Ketamine and Suicidal Thoughts: What Older Adults and Caregivers Should Know Epi 54

This article explains the evidence, limitations and safety considerations surrounding ketamine and esketamine for depression and suicidal thoughts, with special guidance for older adults and family caregivers.

Immediate help: If you or someone you know is thinking about suicide or may be in immediate danger, call or text 988 to reach the Suicide & Crisis Lifeline or use the online chat at 988lifeline.org. Veterans and service members can call 988 and press 1 or text 838255. If there is an immediate, life-threatening danger, call 911 or go to the nearest emergency department. Do not leave a person at immediate risk alone.

Medical disclaimer: This article is for education only. It does not provide medical advice, diagnose a condition or replace evaluation and treatment by qualified healthcare professionals. Ketamine and esketamine must be administered under appropriate medical supervision.

A Mother’s Reason for Sharing This Information

Welcome to Caregiver Relief. I’m Diane Carbo, RN.

Suicide prevention is not an abstract subject for me. My son, Geoff, was a disabled Army veteran who lived with post-traumatic stress disorder, depression and complex regional pain syndrome, also known as CRPS or RSD, reflex sympathetic dystrophy.

CRPS can cause severe, persistent pain. For Geoff, even small changes in temperature, moving air or water temperature could trigger unbearable symptoms. He required powerful pain medication and experienced episodes in which opioids suppressed his breathing and naloxone was needed to reverse the overdose. Even aggressive treatment did not adequately control his pain.

Like many people with severe chronic pain, Geoff sometimes felt dismissed and accused of seeking drugs. Those experiences increased his isolation and hopelessness at a time when he needed compassionate, coordinated physical and mental healthcare.

During a hospitalization at Madigan Army Medical Center, Geoff expressed suicidal intent and was assigned continuous one-to-one observation. When the observer left without a replacement, Geoff attempted suicide in his hospital room. A chaplain found him, and he survived that attempt.

Eight years later, Geoff died by suicide.

I share this carefully because people living with severe pain, depression or trauma need to be heard and taken seriously. Caregivers also need reliable information. When I began reading about ketamine and its potential to reduce suicidal thoughts rapidly in certain patients, I wanted to understand what the evidence actually showed—and what it did not show.

Ketamine may offer hope for some people, but hope must be presented responsibly. No medication replaces immediate crisis care, a thorough psychiatric evaluation, a safety plan or hospitalization when it is needed.

Suicide Risk in Older Adults Deserves Attention

Depression is not a normal part of aging. Older adults may face chronic pain, serious illness, disability, grief, reduced independence, financial strain, social isolation and caregiver stress. These circumstances can increase emotional distress, but effective treatment and support are available.

Suicidal distress may be missed in older adults because symptoms can be mistaken for physical illness, medication effects, dementia or “normal aging.” Some people may also hide their thoughts because of shame, fear of hospitalization or concern about becoming a burden.

Caregivers can help by taking changes in mood, behavior and language seriously. A person does not need to meet every risk factor or display every warning sign to need help.

Warning Signs of a Possible Suicide Crisis

The National Institute of Mental Health identifies warning signs that may include:

• Talking about wanting to die or having no reason to live
• Saying they feel hopeless, trapped, ashamed or like a burden
• Experiencing unbearable emotional or physical pain
• Withdrawing from family, friends or meaningful activities
• Saying goodbye or giving away valued possessions
• Making a plan or searching for ways to die
• Increasing alcohol or drug use
• Displaying extreme mood changes, agitation, anxiety or rage
• Taking unusual or dangerous risks
• Sleeping or eating much more or much less than usual

Take new, escalating or crisis-related changes seriously—especially when the person has attempted suicide before, has access to lethal means, has recently experienced a loss or is living with severe pain, depression or another mental-health condition.

What Caregivers Can Do

If you are concerned, ask directly and calmly: “Are you thinking about suicide?” Asking this question does not put the idea into someone’s mind. It can open an honest conversation and help you determine whether urgent intervention is needed.

The NIMH recommends five practical actions: ask, be there, help keep the person safe, help the person connect with support and follow up. You can review its Five Action Steps for Helping Someone in Emotional Pain.

When someone may be at risk:

1. Listen without arguing, lecturing or expressing shock.
2. Ask whether the person has a plan and access to the method they intend to use.
3. Reduce access to firearms, large quantities of medication and other lethal means when this can be done safely.
4. Call or text 988 together and involve a trusted healthcare professional or family member.
5. Call 911 or go to an emergency department if the danger is immediate.
6. Do not promise to keep suicidal intentions secret.
7. Continue supportive contact after the immediate crisis or hospital discharge.

Why Rapid Treatment Matters

Traditional antidepressants may take several weeks to provide their full benefit. A person experiencing acute suicidal thoughts may not have the luxury of waiting without intensive support.

That treatment gap is one reason researchers have studied ketamine. Some controlled studies have found that ketamine can reduce suicidal-ideation scores more rapidly than comparison treatments in certain adults with severe depression. However, a rapid change in a symptom score is not the same as proving that a medication prevents suicide.

What the Ketamine Study Actually Found

A randomized clinical study led by Dr. Michael Grunebaum included 80 adults with major depression and clinically significant suicidal thoughts. Participants received either an intravenous ketamine infusion or midazolam, a sedative used as an active comparison.

Twenty-four hours after treatment, the ketamine group showed a greater average reduction in suicidal-ideation scores than the midazolam group. In the study, 55% of participants who received ketamine achieved at least a 50% reduction in their suicidal-ideation score, compared with 30% of those who received midazolam.

