Ketamine Therapy
Ketamine is an FDA-approved anesthetic agent that can be used as an in-office, medically monitored treatment for depression.
Is Ketamine Available In My State?Table of Contents
- What is Ketamine?
- How does it work?
- Potential for addiction?
- Do I stop other medications?
- What do patients experience?
- How long will the results last?
- Should I continue seeing my provider?
- Is it expensive?
- Are there any dangerous conditions?
- What are the risks?
- How do I maximize the benefits?
- How does Ketamine compare?
- Citations
- Frequently Asked Questions
What is Ketamine?
Ketamine is a medication that has been used in general anesthesia for decades. About 25 years ago, researchers at Yale discovered that ketamine can lead to a dramatic improvement in symptoms of depression, even in patients who have severe, chronic, treatment-refractory mood disorders. Ketamine is an FDA approved anesthetic agent. Use of Ketamine outside of the anesthesia application is considered an “off label” use. At sub anesthetic doses (doses below the amount necessary for anesthesia), Ketamine may be useful in the treatment of depression.
How does it work?
Ketamine infusion works by providing medication directly into the bloodstream through an IV infusion. Ketamine works to treat depression by altering brain chemicals, including neurotransmitters and neurotropic factors, associated with depression and brain synaptic plasticity.1
According to one study, nearly 71% of patients experienced a least a 50% reduction in depressive symptoms and 29% no longer met criteria for a diagnosis of depression, the day following treatment.2
A typical treatment protocol includes 6 infusions over a 3-week time period, followed by maintenance treatment. Maintenance treatment every 2 weeks to 3 months, is typically required to sustain the effects.
Potential side effects from Ketamine include dizziness, bad dreams, perceptual disturbances including hallucinations and feelings of being separated from one’s body, confusion, elevation in blood pressure, euphoria, dizziness, and nausea. These side effects are transient and resolve prior to discharge. With proper education, monitoring and support, Ketamine treatment is well tolerated. Patients may not leave the clinic until deemed stable by medical staff members.
While Ketamine IV has demonstrated efficacy in treating Major Depressive Disorder and decreasing suicidal thoughts in patients with depressive disorders, there is increasing clinical evidence that it may also be effective in treating patient struggling with:
- Bipolar Depression
- Generalized Anxiety Disorder
- Obsessive Compulsive Disorder
- Post-traumatic stress disorder
- Eating Disorders
- Substance Use disorders
Is there a potential for addiction?
Some may have heard that Ketamine is used as a “party drug” and worry about addiction potential. Studies and clinical experience have found that in the very low doses used, medical setting, lack of access at home, and infrequent dosing, there is a low potential for addiction or abuse.
Do I have to stop my other medications?
There are very few medicines that cannot be taken in combination with Ketamine. When you arrive for an initial consultation, your doctor will look at your list of medications and advise you on any necessary changes. Never hide any medication from your doctors as this could result in the treatment not working or other dangerous consequences.
What do patients experience during Ketamine IV therapy treatment?
Patients participate in a consultation with a psychiatrist to review their psychiatric and medical history. This includes a review of medical concerns, medication they take and psychiatric symptoms that may rule out Ketamine as a safe treatment for a patient. Patients will complete depression and anxiety scales which, combined with the consultation, will help clarify if they have the type of depression Ketamine can help treat.
During treatment with a Ketamine infusion, a nurse will place an IV and the 40-minute infusion of medication will begin. Patients are closely monitored for side effects and supported if they become uncomfortable. Patients may begin to feel better within the first few days of treatment. Many experience dramatic relief of dread and hopelessness. Ketamine treatment is provided in a safe, nurturing and healing environment. Patients are treated in private, comfortable treatment rooms with space to accommodate a family member or friend. All treatments are supervised by a physician.
How long will the results last?
A single infusion typically lasts anywhere from a couple of days up to 1-2 weeks. A series of 6 infusions may last anywhere from weeks to months, and often a single booster infusion when effects are wearing off can restore response. The number of treatments needed for a positive response is highly dependent on each individual’s unique circumstances. For Ketamine infusions, it is recommended to have 6 within the first 2-3 weeks. After that, maintenance (booster) infusions may be scheduled to maintain response.
