Depression can be a disabling and potentially deadly disorder. Even though there are many good medications to help with depression, their effects are typically slow in onset (a matter of weeks), and often require several trials of different medications before finding a medication that works well. At the worst, some people just do not respond even to multiple trials of antidepressants (about 30% of patients), which can lead to missing work or school, disability leave, inability to care for oneself or family, and even hospitalization and more dramatic interventions such as ECT (Electroconvulsive Therapy).
However, over the last decade, researchers at the U.S. National Institutes of Health and worldwide have been looking into novel ways to battle depression, and have found the use of ketamine infusion to have extremely rapid (less than 24 hours for many) and profound improvement in depression for many sufferers, even those that have not benefited from multiple other medications and even ECT treatments. Strong research has shown that ketamine can quickly and significantly ease the burden of depression and may overall speed the recovery from the disabling effects of depression.
Practically speaking, ketamine therapy may save a sufferer time, money, and the pain of experiencing a severe depressive episode, and put them on the road to recovery more rapidly than using traditional antidepressant medications or other therapies alone.
How Ketamine Works To Treat Depression
Standard antidepressants like Prozac work on a group of chemical messengers in the brain called the serotonin system. Researchers once thought that a lack of serotonin was the cause of depression, and that these medications worked by simply boosting serotonin levels in the brain.
More recent research suggests a more complicated explanation: serotonin medication work in part by stimulating the birth of new brain cells, which eventually form new connections in the brain. But creating new brain cells takes time — a few weeks, at least — which is thought to explain the typical expected delay in response to antidepressant medications, for the most part.
Ketamine, in contrast, works on a different neurochemical system in the brain – the glutamate system. Researcher Ron Duman at Yale believes ketamine rapidly increases the communication among existing brain cells by creating new connections among them. This is a quicker process than waiting for new neurons to form via the serotonin pathway, and accomplishes the same goal of enhancing brain circuit activity.
Ketamine vs. ECT vs. TMS
ECT, Electroconvulsive Therapy, has for decades been a dramatic treatment for severe psychiatric disorders, including depression that is unresponsive to psychotherapy and antidepressant medications. ECT typically consists of a hospitalized patient receiving brief electrical pulses over the scalp while completely under anesthesia, usually every other day for a week or two. If improved, a patient can be transitioned to outpatient hospital-based ECT sessions every other day for a week or so. Patients are then put on antidepressant medication, and followed as a regular patient would be from then on for outpatient medication management. However, most people will eventually relapse into depression at some point, necessitating re-hospitalization and more rounds of ECT treatment as before over the course of several weeks. Obviously, a patient undergoing ECT will be off work for several weeks, staying in the hospital for some time, will be under anesthesia several times a week, and will incur bills for hospitalization, psychiatrist fees, and anesthesiologist fees (these are covered by medical insurance, minus your deductible). Notable potential side effects of ECT treatment include persistent memory loss. However, ECT is the gold-standard at present for severe depression, and remarkably effective for the vast majority of patients.
TMS, Transcutaneous Magnetic Stimulation, is a recently offered, treatment for mild to moderate depression, whose clinical effectiveness is unclear. The FDA, controversially, approved the use of a TMS device in 2011. This device consists of a handheld magnetic coil that is placed on the scalp to induce small amounts of electrical activity in an outpatient office. No anesthesia or specific safety precautions seem necessary. A patient typically undergoes a one hour treatment session daily, 5 days per week, for 4 to 6 weeks (approximately 20 to 30 treatment sessions total). Very few insurance companies pay for TMS because of its controversial effectiveness, and an entire treatment course can therefore cost $10,000 to $20,000 out of pocket over the course of the 4 to 6 weeks of treatment. Most studies suggest that TMS therapy takes several weeks to work (just like typical antidepressant medications), and is ultimately no more effective than simply switching your antidepressant medication. In the end, it is not known at this point whether TMS can be used to treat depression for the long term, or if you may require periodic re-treatment in the future.
Ketamine, in contrast to ECT and TMS, has a very rapid and robust antidepressant (and anti-suicidal) effect. Like ECT, the data supporting Ketamine are solid and unequivocal, and have proven value in very hard-to-treat depression. TMS, in contrast, does not have strong data to support its effectiveness, even in non-severe depression, and takes several weeks to work. Both ECT and TMS can be quite expensive (costs of hospitalization, days off work, etc.) compared to Ketamine. Like TMS, Ketamine therapy can be done in an outpatient office setting without anesthesia and with minimal hassle and side effects.
However, the one thing that Ketamine, ECT, and TMS have in common is that they likely all will require continued use of antidepressant medications for relapse prevention over time.
Is this treatment for everyone? No. Ketamine treatment currently is for severe depression that has not responded to several adequate antidepressant medication trials, but not for patients with less-severe depression, ongoing substance abuse, psychosis, severe heart or respiratory disease, head trauma, stroke, or seizures.
