Comments on “Ketamine’s double-edged sword: Therapeutic benefits and adverse events in adolescent treatment-resistant obsessive compulsive disorder (OCD)—A case series”

Dear editor,

We read with great interest the article titled “Ketamine’s double-edged sword: Therapeutic benefits and adverse events in adolescent treatment-resistant obsessive compulsive disorder (OCD)—A case series” by Kumar et al.,[1] which we discussed in detail during our departmental journal club. The article addresses a highly relevant and complex area in psychiatry, exploring novel treatment options for adolescent patients with treatment-resistant OCD, an area with limited interventions. While the case series adds clinical perspective, we feel its impact is somewhat diminished given that few open-label studies,[2] randomized controlled trials (RCT),[2,3] including one in adolescents,[4] and reviews[5] on ketamine’s role in OCD have already been published (two of that are cited by the author). An RCT would have more meaningfully contributed to the literature.

We also noted certain issues that, if addressed, could improve the manuscript. The inclusion of keywords already presents in the title felt redundant. Lack of clarity on whether cases were inpatient or outpatient, and inconsistencies in illness duration and medication history—for instance, Case 1 reports an 8-month history of OCD, yet mentions 14–16 weeks of fluoxetine and sertraline each, followed by 18 months of fluvoxamine and clomipramine, raising confusion about the total illness duration. In contrast, Cases 2–4 mentions total illness durations of 2–4 years. A consistent and clearly delineated illness timeline would aid interpretability. In Case 1, using standard psychosis scales and describing whether symptoms went beyond tactile hallucinations, whether they were distressing, and their overall impact would have clarified the rationale for starting risperidone. Reporting its dose and duration would also have been useful for clinicians facing similar situations. If hallucinations were limited and non-distressing, the need for risperidone itself is debatable. As ketamine-induced psychosis remains a debated entity, a more detailed elaboration in the discussion section, on whether it is self-limiting, whether it warrants treatment, and the inconsistencies in existing research would have added valuable depth, especially in the context of the title “ketamine’s double-edged effects.” Important details like the use of amantadine in Case 2 (a potential confounder to ketamine response due to its NMDA-modulating effects) is only mentioned as a footnote in a table, not in the main text. The tables lack expanded abbreviations. Although five ketamine sessions were mentioned initially, some cases appear to have received six, and per the text and the graph, which needs clarification. Furthermore, improvement in depressive symptoms, particularly in Cases 3 and 4, could have influenced OCD outcomes; hence, follow-up HAM-D scores would have helped clarify the specifics of response. In case 3, the use of CY-BOCS in a 19-year-old patient could have been avoided. Possible long-term maintenance plans like booster doses could have been mentioned considering the short acting nature of ketamine’s response.

Despite these concerns, we appreciate the authors’ effort in presenting a clinically valuable case series that serves as a meaningful primer for future research, with a well-structured discussion section that thoughtfully explores age-related sensitivity to ketamine, temporal response patterns, and underlying neurobiological mechanisms, thereby enhancing the reader’s understanding of key clinical nuances.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.