That result must be described carefully. It does not mean that ketamine reduced every patient’s suicidal thoughts “by half within 24 hours.” It means that a larger percentage of the ketamine group met the study’s defined response threshold on a symptom-rating scale.

The study was also not designed specifically for elderly patients. Its findings should not be presented as proof that ketamine is established as a rapid suicide treatment for older adults. Older people may have medical conditions, cognitive concerns, blood-pressure risks and medication interactions that require individualized assessment.

You can read the peer-reviewed study abstract in the American Journal of Psychiatry.

Ketamine and Esketamine Are Not the Same Treatment

The terms ketamine and esketamine are sometimes used as though they describe the same medication and approval status. They do not.

Intravenous ketamine

Ketamine is FDA-approved as an anesthetic. When clinicians administer IV ketamine for depression or suicidal thoughts, they are using it off-label. Off-label use is a recognized part of medical practice, but it means the FDA has not approved IV ketamine specifically for that psychiatric indication.

IV ketamine for depression is generally administered in a medically supervised setting. Treatment protocols, screening standards and follow-up care can vary, so patients and caregivers should ask who will monitor the treatment, how emergencies are handled and how ketamine fits into the patient’s larger mental-health plan.

Intranasal esketamine

Esketamine, sold under the brand name Spravato, is chemically related to ketamine but is a distinct prescription medication delivered through a nasal spray.

According to the current FDA prescribing information, Spravato is approved for:

• Treatment-resistant depression in adults, either by itself or with an oral antidepressant
• Depressive symptoms in adults with major depressive disorder and acute suicidal ideation or behavior, when used with an oral antidepressant

The FDA label also contains a critical limitation: Spravato has not been demonstrated to prevent suicide or to reduce suicidal ideation or suicidal behavior. Improvement after a dose does not eliminate the need for hospitalization when hospitalization is clinically appropriate.

Because esketamine can cause sedation, dissociation, respiratory depression and other serious effects—and has the potential for misuse—it is available through a restricted safety program. It must be administered under healthcare supervision, and patients must be monitored for at least two hours after each treatment session.

Potential Risks and Questions to Discuss

Ketamine-related treatment is not appropriate for everyone. Depending on the person and the treatment, concerns may include:

• Sedation or impaired alertness
• Dissociation or perceptual changes
• Increased blood pressure
• Respiratory depression
• Nausea or vomiting
• Cognitive effects
• Misuse, abuse or dependence
• Interaction with medications or substances that affect the central nervous system
• The need for transportation and supervision after treatment

Older adults may have additional vulnerabilities because of cardiovascular disease, fall risk, cognitive impairment, multiple prescriptions or reduced ability to metabolize medications.

Questions for a qualified psychiatric or medical professional include:

1. Is the proposed treatment IV ketamine or FDA-approved intranasal esketamine?
2. Is it being offered for treatment-resistant depression, acute depressive symptoms or another condition?
3. What evidence supports its use for this particular patient and age group?
4. What medical and psychiatric screening will occur first?
5. How will blood pressure, breathing, consciousness and side effects be monitored?
6. What happens if suicidal thoughts continue or worsen?
7. Is hospitalization or a higher level of care currently necessary?
8. What psychotherapy, medication management and follow-up care will accompany treatment?
9. How will the treatment team communicate with the family caregiver, with the patient’s permission?
10. What are the total costs, and what portion might insurance cover?

Ketamine Is Not a Stand-Alone Suicide-Prevention Plan

Even when a person experiences rapid relief, suicidal thoughts can return. Treatment should be part of a coordinated plan that may include psychiatric care, psychotherapy, medication management, treatment for pain or other medical conditions, restriction of lethal means, caregiver education and continued follow-up.

No family caregiver should be expected to manage a suicide crisis alone. Caregiver exhaustion, fear and isolation also deserve attention. If you are caring for someone with severe depression, chronic pain, dementia or suicidal behavior, tell the clinical team clearly what is happening and what you can and cannot safely manage at home.

If a discharge plan appears unsafe, ask for a formal suicide-risk assessment, written safety plan, medication plan, follow-up appointments, crisis contacts and clear instructions about when to return to the emergency department.

Hope Must Be Paired With Safe, Compassionate Care

Research into ketamine has created a potentially important option for some adults with difficult-to-treat depression. It is reasonable to feel hopeful about a treatment that may work more quickly than traditional antidepressants for certain patients.

But responsible hope requires accuracy. IV ketamine is not the same as FDA-approved intranasal esketamine. Neither should be described as a proven way to prevent suicide. The evidence should not be generalized specifically to elderly patients when the underlying research did not establish that conclusion.

Most importantly, someone experiencing suicidal thoughts needs immediate human connection and professional assessment—not simply information about a medication.

If you are worried about yourself or someone you love, reach out now. Call or text 988 or visit 988lifeline.org. Veterans and service members may call 988 and press 1 or text 838255. In an immediate, life-threatening emergency, call 911 or go to the nearest emergency department.

You are not alone, and asking for help is an act of courage.

Sources and Further Reading

• 988 Suicide & Crisis Lifeline
• NIMH: Warning Signs of Suicide
• NIMH: Five Action Steps for Helping Someone in Emotional Pain
• Grunebaum et al.: Ketamine for Rapid Reduction of Suicidal Thoughts in Major Depression
• FDA: Spravato Prescribing Information