I recently had someone ask me several excellent questions about ketamine treatments for depression. They were such good questions, that I want to publish them with my responses below. I hope it helps answer some questions you may have as well.
I heard the benefit of the treatment last on average 2 weeks. Is this true?
It appears variable. We're seeing a range from about 2 weeks to 8 weeks. Most people fall in the 3-4 week range. For people who need to come in more frequently than once a month we consider ketamine extenders- such as sublingual ketamine. It does not work as well as the IV ketamine, but it can help people get a couple extra weeks of benefit.
Doctors don't know the consequences and potential side effects of taking doses long term over and over again. True?
No. It has been used in some pain patients in the longer term, and now has been used for depression in some patients for several years.
People can become dependent on it, and long term use has been linked to bladder toxicity and cognitive problems. True?
With medical ketamine, dosed intermittently for depression, long term side-effects are exceedingly rare.
Bladder toxicity is common with street abusers of ketamine, who tend to take higher doses on a daily basis. It appears to be related to the duration of use and frequency of the ketamine doses. Intermittent dosing - like we do with our initial series and boosters allow time for the bladder to heal itself from any insult before the next ketamine dose. I am aware of one patient in California who has been getting ketamine treatments for over 10 years who recently developed ketamine bladder toxicity. She feels urinary urgency and abdominal pain for about a week after each ketamine treatments, but she continues with them monthly because it is the only thing she has found that allows her to function normally. It is always a concern of mine, and we watch for it.
As far as cognitive deficits, they have never been shown with medical ketamine. In fact, generally concentration improves as a consequence of improving depression.
How safe is the environment administered? Is blood pressure monitored, as well as pulse?
We monitor all our patients' blood pressure, heart rate, oxygen level with pulse oximetry, and EKG throughout the procedure using surgical level monitoring. All staff is either BLS or ACLS certified.
If you have any other questions about ketamine for depression, PTSD, bipolar we'd be happy to personally answer them. Just shoot an email to firstname.lastname@example.org
Kevin Kane, MD
A new paper in the journal Nature may have found another mechanism by which ketamine works.
People with depression may have an over-active lateral habenula (LHab), which is called the "anti-reward center" in the brain.
The LHab shows specific burst activity which appears to drive the anhedonia seen in depression.
Ketamine tames this burst activity, making the anti-reward center less active, and allowing people to feel reward and pleasure again.
I'm happy to announce that I'll representing Wisconsin at the KRIYA Ketamine Conference in San Francisco this November. This conference is the largest gathering of ketamine practitioners in the country, and probably the world, with speakers coming form as far away as England and New Zealand.
At the KRIYA Conference practitioners from multiple specialties and top researchers exchange ideas on all things ketamine. We'll be discussing routes of administration, best practices, and other aspects of using ketamine to treat depression, OCD, PTSD, and more.
The speakers at KRIYA 2017 include the some of the world's leading ketamine specialists including researchers Gerard Sanacora from Yale, Carolyn Rodriquez from Stanford, and clinicians Steven Levine and Steven Mandel, who have a combined experience of well over ten thousand ketamine infusions.
I'm excited to be able to discuss ketamine with some of the leading minds on the topic- and most importantly, for a chance to bring that knowledge back to the people of Wisconsin.
Kevin Kane, MD
Ketamine therapy is not more mainstream for a couple of reasons. First of all, medicine is slow moving, with lots of inertia- especially here in Wisconsin and the midwest. Many physicians want to see large randomized controlled trials and years of experience with a drug before using it. With ketamine, we have 50 years of experience using it as an anesthetic, and somewhat less for depression- around 10 years- but there are still few large studies.
To find the reason, as usual, follow the money.
As a generic drug, pharmaceutical companies don't have a financial incentive to study ketamine- they can't patent and make money off it - so there is less money available to fund large-scale studies. Most likely they will never happen.
Another reason ketamine is not yet mainstream relates to complaints of potential side-effects. I hear psychiatrists say that the dissociative side effects are risky. I disagree. At the sub-anesthetic doses we use, the side effects are mild, self-limiting and resolve within 20 minutes of stopping the infusion.
Some physicians also worry about long-term cognitive side effects with ketamine. The only studies showing adverse long-term cognitive effects that I have found involve much higher and more frequent does than what we give for depression and mood disorders- think chronic drug abusers. More studies on this with sub-anesthetic doses for depression do need to be performed. However, depression itself has cognitive side-effects, and lifting depression has such a strong positive effect on improving concentration and overall functioning, that I don't know how you can really say that clinically ketamine has adverse cognitive effects. (It's funny, some of the same docs will give someone 30 ECT treatments causing severe short-term memory loss, but it's ketamine they worry about ECT.)
There is one side effect I worry some about, ketamine cystitis. It has been described in chronic, daily abusers, but never in patients using low-dose ketamine for depression or pain. I always ask patients about urinary symptoms and will discontinue therapy if that ever occurs.
With all that being said, ketamine is rapidly gaining acceptance by the medical community because they cannot dispute that it is effective- even when standard treatments have failed. In fact, the American Psychiatric Association just put out a very favorable consensus statement on the use of ketamine for mood disorders this past May.
As with all medical therapy, one must weigh the risks and benefits of ketamine infusions for depression. I don't recommend ketamine as a first-line drug for depression at this time. But for about 1/3 of people with depression who have tried 2 or more conventional medications without relief, ketamine offers hope for rapid and real improvements in their depression and their lives.
Ketamine continues to get national press coverage. This week the LA Times ran a big feature on a ketamine clinic in California. We are proud to bring that same new depression treatment to Wisconsin.
According to the article, "Nobody in the psychiatric community disputes that ketamine infusions are a highly effective treatment for depression."
To help you understand the effects of ketamine on depression, they interview several patients.
They quote a patient named Angel Piper who "describes a '180-degree difference' in her mental health." She told the Times she was more functional, doing things around the house that she just couldn't before. "I suddenly realized I was doing all the things that were so impossible to do for so long."
Another patient told the paper that after ketamine, "instead of wasting another weekend in bed, she went on a bicycle ride, something she had't been able to do for the last 18 months." She was quoted, "I thought that ketamine would give me all this energy, like I'd want to run ten miles in the morning. That didn't happen. But now anytime I need to do something, it's just that much easier. It's not rocket boosters. It's more like power steering, but that feels really, really nice."
If you are in Wisconsin and considering ketamine for yourself or a patient, please contact us to learn more.