Should I continue seeing my current psychiatrist, therapist, or primary care physician as a follow-up after Ketamine therapy?
Yes. Our clinicians are serving in a consulting capacity to provide this procedure. In some cases, patients may choose to see one of our doctors as their primary psychiatrist. But in most cases, people will continue with either their primary psychiatrist or primary care doctor and are highly encouraged to either begin or continue talking with a therapist.
LifeStance Health specializes in Ketamine Therapy with multiple locations in 1 state. Services vary by location.
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Is it more expensive than taking an oral medication?
An infusion of Ketamine is more expensive than a typical doctor’s visit and medication copay. However, when also considering the financial toll of ongoing depression symptoms affecting work and social function, as well as multiple office visits and ongoing medication costs, rapid relief from depression by Ketamine is an excellent value.
Are there any conditions that may make Ketamine dangerous or ineffective?
Uncontrolled high blood pressure, unstable heart disease, increased intracranial or intraocular pressure, interstitial cystitis, active substance abuse, current manic phase of bipolar disorder, active psychotic (hallucinations or delusions) symptoms.
What are the risks?
The dose used for the treatment of mood and anxiety disorders is very low and safe. For a few minutes during the infusion itself, blood pressure and heart rate may increase. This is monitored to ensure safety and medications administered as necessary to manage problematic increases in blood pressure, episodes of nausea or anxiety.
How do I maximize the benefits of Ketamine Treatment?
It is common to get advice when depressed that makes sense intellectually but is impossible to follow through on because of the depressive symptoms. This includes things like, “eat well, exercise, engage in talk therapy, find social support, stay busy, etc.” Ketamine often helps patients be able to act on these important activities. In addition, Ketamine likely helps the brain with learning and making new connections. Talk therapy can be an ideal way to “lock in” therapeutic learning and capitalize on this unique benefit from ketamine infusion treatment.
How does Ketamine compare to other depression treatments?
Typical antidepressants take weeks to months to work. There are many to choose from and it can be difficult to know if one or another will be effective and well-tolerated. Many patients struggle with medication ineffectiveness or intolerable side effects medications have common side effects of weight gain, sexual dysfunction, gastrointestinal disturbances, sleep disturbance, fatigue, and emotional blunting. Some newer “add-on” antidepressants also have risks of causing diabetes and metabolic syndrome. Unfortunately, not everyone will respond to Ketamine, but patients typically see a difference within the first 2-3 treatments, this minimizes the amount of time or money invested in treatment.
Citations
1. Lener MS, Kadriu B, Zarate CA Jr. 2017 Mar;77(4):381-401. doi: 10.1007/s40265-017-0702-8. PMID: 28194724; PMCID: PMC5342919
2. Zarate CA Jr, Singh JB, Carlson PJ, Brutsche NE, Ameli R, Luckenbaugh DA, harney DS, Manji HK. Arch Gen Psychiatry. 2006 Aug;63(8):856-64. doi: 10.1001/archpsyc.63.8.856. PMID: 16894061
3. Comparative Effectiveness of Intravenous Ketamine and Intranasal Esketamine in Clinical Practice Among Patients With Treatment-Refractory Depression: An Observational Study. Singh B, Kung S, Pazdernik V, Schak KM, Geske J, Schulte PJ, Frye MA, Vande Voort JL. J Clin Psychiatry. 2023 Feb 1;84(2):22m14548. doi: 10.4088/JCP.22m14548. PMID: 36724113
4. Rapid neuroplasticity changes and response to intravenous ketamine: a randomized controlled trial in treatment-resistant depression. Kopelman J, Keller TA, Panny B, Griffo A, Degutis M, Spotts C, Cruz N, Bell E, Do-Nguyen K, Wallace ML, Mathew SJ, Howland RH, Price RB. Transl Psychiatry. 2023 May 9;13(1):159. doi: 10.1038/s41398-023-02451-0. PMID: 37160885 Free PMC article.
