Ketamine for depression – A Powerful but Tricky Solution


– Ketamine is a very
powerful anesthetic drug that’s made its way into psychiatry. I’m gonna talk about what it
does and what it doesn’t do. I’m Dr. Tracey Marks, a psychiatrist. And this channel is about mental health education
and self-improvement. Click subscribe and the notification bell if you don’t wanna miss an episode. Ketamine is known on
the street as Special K. It’s a hallucinogen and
induces dissociation, which is detachment from your environment. In clinical medicine, the
drug is primarily used to start and maintain anesthesia. It’s a dissociative
anesthetic, which means it makes you immobile,
it makes you forget, but it doesn’t completely
make you unconscious. And so, that’s why its usually used in conjunction with
another anesthetic agent. It’s one of those medications that gives you that floating feeling. Chemically, it’s an NMDA receptor agonist. NMDA stands for N-methyl-D-aspartate. How it treats depression is still unclear, but the latest thought
is that it’s through a metabolite or breakdown
product of ketamine. At lower doses than we use for anesthesia, ketamine does have
anti-depressant effects. In fact, not only does
it improve depression, but it removes it quickly,
and it’s the best drug we have so far to treat suicidality, even better than lithium. In 2000, the first randomized
control trial showed that ketamine produced rapid
improvement in depression. It’s not FDA approved yet
for the use in depression, but it’s gonna need more studies, and we need more answers
on longterm safety. So how does it work and what’s the catch? Ketamine is infused through an
IV, usually over 40 minutes. During and after the infusion, you can experience hallucinations and a feeling of depersonalization
or derealization. You can feel unreal or like
things around you aren’t real. But these effects are only
temporary, and go away within minutes to hours of
receiving the infusion. You can feel better within 24
hours, but here’s the catch. The antidepressant effect only lasts about five to seven days, but you can get some lower level of improvement that lasts maybe a week or two from
that single infusion. So to extend the effect, people will administer multiple infusions. How many infusions it takes for the person to get better and stay
better is individual, and we don’t have a set protocol for that. Some people have gotten
one or two infusions and then are maintained
on antidepressants, maybe at a lower dose than they were before they started the infusions, or some people will get a few infusions and then are maintained
on ketamine nasal spray. Currently to get the nasal spray, you have to go to a compounding pharmacy
to have it made for you. A compounding pharmacy
is a specialty pharmacy that makes preparations to
fit a specific medical need. So in this case, nasal ketamine is not commercially available, so a compounding pharmacy
will make the product. But, esketamine is a
commercial formulation that’s still in the approval phase to be used for
treatment-resistant depression and depression with
imminent risk of suicide. So, if and when that
medication is approved, it will be sold by Janssen Pharmaceuticals under the brand name Spravato. And that will eliminate the need to go to a compounding pharmacy. Newsflash, since I made this video, the FDA has approved Spravato. (people applauding)
Yeah, that’s right. But before you get too excited, here’s a few nitty gritty details. For the first four weeks you
do two treatments a week, then from week four to eight, you do a treatment once a week. Then after eight weeks, you can go either weekly or every two weeks. You can’t just go pick it up from the pharmacy and do it yourself. You have to go to your doctor’s office, and that doctor has to be registered within this monitoring system. Also, once you go and get the treatment, there’s certain rules or
procedures you have to follow. It’s similar to going and
getting a colonoscopy. You can’t eat or drink for a certain period of time beforehand,
and you’re required to sit in the doctor’s office for two
hours after you do the spray. You do the spray yourself, but then you have to
wait there for two hours, and you’re instructed to
have someone drive you home. So that’s a pretty big time commitment. Probably not much more than if you were getting the infusion, but I think because it’s the spray that it’s just implied or
people automatically think that it’s gonna be a whole lot easier. But it’s still very well
managed as far as the protocol and the rules to follow and all of that. Also, when you go to the
doctor’s office twice a week, are you gonna be charged
for those appointments? You don’t really have to see the doctor, but there’s gonna need
to be a dedicated person who does all of the monitoring and checking you in and all of that. So the answer is probably yes. It may be a nurse’s visit
or a medical tech visit or something, but I doubt that they’ll be no charge for you to show
up and get your spray. So despite all these little
nitty gritty details, this is still a breakthrough in the treatment of
treatment-resistant depression. (static crackling) What are the downsides? Well, as for side effects,
you have the dissociation that I mentioned, and then
other common side effects are things like nausea,
dizziness, and drowsiness. But another practical issue is cost. Here in Georgia, it could run
you $250 to $300 per infusion. And since this is not FDA approved, it probably won’t be
covered by your insurance. So if you need several insurance, then you’re talking about
spending about $1,000. And then on the maintenance, the nasal spray can run you
anywhere between $45 to $125 depending on how often you use the spray. Some people may only use it once a week, but some people could use
it three times a week. Then there’s the issue
of finding a provider. I’m in a metropolitan
area where there’s a few major providers who have people who are trained in the use of
anesthesia doing the infusion. But if you don’t have that, then you have to find a psychiatrist who is comfortable putting
a needle in your arm and running an infusion
and giving you anesthesia. I have a feeling the nasal spray won’t have as dramatic an effect or may not last as long as the infusion. Because there’s just no
substitute for putting something directly into your bloodstream. But, it can still make a huge difference in how we treat people
with suicidal depression and treatment-resistant depression. Check out my video on
treatment-resistant depression to get a better sense of the obstacles that we face in the current
treatments that we have, and share this video with others. See ya next time.

