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New Year Brings Fast-Acting Treatment for Depression: Ketamine

By Eric Milbrandt, MD, MPH

Depression is characterized by low mood lasting at least two weeks and is often accompanied by low self-esteem, loss of hope, lack of interest in activities, and unexplained pain. Depression affects 1 in 5 people at some point in their lifetime. Some have periods of depression separated by years of “normal” mood, while others have nearly continual symptoms for many years to decades. Depression negatively impacts all aspects of a person’s life, including personal relationships, work, education, sleep, eating, and health. Most concerningly, as many as 8% of adults with major depression die by suicide.

Depression has many overlapping causes, including genetic, environmental, and psychological. Contributing factors include family history of depression, major life changes, certain medications, chronic medical problems, and substance abuse. Genetics plays a role in about 40% of cases.

Counseling and antidepressant medications are the mainstay of treatment. Unfortunately, these treatments take weeks to months to work. For 20-33% of depressed patients, counseling and antidepressants are ineffective, leading many to fall into despair. In the past, these “treatment-resistant” patients’ only hope of returning to normal was electroconvulsive, or shock, therapy. Shock therapy helps about 60% of the time, but side-effects such as confusion, memory loss, and muscle aches are common.

Ketamine – an old drug with a new use
Ketamine is a medicine developed more than 50 years ago for anesthesia during surgery and other painful procedures. High-dose ketamine has been used safely for that purpose in children, adults, and animals for decades. More recently, low-dose ketamine has been found to be a valuable and highly effective treatment for depression, anxiety, and certain pain disorders.

About 15 years ago, medical researchers began studying low-dose ketamine infusions for treatment-resistant depression. Since then, studies have proven conclusively that the drug not only works but works quickly. Studies show that ~70% of treatment-resistant depression patients see improvement in symptoms within 24 hours of being injected with low-dose ketamine. According to Yale researchers, its effects are highly rapid and long-lasting. The effects from a single infusion last between seven and 14 days.

In an official consensus statement published in 2017 in the journal JAMA Psychiatry, the American Psychiatric Association states that ketamine “produces rapid and robust antidepressant effects in patients with mood and anxiety disorders that were previously resistant to treatment.” The consensus statement go on to establish standards for providing IV ketamine treatments for mood disorders, including patient selection, clinician training, drug dosage and delivery, follow-up, and essential safety measures. In doing so, the consensus bring ketamine infusion out of the realm of experimental research and into everyday medical clinics, such as The Infusion Clinic of Ocala.

Ketamine infusion – what to expect
Before beginning treatment with ketamine, your infusion provider will thoroughly review of your history and perform a physical exam to determine if ketamine is right for you. Treatment consists of two phases. The first, a loading phase, consists of six 40-minute infusions given in an outpatient clinic over a two-week period. Many patients experience relief within hours of their first infusion and most know by their third infusion whether they will benefit from ketamine. After the initial loading phase, 40-minute maintenance infusions are given typically once a month, though some patients can stretch this out farther. While undergoing ketamine infusion therapy, the patient continues to work with their primary medical provider, psychiatrist, and/or therapist. Adjustments to any of the patient’s chronic medications remains under the direction of these providers, who receive progress reports from the infusion provider to be sure they are kept in the loop.

Patients are typically awake and interactive during the infusion, which achieves an effect described by the American Society of Anesthesiologists as “minimal sedation or anxiolysis.” Some patients describe colors as being more vibrant and sounds being more accentuated.

Side effects of ketamine infusion are generally mild and self-limited. Nausea near the end of the infusion is the most common reaction, occurring in <5% of patients, and is treated with antiemetics, such as Zofran. Less commonly, anxiety reactions can occur and are treated with IV benzodiazepines, such as Versed. Your provider will be well-prepared to manage these and any other reactions that might occur.

Patients should not eat food within 6 hours or drink fluids within 2 hours of their infusion. In our clinic, The Infusion Clinic of Ocala, you are welcome to bring a companion to be with you during your infusion. We recommend that you bring headphones and music that is relaxing for you. You will be placed in a comfortable massage recliner in a private room, an IV catheter gently inserted, and the infusion started. During the infusion, you remain connected to a device that monitors your heart rate, blood pressure, and oxygen level. You may listen to music, read, relax or even nap during the 40-minute treatment. Afterwards, you are required to stay for a short recovery period, typically 30-45 minutes. You will need to have an adult present to drive you home from your appointment.

Conclusion
Depression is a common and debilitating condition that robs a person and their loved ones of the joy of living life. Most cases improve with counseling and antidepressant medications, though these treatments often take weeks to months to be effective. For the 20-33% of patients with treatment-resistant depression, ketamine infusion therapy offers rapid and lasting relief. Find out more or schedule a consultation at www.infusionclinicocala.com or call (352) 325-5755.

Dr. Eric Milbrandt is owner of The Infusion Clinic of Ocala, located at 40 SW 1st Ave, Ocala, FL 34471. Dr. Milbrandt is a critical care medicine specialist with over 15 years of experience providing care to the sickest of hospitalized patients, including those with severe depression. He is board certified in Critical Care Medicine, completed a fellowship in Quality Improvement and a Master of Public Health at Vanderbilt University. He is a graduate of The Ketamine Academy, a leading provider of comprehensive online training for all major aspects of ketamine therapy. The content in this training adheres to the guidelines and recommendations published by The American Psychiatric Association, The American Society of Anesthesiologists, The American Association of Nurse Anesthetists and The American Society of Ketamine Physicians. In his own words:

I have personally struggled with depression much of my adult life. I know just how painful and debilitating this disease can be, not only for those suffering from it but for their loved ones as well. I have been fortunate to achieve good control with traditional pharmaceuticals, but as many as 1 in 3 patients with depression do not. Ketamine infusion therapy offers hope for treatment-resistant patients. I am thrilled to be able to offer this option locally for Ocala and surrounding areas.

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