Ketamine IV

Spravato

TMS

What conditions does IV Ketamine treat?

■ Treatment Resistant Depression* (Off label)

■ Bipolar depressive phase (Off Label)

■ Depression with SI (Off Label)

■ Post-Traumatic Stress Disorder (Off Label)

How long are the treatments?

Your total appointment time is 1 hour and 15 min. The IV portion is around 40 minutes and the recovery time an additional 30 minutes where you will continue to be monitored.

How many infusions will I need?

The IV initial series is 2 treatments per week (at least 1 day in between) for 3 weeks. If there is a good response, then treatments are spread out to 1 treatment per week for 3 weeks. After this point, how often a person needs booster treatments will depend on how long the antidepressant effect lasts for that individual person.

Can I drive myself home after treatment?

After the recovery time, you will need a driver to take you home. It is suggested to rest the remainder of the day and not make any big or legal decisions or operate any heavy machinery, including vehicles.

What Contraindications Would Disqualify Me From Receiving Ketamine?

■ Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels) or arteriovenous malformation.

■ History of intracerebral hemorrhage (brain bleed)

■ Hypersensitivity (allergy) to esketamine, ketamine, or any of the excipients.

■ It may not be a suitable option for those who have a history of substance abuse or a diagnosed addictive disorder, depending on the circumstances.

Is Ketamine safe, both short term and long term?

Short term safety for Ketamine has been widely established, especially at the very low doses that we are using for psychiatric indications. Safety of Repeated Administration of Parenteral Ketamine for Depression - PubMed (nih.gov) Long term is not as well-known. The most data we have about long-term risks of Ketamine are from studies on patients who were using high doses recreationally for a long time. Given the low dose, low frequency of treatments, and overall mild side effect profile, in terms of safety and side effects Ketamine is favorable, especially if people have had significant side effects with traditional antidepressants. In addition, in the studies where people did have negative effects from long-term Ketamine use, those effects went away after Ketamine was stopped. Comprehensive assessment of side effects associated with a single dose of ketamine in treatment-resistant depression - ScienceDirect

What is the infusion like?

You will be asked to fill out a questionnaire prior to every treatment electronically or done in our office before your treatment is started. You will be seated in a comfortable recliner in one of our treatment rooms. The nurse will insert a small IV and apply our wireless monitors that will record your pulse, blood pressure, and oxygen levels by using one of your hands/wrists. These vitals will be monitored while you have your infusion. You will be given noise cancelling headphones with calm music to help you be as comfortable as possible during treatment.

What Should I Expect During a Ketamine Infusion?

You can expect to be sitting in a reclining chair during the infusion treatment for about 40 minutes. You will not lose consciousness during your experience, but you may feel mild to moderate sedation and pain-alleviating effects. Some patients report a distorted perception of light and color, among other unusual sensory experiences.

In most cases, Ketamine infusion patients leave the clinic within a half hour after the infusion finishes. However, patients suffering from a greater-than-usual severity of nausea or dissociation may require extra supervision time before being discharged. On-site medical staff will ensure that you are comfortable and safe during the infusion and before you leave the clinic.

What Medications Should Not Be Combined With Ketamine?

Theophylline and Ketamine together increase the risk of seizures, so this combo should be avoided.

Medications that we need to take extra precautions around are: sedating medications such as opioids, benzodiazepines, and muscle relaxers; medications that raise blood pressure such as stimulants and SNRI antidepressants

Patients taking large doses of benzodiazepines (Ativan, Xanax and Klonopin) may have a reduced response to ketamine. Frontiers | The Antidepressant Effect of Ketamine Is Dampened by Concomitant Benzodiazepine Medication | Psychiatry (frontiersin.org)     

Naltrexone blocks one of the systems that is responsible for the antidepressant effect, so Ketamine may be less effective Attenuation of Antidepressant Effects of Ketamine by Opioid Receptor Antagonism | American Journal of Psychiatry (psychiatryonline.org)

Will IV Ketamine work for me?

In most major studies, Ketamine works in about 50-70% of people, which is quite good compared to most antidepressants, especially if you haven’t responded to previous antidepressant trials. While everyone is different, Ketamine can be an effective treatment with fast results that range from within a few hours, to some noticing benefits after 1-3 treatments. There are some that may not feel any results until after all 6 treatments have been completed, but the treatment team will monitor effectiveness with ongoing treatments. 

Ketamine is only one part of a robust overall mental health treatment plan, and it is recommended that daily medication and psychotherapy continue for the best possible results.

Other clinics say that their success rate is higher than this? What’s up with that?

Most clinics use the same type of Ketamine (the generic version of Ketalar), so there isn’t anything special about that from one clinic to another. Currently there is no scientific evidence showing that adding other elements or proprietary blends to the infusions makes them more effective. The standards for response, remission, and the patients chosen for studies tend to be stricter than in general practice, and in studies there are placebo controls and randomized selection of patients. In regular clinic practice, there is no randomization, and the placebo effect is incorporated into the “success” rate of a clinic as well. All in all, we believe in letting the science speak for itself.