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Comments

  1. Hi Dr. Marks my doctor who is a cardiologist gave me a lexapro which I stop drinking because i thinkt has a side effect.Pls. help me need your opinion on this . I have an anxiety for aboout six months now. Thank you hope you' lle reply.

  2. Is borderline comboroid with ocd the worst and painful problem…or is there any more complicated and combined disorders..

  3. Thanks for making this video, I watched a few and subscribed because I like that you speak about mental illnesses and disorders without judgement. I had my first Ketamine infusion today. I've been diagnosed with BPD, major depression and I also have pretty severe chronic pain. My anesthesiologist had me do the infusion for my pain this morning, which has gotten so intrusive and mind numbing that I've had some suicidal episodes in the last 2 months (yes, more than 1), leaving me on sick leave from work.

    I'm definitely not 100 % ; even though I got unplugged from the infusion at around noon, I'm already starting to feel some of the pain relieving, which will greatly help my depression by proxy. But I'm glad to hear/learn it could also help my depression, not just by proxy of helping my pain. I know it's short lived, but the idea of having at least a handful of days with no depression sounds like a blessing right now, so I'll take it.

  4. Dr. Marks I am a 66 yo male who has suffered with anxiety and depression since I was in my late teens. I have also been diagnosed with CPTSD a few years ago. I have been in therapy for years and been on numerous anti depressants. I have thought about suicide and have dicussed it with my psychiatrist and therapist. I am at my wit's end. Things have gotten worse. I am seriously thinking about iv Ketamin. I have recently had an ablation for A Fib and was wondering if this would keep from having the treatment. I have no CAD or CHF. of course I will discuss it with my Cardiologist and EP. I need to do something.

  5. I inquired about ketamine treatments and was contacted by an office in a town about an hour away. I was told each treatment is $400.00 and its not covered by insurance. Also, they said I would be required to take 3-4 treatments at $400 each and then be treated depending on how I reacted to the treatments. Im on disability due to depression/anxiety and I'm told I'm probably treatment resistant due to the countless medications I've taken since 2008. How does anyone afford those ketamine treatments? I live in N.C.

