European Psychiatry - Volume 41 - April 2017

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S420 25th European Congress of Psychiatry / European Psychiatry 41S (2017) S405–S464
EV0049
Intramuscular ketamine in
depression, suicidal thoughts and
anxiety: A report on two cases
M. Cigognini ∗, R. Moreno
Institute of Psychiatry, GRUDA, São Paulo, Brazil
∗ Corresponding author.
Introduction Several studies have shown that ketamine, an
antagonist of NMDA receptors, represents a promising alternative
in the treatment of depression. The therapeutic use of ketamine,
commonly used at a dose of 0.5mg/kg, and in a single application
IV has been short and requires monitoring in a hospital setting.
IM use has been shown to be effective in treating depression and
suicide risk, and have low side effect profile.
Methods Two patients diagnosed with bipolar depression
and suicide risk were submitted to ketamine IM application
(0.75mg/kg), receiving one application of ketamine IM every two
days, totaling 4 applications. Patients were under medical moni-
toring for 2 hours after injection verifying vital signs and potential
side effects. Responses were measured using BDI, BAI and BSI.
Aim To evaluate response of ketamine IM injections on depres-
sive, suicidal and anxious symptoms.
Summary Case 1: female, 20 years old, single with three recent
suicide attempts, symptomatic for two months. Started lithium
450mg daily. Side effects of ketamine were nausea, drowsiness
and paresthesia. Case 2: female, 24 years old, single with symp-
toms lasting for six years. Started aripiprazole 5–10mg and 25mg
lamotrigine concomitantly. Side effects of drymouth, dizziness and
dissociation.
Conclusions The use of ketamine IM showed reduction of
75.5%–83.3%–85.7% (case 1) and 71.4%–77.2%–60.8% (case 2) in BDI,
BAI and BSI, respectively as well as safety and tolerability in use.
Disclosure of interest The authors have not supplied their decla-
ration of competing interest.
EV0050
Reversible cognitive impairment
associated with a high free fraction
but subtherapeutic total blood level of
valproic acid due to
hypoalbuminemia in a bipolar patient
G. Dautzenberg ∗, M. Nederlof , E. Heerdink , A. Beekman
1 Altrecht GGZ, Old Age Psychiatry, Utrecht, The Netherlands
2 Utrecht University, Utrecht Institute of Pharmaceutical Sciences,
Utrecht, The Netherlands
3 VU University Medical Center, Department of Psychiatry,
Amsterdam, The Netherlands
∗ Corresponding author.
Valproic acid (VPA) is widely used in the treatment of epilepsy and
bipolar disorder. It is largely bound to serum proteins (80–95%) in
particular albumin, with a saturable binding capacity. Under con-
ditions of hypoalbuminemia, protein binding of VPA will decrease
and its pharmacologically-active free fractionwill rise, even to toxic
levels while measuring subtherapeutic VPA total blood levels
We present an elderly bipolar patient with (sub)clinical total levels
of VPA and a high free fraction of VPA due to hypoalbuminemia
(14–24 g/L) leading to severe reversible cognitive impairment.
VPA and the free fraction in particular, was the most likely cause
of the cognitive impairment There was a time-correlation
with increasing blood levels of total VPA (68mg/L, reference
80–120mg/L notably the free fraction (37.5mg/L, reference
5–15mg/L), and the intoxication.
For therapeutic drug monitoring in laboratories, generally, total
VPA concentrations (free + protein-bound) are measured instead of
free fractions, due to technical difficulties, a lack of established ref-
erence ranges nd (inter)national guidelines ot requiring
it. This presentation and literature points out that it is clinically rel-
evant to measure the free fraction specially in patients with
hypoalbuminemia o prevent unnecessary side effects and
toxicity.
We recommendmeasuring albumin during VPA use; particularly in
patients with nephrotic syndrome, liver disease r older adults
ypoalbuminemia demands a free fraction measurement.
Disclosure of interest The authors have not supplied their decla-
ration of competing interest.
References
[1] Hermida 2005.
[2] Naranjo 1981.
[3] TDM .
[4] Dasgupa 2002.
[5] NICE or NvVP bipolar disorder guidelines.
[6] Dols 2016.
[7] Levy 1980.
[8] Jager Roman 1982.
[9] Haroldson 2000.
[10] Maat de 2011.
[11] Jansen 2012.
[12] Dasgupta 2007.
[13] Rej 2012.
[14] Beyenburg 2007.
[15] Kodama 2002.
EV0051
Care pathways for patients with
bipolar disorders at Psychiatry Clinic
Affektiva, Gothenburg: Identifying
and solving issues for a more efficient
and safe care
M. Dellepiane ∗ oldt-Christmas , G. Jungestrand , P. Asplund ,
R. Ahmed , T. Nordin
Sahlgrenska University Hospital, Psychiatry, Gothenburg, Sweden
∗ Corresponding author.
Introduction The Psychiatry Clinic Affektiva has developed a care
pathway for patients with bipolar disorder (BD). It consists of one
outpatient clinic and two inpatient wards. Clinical observations
suggest that patients with BD benefit from treatment in a dedi-
cated unit with tailored care programs and that better outcomes
are achieved in terms of reduced average length of stay and safer
transitions to outpatient care for this group.
Aims The aim is to improve the care of bipolar patients by
increasing bed-availability and overall continuity in the care path-
way andmonitoring core aspects in themanagement of outpatients
in order to reduce admissions and to facilitate standardized treat-
ment and collaboration between in- and outpatients unit.
Method We developed a structure to monitor and measure spe-
cific outcomes such as readmission within 28 days, relapse within
12 months and the use of lithium in this group. We also developed
a standardized care protocol in order to improve the safety and the
equality.
Results At this stage our preliminary results from our efforts are
promising but further monitoring is needed to confirm our hypoth-
esis. More data will be collected during 2017.
Conclusions Affektiva Psychiatry Clinic has developed a model
for continuously monitoring several essential aspects in the care of
patients with BD and providing a specific care program.
Disclosure of interest The authors have not supplied their decla-
ration of competing interest.