How long do the results of Ketamine last?

While Ketamine generally kicks in pretty quickly (hours to days), certainly more quickly than other antidepressant treatments, how long the effect lasts varies quite a bit, ranging in between a week and a month on average. After the acute course of 6 treatments over 3 weeks, it’s not uncommon for people to come in for maintenance about once per month, but we have to base it on how your brain responds. Some people are able to ride the momentum from treatment to make greater changes that last for months. That’s why we use the Osmind app to get rating scales on a weekly basis, so we can see what your particular trajectory is like. Research is ongoing in regard to how to make the antidepressant effect last longer in between treatments, but one of the main things you can do is regularly attend psychotherapy and use what you learn in the Ketamine sessions to make positive changes in your life, as well as continuing medication management with your outpatient psychiatrist. The brain changes that occur with Ketamine may help your current meds and therapy work more effectively.

How does Ketamine work?

The exact details of how it works in depression are still being researched, but so far it appears that Ketamine’s antidepressant effect is likely due to a combination of different systems in the brain, including the glutamate system, the opioid system, and a chain reaction that results in building more connections between brain cells. This is a big deal in psychiatry because up until this point, antidepressants have acted on Serotonin, Norepinephrine, and Dopamine. Ketamine works on an entirely different system. We are following the research with great interest, and as we learn more, we can adjust our treatment approach with the scientific evidence being our guide.

Is Ketamine safe in pregnancy? What about breastfeeding?

There is not enough research on Ketamine in pregnancy to be able to say it’s safe or unsafe, so the safest would be to not have Ketamine during pregnancy. However, there are some very real risks of depression in pregnancy, so this needs to be taken into account and evaluated on a case-by-case basis. Ketamine (Ketalar®) - MotherToBaby

As for breastfeeding, the literature is mainly limited to patients who received Ketamine for their c-section and the outcomes were measured. In those specific circumstances, the babies were okay. Our situation is quite different, as Ketamine would be given on a more regular basis. At this time breastfeeding while receiving treatments is not recommended. Ketamine - Drugs and Lactation Database (LactMed) - NCBI Bookshelf (nih.gov)

What are the side effects of Ketamine?

The most common “side effect” of Ketamine or Esketamine is dissociation. The trip is quite expected and for many people is a helpful part of the therapy. During Ketamine treatment, the mind is able to enter different perceptual, cognitive, and emotional states than it would normally, and many patients remark that they were able to process challenging feelings and memories with more understanding and less distress. Everyone’s experience is different, and we’ll help guide you through it. Whether the trip is required to get the antidepressant effect is a very active question right now, and studies are mixed: Do the dissociative side effects of ketamine mediate its antidepressant effects? (nih.gov)

Another common side effect is nausea. That’s why we recommend not eating or drinking anything in the 2 hours before the treatment.

Lastly, Ketamine and Esketamine both have the potential to raise your blood pressure while undergoing treatment (not after or in between treatments). This is one of the main reasons why we monitor your vital signs. It’s also why we coordinate with your outpatient doctors to make sure that your medical conditions are properly treated, especially when it comes to your cardiovascular health, so that this increase in blood pressure does not cause complications. In the studies on Ketamine for depression, the risk of issues from this temporary blood pressure increase has been miniscule, but it’s good to be conscientious, regardless.

These are the three most common, but like any medication, there are many other possibilities. Full list of possible side effects: Ketamine Side Effects: Common, Severe, Long Term - Drugs.com 

Does age play a role? Will Ketamine work in older adults?

The research does not show a difference in older vs younger people in terms of Ketamine’s ability to work, so even if you have had depression for decades, it is still totally viable. Pilot Randomized Controlled Trial of Titrated Subcutaneous Ketamine in Older Patients with Treatment-Resistant Depression - ScienceDirect For older adults, we should be conscientious about other medical conditions and the risks, but given the side effect profiles of Ketamine vs long-term psychiatric meds, Ketamine is quite favorable overall.

Do you provide Ketamine-Assisted Psychotherapy, or just the medicine?

At this time we do not provide formal psychotherapy services. Our staff act as guides, assisting with setting an intention for the session, facilitating a healing mindset and therapeutic environment (“set and setting”), providing reassurance when needed, and monitoring for safety. We coordinate with your outpatient psychotherapist to assist with the care you are already receiving with a therapist you know and trust.

We also know from extensive research on NMDA blockade and disruption of reconsolidation that medication-assisted exposure therapy for anxiety and PTSD is equally effective when given after a therapy session.  See review by ketamine pioneer John Krystal and colleagues and here’s a recent example of human NMDA blockade by the ketamine-related drug D-Cycloserine.

What conditions does Spravato treat?

■ Treatment Resistant Depression*

■ Depression with SI

How long are the treatments?

The process takes approximately 2 hours of being monitored after receiving nasal sprays

Can I drive myself home after treatment?