  6. I did a series of 6 infusions a year ago, plus a few occasional boosters. I've had dysthymia with major depressions, for most of my life. Nothing else has ever actually helped me feel better. I wasn't sure if it was working for me until about the 4th infusion. But then I realized the relentless, vicious voice in my head was silent, for the first time I could ever remember. And I just felt calm, balanced, at peace. I felt like everything was going to be OK because I could handle whatever the future held. I was like, holy shit, I think this is was "normal" feels like… Downsides: Obviously the expense! Ack! And the possibility that you might need boosters for a while, or indefinitely. The disassociation is intense. You need to be OK with a very vivid mind trip. I describe my experience like, my body moving in dreamlike ways through psychedelic landscapes and tunnels of color and texture. I thought I had mellow music (with headphones) to listen to, Air, I think, but that was waaay too intense. I found Brian Eno's Music for Airports and the like, fully reclined, with a heated blanket in a dimly lit room, to be best for me. I immediately feel myself coming back to reality when the IV runs out. After about 30 minutes I'm back to normal and don't feel any lingering effects, although everyone's different. It's super important to find a doctor that has a lot of knowledge & experience. My doc started me a lower mg/kg dosage amount and gradually worked up, making sure I was OK with the disassociative effects. I can't imagine starting at a high dose… You'd need therapy just from that! lol Oh, and weird, but I also try not to drink anything for several hours beforehand. The IV fluids, plus side effect of ketamine make me have to go pee so badly! And trying to get up when all woozy with an IV attached to go to the bathroom just sucks. πŸ˜‰

  7. I’ve done it recreationally and it’s definitely not good at high doses for people with mental illness.

  8. I can't remember if I asked this but what are your thoughts on people starting lithium and having Hashimotos disease along with hypothyrodism? Do they have to fear "hashimoto's encephalopathy" like all the reports say?

  9. CORRECTION – I said Ketamine is an NMDA receptor agonist. It's an antagonist meaning it blocks the receptor.

  10. I took my ketamine in my drs office, placed amount in a small glass of water and held it under my tongue for a minute or so. The treatment lasted an hr and I was able to take the bus home by myself. The dissociative effects only lasted about 20 minutes and my psychiatrist sat with me as I worked through the effects. I even picked up my prescription myself and brought it to my drs office. It was not very expensive this way either, much less than the nasal spray.

  11. Dr Marks, thanks for the informative video. I've been approved for Spravato but want to share my experience in actually trying to get the treatment started. Janssen has a program called CarePath that can assist getting the Spravato for a $10 out-of-pocket co-pay per treatment. The maximum annual cap on that program benefit is $7150. That leads you to believe that, at $10 a treatment, you're most likely not going to exceed the $7150 limit during the calendar year. What they didn't tell me was that, behind the scenes, they charged my insurance provider $2075.33 for the initial Spravato that was delivered from the specialty pharmacy. So, in reality, if each treatment "benefit" is charged at $2075.33, you'll use up that CarePath total after the third treatment. I'm assuming that, after that time, the "real" cost will be applied to your deductible and, depending on your insurance caps, you could be responsible for alot of $$$ out-of-pocket to continue the treatments. The other issue I've found is related to the 2 hour observation period required at the doctor's office. Many psychiatrists never had a need to negotiate the codes related to the observation period with the various insurance providers until now. What I found was that, even though the codes were valid and accepted by my insurance provider, my MD wasn't approved to submit them. Therefore, if they did submit the codes for the 2 hour observation period, my insurance would reject the codes and the provider would have to eat the cost. So what did my MD do? She told me I would have to pay $590 out-of-pocket for each office visit to receive the Spravato. That amount won't come down until such time as my MD negotiates pricing and gets approved to submit those codes. Moral of the story? Just because Janssen and your MD say they offer the Spravato, make sure you understand all the "other" hidden costs that can drain your bank account.

  12. What about people who have psychotic depression or psychotic episodes? Isn't ketamine a pro-psychotic drug?
    And if it can take people out of depression is there a risk of kicking off mania?
    I suppose what I'm asking in a nutshell is do you think ketamine would be suitable for people who have very serious depression or bipolar 1 disorder — or even schizoaffective disorder?

  13. I would definitely recommend Ketamine for treatment resistant depression, if you can find a legitimate clinic in your area and if you have the means to afford it. I did one infusion a few moths ago (would love to do more in the future) and I do feel that it helped me and driving the next day after the infusion, at a red light, I was looking around at the cars passing in the opposing lane and I felt like I could see color again. Depression sucked the β€œcolor” out of everything in my life. Ketamine gave some of it back and I am grateful. I can only imagine how well I would feel after having the full course of infusions (6 infusions). It was a positive experience throughout. The only downside is the cost. Where I’m at it’s $480 per infusion. Best of luck to everyone out there that is suffering right now.

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