What is Ketamine? How is it used to treat depression and how does it work?
Ketamine is an anesthetic medications that has been around since the 1960’s. Today, it is often the first line medication for temporary anesthesia for children in the emergency department because of its excellent safety profile, and has also been found to be extremely helpful in treating depression, even in individuals with severe cases who have not responded to multiple other treatments. Unlike typical antidepressants, ketamine works very rapidly, and people can notice improvement in their symptoms within hours. In Dr. Hoffman’s psychotherapy suite, ketamine is most often administered intramuscularly, and both Dr. Hoffman and a co-treating psychotherapist monitor the patient the entire time in a comfortable setting. Our treatment team aims to ensure an optimized whole person healing experience. This is true for the initial encounter, medication management, diet and lifestyle counseling, mindfulness facilitation, ketamine administration, psychotherapy before, during and after administration, as well as all follow up care visits.
What about ketamine-assisted psychotherapy?
Combining ketamine with psychotherapy, or mindfullness, can yield an even greater benefit than ketamine treatments alone. The altered states of consciousness that arise during the ketamine experience provide for significantly more material to work with than a typical therapy session, especially in the context of a long-term therapeutic relationship. While studies examining this particular application of ketamine are limited, work with other compounds that create altered states of consciousness--such as MDMA, LSD, and psilocybin--suggest an important role of altered states and psychotherapy that is independent of the well established biochemical antidepressant effects of ketamine. Research into "classical hallucinogens" (LSD, psilocybin, mescaline, DMT, ayahuasca) drastically slowed in the 1970s due to political pressure, but have in recent years resumed with promising preliminary findings. Similarly, the well known entheogen MDMA (methylenedioxymethamphetamine), was used by psychiatrists in the 1980s to augment psychotherapy. Results were quite promising, but research essentially halted after the DEA scheduled MDMA as a controlled substance in 1985, resuming only recently. Studies of MDMA-assisted psychotherapy suggest efficacy in treatment of PTSD, even in individuals who exhausted all other available treatment methods. Perhaps most exciting is the study that suggests benefits from such assisted psychotherapy last for years after the initial course of therapy. Ultimately, patients who undergo ketamine sessions are encouraged to continue with or begin their own psychotherapy, though this is not an absolute requirement to treatment. Individuals with an existing therapist are welcome to continue seeing them, and those without have the option to be seen by one of the therapists who works with Dr. Hoffman.
Patients who are interested and able to commit to an intensive mindfulness program, and meet all other qualifications, may after review with Dr. Hoffman, be good candidates for Ketamine-assisted mindfulness. In this approach, Dr. Hoffman and the patient use mindfulness based techniques to help navigate what is going on in their lives, and develop a sense of sustainable contentment. These techniques are also applied around ketamine sessions. We examine what arises before, during, and after ketamine sessions. Ketamine session can provide a broad spectrum of emotions and experiences with which to practice and gain perspective, insight, and wisdom. With this approach, patients are also encouraged to continue their outside therapy for integration work.
Is ketamine safe? What are some reasons I would not be eligible (contraindications)?
Ketamine is a unique among anesthetic medications in that it is extremely safe, having been used in various settings for more than fifty years, even in poorly monitored settings such as battlefield anesthesia and developing countries, "ketamine has a good safety profile and is easy to use, especially in under-resourced health systems and emergency settings where clinical conditions and medical equipment are generally not available" (World Health Organization). Ketamine has an even higher margin of safety when used to treat depression because such doses are much lower than those used in surgery. Patients typically remain conscious the entire time, though may feel somewhat altered and experience perceptual changes. When used in higher surgical and anesthetic doses, ketamine requires the presence of a trained physician for full airway and cardiac monitoring, while the lower doses used in depression do not. There are specific reasons you would not be eligible for ketamine, including recent myocardial infarction (heart attack), recent psychosis (hallucinations, delusions), or recent bladder inflammation (cystitis). Administration of ketamine and medical monitoring throughout the session is performed by Dr. Hoffman who has training in airway management techniques.
What is the best route of administration for treatment of depression?
Ketamine can be administered in several different ways: Intravenous (IV), intramuscular injection (IM), intranasal, sublingual, and oral. IV has been used in the most studies for depression as it is the route that is also used for anesthesia and hence the most familiar. IM treatments appear to have equal efficacy to IV for most conditions, while having the benefit of increased patient comfort and lower cost. Sublingual dosing is convenient for lower doses and may even be transitioned to at home use after patients have proven well.