5. Efficacy and safety of racemic ketamine and esketamine for depression: a systematic review and meta-analysis.
Bahji A, Zarate CA, Vazquez GH. Expert Opin Drug Saf. 2022 Jun;21(6):853-866. doi: 10.1080/14740338.2022.2047928. Epub 2022 Mar 9. PMID: 35231204 Free PMC article.
6. Ketamine for bipolar depression: an updated systematic review. Fancy F, Haikazian S, Johnson DE, Chen-Li DCJ, Levinta A, Husain MI, Mansur RB, Rosenblat JD. Ther Adv Psychopharmacol. 2023 Sep 26;13:20451253231202723. doi: 10.1177/20451253231202723. eCollection 2023. PMID: 37771417 Free PMC article.
7. Real-world experience of esketamine use to manage treatment-resistant depression: A multicentric study on safety and effectiveness (REAL-ESK study). Martinotti G, Vita A, Fagiolini A, Maina G, Bertolino A, Dell’Osso B, Siracusano A, Clerici M, Bellomo A, Sani G, d’Andrea G, Chiaie RD, Conca A, Barlati S, Di Lorenzo G, De Fazio P, De Filippis S, Nicolò G, Rosso G, Valchera A, Nucifora D, Di Mauro S, Bassetti R, Martiadis V, Olivola M, Belletti S, Andriola I, Di Nicola M, Pettorruso M, McIntyre RS, di Giannantonio M; REAL-ESK Study Group. J Affect Disord. 2022 Dec 15;319:646-654. doi: 10.1016/j.jad.2022.09.043. Epub 2022 Sep 24. PMID: 36167246
8. Treating bipolar depression with esketamine: Safety and effectiveness data from a naturalistic multicentric study on esketamine in bipolar versus unipolar treatment-resistant depression. Martinotti G, Dell’Osso B, Di Lorenzo G, Maina G, Bertolino A, Clerici M, Barlati S, Rosso G, Di Nicola M, Marcatili M, d’Andrea G, Cavallotto C, Chiappini S, De Filippis S, Nicolò G, De Fazio P, Andriola I, Zanardi R, Nucifora D, Di Mauro S, Bassetti R, Pettorruso M, McIntyre RS, Sensi SL, di Giannantonio M, Vita A; REAL-ESK Study Group. Bipolar Disord. 2023 May;25(3):233-244. doi: 10.1111/bdi.13296. Epub 2023 Jan 18. PMID: 36636839
Dr. Dalthorp is board certified by the American Board of Psychiatry and Neurology and a Fellow of the American Psychiatric Association. She is a former member of the board of directors for the American Association of Ketamine Physicians and founding board member of the nonprofit International Society of Reproductive Psychiatry. She currently serves as Secretary and member of the Executive Council, CME, and DEI committees of the Oklahoma Psychiatric Physicians Association.
FAQ: Evaluating and Managing Patient Risks in Ketamine Treatment
- Treatment Resistant Depression, or TRD, is a form of Major Depressive Disorder in a patient who has previously taken or is currently taking traditional antidepressant medications but continues to experience depression. Even after weeks of taking medication and increasing dosages, the medication isn’t effective at relieving the symptoms of depression. Patients who take antidepressant medications but cannot continue them due to medication side effects are also classified as having TRD.
- Initial screening is done through the use of validated scales as well as a clinical interview.
- Data is collected on prior antidepressant and psychotropic medication history and side effects, as well as information on the severity of symptoms, history of inpatient hospitalization, and prior suicide attempts.
- Validated screening tools and DSM IV diagnostic criteria are used for each patient.
- Patients are also screened for undiagnosed bipolar disorder, a history of psychosis, and past or present substance use disorders.
- A thorough psychiatric history, including co-occurring mental and physical health disorders, is collected and integrated into the treatment plan.
- The patient’s prescription monitoring report is reviewed prior to initiating treatment to ensure a patient doesn’t have a history of controlled prescription substance abuse and isn’t currently taking controlled substance that could increase the risks of treatment.