After the recovery time, you will need a driver to take you home. It is suggested to rest the remainder of the day and not make any big or legal decisions or operate any heavy machinery.

How many treatments will I need?

The Spravato initial series is 2 treatments per week (at least 1 day in between) for 4 weeks. If there is a good response, then treatments are spread out to 1 treatment per week for 4 weeks. After this point, how often a person needs booster treatments will depend on how long the antidepressant effect lasts for that individual person.

What Contraindications Would Disqualify Me From Recieving Spravato?

■ Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels) or arteriovenous malformation.

■ History of intracerebral hemorrhage (brain bleed)

■ Hypersensitivity (allergy) to esketamine, ketamine, or any of the excipients.

■ It may not be a suitable option for those who have a history of substance abuse or a diagnosed addictive disorder, depending on the circumstances.

What Are Most Common Side Effects?

Most common side effects are dissociation, dizziness, nausea, sleepiness, diminished sensation, blood pressure increase.

What Medications Should Not Be Combined With Spravato?

CNS depressants (e.g., benzodiazepines, opioids, alcohol):

■ Having both in your system may increase sedation

■ Benzodiazepines before or during treatment may cancel out benefits of ketamine

Psychostimulants (e.g., amphetamines, methylphenidate):

■ Having both in your system may increase blood pressure

What is Dissociation?

Patients may describe these symptoms as feeling disconnected from themselves, their thoughts and feelings, space and time. The most common psychological effects of Spravato have been dissociative/perceptual changes (including distortion of time and space, and illusions), derealization, and depersonalization.

Is there a difference between Ketamine and Esketamine (Spravato)?

In a head-to-head comparision, IV Ketamine did better than Spravato, so that is something to consider when deciding between them. Comparative efficacy of racemic ketamine and esketamine for depression: A systematic review and meta-analysis - ScienceDirect

What conditions does TMS treat?

■ Treatment resistant depression*

■ OCD

■ Many more are emerging, so stay tuned

What does TMS stand for?

■ Transcranial Magnetic Stimulation

■ Just like a wireless charger, it works by rapidly changing a magnetic field which causes an equal & opposite electrical response in the brain.

■ Theta Burst Stimulation (TBS) is a special type of TMS.

Which TMS machine will AP be using?

■ MagVenture

How does TMS work?

During treatment, magnetic pulses are delivered through a magnetic coil to stimulate nerve cells in the part of the brain controlling the mood. Repeated stimulation of this area of the brain can have an antidepressant effect on people suffering from Major Depressive Disorder (MDD). TMS (transcranial magnetic stimulation) therapy has been recommended by the American Psychiatric Association since 2010 for treatment of major depressive disorder.

It may furthermore be used as an adjunct treatment of adult patients suffering from Obsessive Compulsive Disorder (OCD).

Watch A Video About How We Think TMS Works

How long are treatments?

■ 3 min for depression (Thetaburst coil)

■ 37 minutes for OCD

■ Newer studies are trying out different treatment regimens, so stay tuned!

How many treatments are needed?

36 treatments total, so daily (M-F) for 7 weeks

What is a “Mapping” and “Motor Threshold”?

We use the motor cortex that controls your right hand to find:

■ How strong a pulse we need to get through your skull

■ Where we are in the brain and find target areas compared to here

■ We re-map 3X throughout the series (every 2 weeks)

What Are The Contraindications That Would Disqualify Me From TMS/TBS?

Serious injury or death may occur if any of the following are not disclosed:

■ Implanted electronic devices and/or Conductive Objects in or near the head

■ Non-Removable metallic objects within 30 cm/11.8 inches from the coil

■ Implanted devices activated or controlled in any way by physiological signals

■ Ferromagnetic (iron-based) or other magnetic sensitive metals implanted in the head

■ Examples include:

·      Cochlear implants

·      Implanted electrodes/stimulators

·      Aneurysm clips or coils

·      Stents and bullet fragments

Will TMS/TBS work for me?

Some people respond faster to treatment than others. Furthermore, although TMS in studies have shown to be beneficial to many patients (approximately 50% response and 30% full remission), it may not work for everyone.

Blumberger et al, The Lancet, 2018, The Lancet

Is there anesthesia involved in this treatment?

No, this is a non-invasive treatment

Will TMS affect my memory?

No, studies show it can even improve your thinking especially if that is part of your depression. Because it does not require general anesthesia and does not produce a seizure, it does not carry the memory risks of electroconvulsive therapy (ECT).

What are the side effects of TMS?

Some patients report of a mild discomfort at the site of treatment or headache. TMS Therapy is a medical procedure and any side effects experienced during or after receiving the therapy should be reported to your doctor.

Can I resume regular daily activities after treatment?

Yes.  There are no known impairments or lasting effects that would impair judgment or reaction time.

Should I continue my medications while having TMS treatments?

■ There is evidence that TMS is effective alone without medications.

■ Insurance may require you to be on an antidepressant.

■ It is also important not make any medication changes without your provider’s instructions.

■ Medication changes during treatment can affect how responsive your brain is to the stimulation.