n2o for acute suicidality and depression in the ed

Conditions: Suicidal Ideation; Major Depressive Disorder; Treatment Resistant Depression

Summary: investigators are conducting this double-blind, randomized control trial (rct), to compare inhaled n2o+ treatment as usual (tau) versus inhaled placebo+tau; demonstrating the feasibility and tolerability of the intervention in an emergency department (ed) setting on an acutely suicidal population.

past studies have shown that a single dose of ketamine, an nmda- receptor antagonist has fast and long lasting anti-depressant effect. although a promising antidepressant and potential anti-suicidal agent, ketamine has very significant side effects including: dissociation, hallucinations, delusional thinking, cognitive impairment, and significant sympathetic nervous system activation. nitrous oxide (n2o) is an nmda-receptor antagonist with a well-known safety profile used as an analgesic. in a proof-of-concept pilot study, this study's investigator recently demonstrated that n2o also has rapid and marked antidepressant effects in patients with severe treatment-resistant depression (trd); further sub-analyses showed n2o significantly reduced suicidal ideation (si). while n2o administration may lead to a reduction in si, it remains unknown whether severely suicidal patients requiring hospitalization on inpatient psychiatric units would benefit. investigators hypothesize that n2o will rapidly and safely dampen suicidal thinking with minimal side effects in this population. participants will be randomized to receive either n2o or placebo. the study intervention is in tandem with prescribed treatment-as-usual (tau) by emergency department physicians relating to diagnosis (depression, anxiety, suicidal ideation); which typically involves anxiolytic medications and/or brief psychotherapy administered by care team psychiatry providers. study intervention response will be assessed using a self-administered psychiatric diagnostic tool (computerized adaptive testing mental health \[cat-mh\] scores relating to suicide, depression, and anxiety; to determine whether a single 45-minute inhalation of nitrous oxide vs placebo reduces symptoms.

Eligibility criteria:
inclusion criteria: * patients 18-65 years of age, acutely suicidal, presenting to the adult emergency department with documented history of non-psychotic major depressive disorder. exclusion criteria: * current psychotic or catatonic symptoms as determined by the hospital care team. * unable or unwilling to give consent for study participation (ability to provide consent will be established by treating physician) * lifetime dsm-v (medical history) diagnoses of schizophrenia, schizoaffective disorders, bipolar disorder, obsessive-compulsive disorder, and panic disorders. * meets current dsm-v substance use disorder of greater than mild severity (other than nicotine or marijuana) * significant pulmonary disease and/or requiring supplemental oxygen. * administration of other nmda-receptor antagonist treatment (e.g., ketamine) within two weeks of entry into study. * contraindications for n2o (pneumothorax, bowel obstruction, middle ear occlusion, elevated intracranial pressure) * chronic cobalamin and/or folate deficiency treated with folic acid or vitamin b12. * women who are pregnant or breastfeeding * any other factor that in the investigators' judgment may affect patient safety or compliance.

Keywords: suicidal depression nitrous antidepressant mdd trd