- Patients are screened for early-life trauma using an adverse childhood experience scale. Childhood trauma is a known factor that makes patients more sensitive to the dissociative side effects from ketamine and esketamine, and knowing this ahead of time allows us to be cautious with dose and provide extra support to keep patients comfortable during treatment.
- Patients are screened to ensure they do not have physical health conditions that might put them at greater risk during ketamine treatment.
- Patients with hypertension are referred to their primary care provider for treatment before initiating ketamine treatment or if concerns arise during a ketamine treatment.
- Patients are educated about medications they are currently taking that may increase sedation or blood pressure, and they are asked to hold these medications on the day of treatment.
- Patients are closely monitored during treatment. This includes monitoring blood pressure and heart rate prior to beginning treatment. Blood pressure, heart rate and oxygen level are also monitored during treatment, at peak medication concentration, and prior to discharge from the clinic.
- Ketamine and esketamine aren’t first line treatments for depression. By the time a patient considers these treatments, they are likely to have moderately severe to severe depression, and many patients may have thoughts of suicide. We consider risk of untreated illness versus risk of treating with these medications as part of treatment planning and patient consent.
- Mental health and medical records are requested and reviewed as needed.
- Collaboration with specialists (cardiology and neurology) is conducted to obtain “clearance” for treatment when indicated.
- Participation in psychotherapy is recommended for all patients receiving ketamine treatment.
- Treatment side effects are screened at every visit to inform ongoing care.
- The patient’s medication list is reviewed and updated as needed.
- Suicidal ideation is screened at every visit, with appropriate steps taken to support the patient and avoid self-harm.
- Patients are not allowed to receive Spravato in conjunction with ketamine infusion or externally prescribed oral ketamine.
- While ketamine has not been studied for safety in pregnant women, animal studies have indicated it could be harmful to a developing fetus. Risks of a fetal exposure to ketamine are minimized by ensuring patients know to use reliable birth control, asking patients when their last menstrual period was and doing a pregnancy test if there is a concern for pregnancy.
- Patients must be at or near their baseline mental status and able to safely move around and care for themselves before discharge.
- A driver must sign the patient in and out to reduce the risk of post-treatment accidents. Violations of the driving policy can result in termination from treatment with ketamine or esketamine.
- Patients are administered depression and anxiety screenings such as the PHQ-9 and GAD-7 at every visit.
- The patient’s response to ketamine treatment is reviewed with the patient to determine whether to continue into maintenance treatments.
- Screening tools are used to measure symptom improvement, with a goal of at least a 50% decrease in a patient’s depressive symptoms. In cases of a lesser response, subjective quality of life improvements and collateral information from the patient’s primary support person are considered in treatment planning.
- With the patient’s permission, updates are sent to their healthcare providers.
- Referring clinicians are informed if the patient was not scheduled or deemed not a good candidate for ketamine treatment.
- Updates regarding the treatment response and maintenance plan are sent to all referring providers.
- All ketamine treatments are supervised by a specialty-trained, licensed physician (board-certified psychiatrist). All esketamine treatments are supervised by a board-certified psychiatrist or an advanced practice practitioner with specialty REMS (risk evaluation and mitigation system) certification.
- The care team includes specialty-trained psychiatrists who are responsible for ordering and supervising treatments. Additional care team members include advance practice practitioners, licensed nurses and medical assistants. Everyone on the care team receives extensive hands-on, specialty training to support patients and manage treatment side effects. All team members maintain Basic Life Support (BLS) certification and familiarity with emergency response protocols, including monitoring patients at risk of respiratory depression and falls.
- Clinics are equipped with adjustable beds, pulse oximetry, and an emergency cart, including an oxygen tank and ventilation equipment.
- Each patient is also monitored by the care team via live video (not recorded or maintained) to ensure patients are constantly monitored in the event the patient needs assistance in between regular nurse monitoring and vital sign measurement. Patients are given a call button for immediate assistance, and support persons may accompany the patient during treatment. The support person must agree to our clinic visitor rules to protect patients and keep the experience comfortable.