Am I a good candidate? How are ketamine treatments structured?
Prior to initiating ketamine treatments, I schedule potential patients for an initial medical evaluation. On this first meeting, we will determine a diagnosis, develop a treatment plan, and assess for any medical or psychiatric issues that may interfere with ketamine treatment. If we mutually agree that ketamine could be beneficial, then we can schedule a subsequent visit for the actual administration. The greatest benefit of ketamine is attained with multiple administrations over the first month of treatment, which is then followed by periodic booster treatments to maintain freedom from depression. I ask patients to commit to a series of 3-6 administrations over about 4-6 weeks, and many patients will then return for periodic booster treatments about every 1-2 months thereafter to prevent depression from returning. It is also possible that some patients may benefit from periodic at home lozenge treatment after the initial series. Please note, it is always your option to stop treatment at any time. Patients must have a friend or family member pick them up after the appointment, as ketamine temporarily impairs one's ability to drive. Ketamine sessions are scheduled for 3 hours in duration, and involve a brief medication management visit, pre-administration psychotherapy or mindfulness session, the actual ketamine administration, followed by post-administration psychotherapy or mindfulness, all of which is integrated into the visit with Dr. Hoffman and usually a therapist.
Are there any precautions?
Individuals receiving ketamine should abstain from any food or drink for the 6 hours prior to receiving the medication, and furthermore, should not drive for the remainder of the day. This is a necessary precaution because the subtle after effects of ketamine can linger for hours after the treatment and impair the ability to drive. Effects typically resolve by the following day, at which time driving is allowed. Typically patients arrange a ride home with a friend or family member, and once tolerability is established can later use a taxi or ride sharing service to return home.
What is the cost of ketamine treatments? Do insurance companies cover it?
I do not directly contract with insurance companies, but instead collect the full fee at time of the visit and provide patients with a superbill that can be submitted to their insurance provider for reimbursement. Visits may be partially covered depending on your insurance plan. The ketamine administration itself is generally not covered by insurance, however the typical 3 hour long ketamine treatment session involves several other components which may be reimbursed for: a detailed medical visit with long amounts of counseling(99215 + up to 5 times 99417). In addition, the initial medical evaluation visit (often 99205) is also typically covered. I suggest potential patients check with their insurance provider to see what their out-of-network coverage benefits are for the above procedures/CPT codes. PPO type insurances usually allow for out-of-network benefits, while HMO plans do not. All sessions can be done on a sliding scale. Ketamine assisted psychotherapy sessions cost $1200 and include all time with Dr. Hoffman and the therapist, as well as drug costs in the office. Ketamine assisted mindfulness sessions cost $750 per session. The 90 minute initial evaluation by Dr. Hoffman is $300.
What can you tell me about the use of ketamine for treatment of addiction or substance use disorders?
Ketamine has been studied for treatment of addiction, especially to the opiate and street drug, heroin. Findings suggest that ketamine, as part of a structured therapy program, can be very effective for the treatment of addiction. It has the potential to decrease the rate of relapse, as well as the severity of a relapse. This findings are perhaps due to biochemical properties as an NMDA receptor antagonist. While studies examining addiction treatment using ketamine are more limited than those examining treatment of depression, work with compounds that create similar states of consciousness--such as the "classical hallucinogens” suggest a role for altered states independent of the biochemical effects of ketamine. Such compounds seem to work to treat addiction via their ability to produce spiritual or mystical experiences. This mystical experience is present in a growing body of literature detailing successful and robust treatment of tobacco and alcohol addiction. Use of classical hallucinogens is illegal, except for ketamine which has been FDA approved for other indications and is consequently available for off-label use to treat such diagnoses as depression, post-traumatic stress disorder, and addiction / substance use disorders.
What other psychiatric conditions has ketamine been used for?
Treatment resistant depression is, by far, the most extensively studied psychiatric application of ketamine, and has a wealth of data to support its use. Other indications (or reasons to use ketamine) include addiction, drug or alcohol use disorders, Post-Traumatic Stress Disorder (PTSD), anxiety, and eating disorders such as anorexia or bulimia.