of withdrawal following chronic use of ketamine. The first case involved a 25-year-old male using ketamine for six years, with anxiety, shaking/sweating, and low mood in the first hours after a prolonged period of use (Critchlow, 2006). The second case involved a 35-year-old male with a psychiatric history of PTSD, bipolar II disorder, alcohol/cannabis use disorder, and borderline personality disorder, who was receiving ketamine infusions for treatment-resistant PTSD (Roxas, 2021).

Discussion: A first hypomanic or manic episode after the age of 50 warrants consideration of underlying organic factors or "secondary mania." These generally include iatrogenic drug use like steroids, strokes, metabolic factors, or cognitive disorders (Sami, 2015). This case and review underscore the importance of considering substance withdrawal syndromes, specifically ketamine withdrawal late-onset mania. The present case report aligns with published evidence indicating that neuropsychiatric symptoms of ketamine withdrawal rapidly emerge and worsen in the first 24 hours of discontinuation. Uniquely contributing to the literature, this case stands out from others as the clinical presentation was one of a full-blown manic episode in the absence of a history of bipolar disorder.

Conclusion/Implications: This case provides a rare clinical insight into a severe acute ketamine withdrawal syndrome, emphasizing the need for further research on the chronic use of ketamine. With the increasing chronic prescription of oral ketamine, understanding potential withdrawal syndromes is crucial.

Reference:

1. Sassano-Higgins, S. (2016). DOI: 10.1002/da.2253.

2. Critchlow, D.G. (2006). DOI: 10.1111/j.1360-0443.2006.01494.x.

3. Roxas, N. (2021). DOI: 10.1176/appi.ajp.2020.20101480.

4. Sami, M. (2015). DOI: 10.1016/j.jad.2015.08.027.

 

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: This poster presentation reflects the work of an early career faculty member who identifies as a member of a sexual orientation minority group.