What does it involve? Intramuscular infusion in a monitored and controlled office environment for 1-2 hours. A friend or relative is required to drive the patient home for safety purposes. The procedure and caution needed is much the same as having a wisdom tooth extracted under IV sedation, except without the pain! The patient will then return to our office for a follow-up visit 5 to 7 days after the treatment for a second infusion. If beneficial, further treatments will be scheduled as clinically appropriate. Patients generally need a series of 2-3 infusions to reach and maintain significant improvements in depression.
What should I expect from it? Studies show that many patients report improvements as soon as 40 minutes after infusion, with benefits lasting 3 to 14 days, depending on the person. Most people will then go on to take standard antidepressant medications afterwards in order to sustain the antidepressant benefit. Rarely, people have reported brief side effects such as hallucinations, panic, disorientation, sedation, confusion, or increased blood pressure, but these effects seem to be predominantly only during the time of the initial effects of Ketamine, and may last 2 to 4 hours after treatment. Patients who know have reported the effects of Ketamine during the infusion to be similar to either that of Nitrous Oxide (“Laughing Gas” at the dentist’s office) or of marijuana usage. Negligible reports of side effects occur beyond the first few hours after treatment.
What does it cost? The initial psychiatric evaluation lasts one hour and is $300; if the patient is appropriate for ketamine infusion, each treatment costs $600 and is payable at the time of treatment. Insurance plans may cover some of the costs incurred with Ketamine therapy, but there is no guarantee of this. However, consider these costs when compared to the costs of hospitalization, lost time from work, lost productivity, and the daily distress and pain associated with waiting for depression to improve with traditional medications and treatment options, even ECT and TMS therapies.
Do I need a referral from my doctor? No.
What do I need to bring to my initial appointment? You will need to bring the following:
1.) copies of your medical records from your current doctor (psychiatrist or otherwise), and
2.) copies of your pharmacy records (the pharmacy can print out a list of the medications you have filled there). If available, a
3.) copy of any psychological testing would be helpful.
4.) Most importantly, the paperwork and questionnaires from our office must be brought and already completed, otherwise we will need to reschedule your visit.
What else should I know? First, Ketamine for use in treating psychiatric disorders is not FDA approved, although Ketamine is FDA approved as an anesthetic agent. As such, Ketamine therapy as described here is “off-label” and is in investigational stages of use in psychiatric disorders.
Second, any decision to undergo Ketamine infusion therapy must be made by the individual patient only after a thorough investigation of the drug and the evidence as a treatment for psychiatric conditions. The information provided here is not to be construed as medical advice or a suggestion of the applicability of treatment for any individual patient, but rather one source for information regarding Ketamine’s emerging use in psychiatric conditions which may be beneficial in assisting patients determine if Ketamine may be an a treatment option to consider.
Third, it should be recognized that Ketamine infusion therapy, as in any treatment for psychiatric disorders, has no guarantee of success. Individual response may vary; it is entirely possible to undergo Ketamine infusion therapy and have little to no beneficial results either in the short term or long term. The decision to proceed with Ketamine infusion therapy must be recognized as purely elective, each patient must make his/her own decision to voluntarily proceed even knowing there is no guarantee of benefit.
William T. Goldman, MD
Dr. Goldman is a Board-Certified psychiatrist in practice since 1998 who specializes in the evaluation, diagnosis, and pharmacologic treatment of a wide variety of mental health disorders in children, adolescents, and adults. His practice scope encompasses a wide variety of behavioral, developmental, and emotional disorders. Dr. Goldman limits his practice to the psychopharmacologic intervention and treatment of disorders such as depression, bipolar disorder, OCD, anxiety disorders, autism spectrum disorders, and ADHD across ages from 4 to 65 years old. Researching and utilizing the most up-to-date and cutting-edge treatment modalities is the prime focus for Dr. Goldman’s practice, being one of the few physicians in the United States to use Ketamine infusions for Treatment Resistant Depression, and now offering Oxytocin therapy for the treatment of Autism Spectrum Disorders.
Dr. Goldman is a Phi Beta Kappa and Magna Cum Laude graduate of the University of Texas at Austin, and earned his Medical Degree from the University of Texas Southwestern Medical School in Dallas. He then completed his psychiatric residency through Parkland Hospital and underwent fellowship training through Children’s Medical Center of Dallas. Previously, Dr. Goldman worked at The Minirth Clinic in Richardson, Texas before opening his private practice. Dr. Goldman is the founder of Southlake Psychiatric & Counseling Center and has been in the Southlake community since 2003. Through frequent Continuing Medical Education program attendance and consistent study of the constantly-updated psychiatric medical literature, Dr. Goldman seeks to provide the latest in state-of-the-art medication treatment of psychiatric disorders. As the medical evidence demonstrates, Dr. Goldman strongly encourages a multi-modal treatment approach that includes medication(s) as well as individual and/or family psychotherapy and counseling. With his many professional connections in the area, he coordinates finding the most appropriate psychotherapist for each individual’s needs, as well as makes relevant referrals to skilled psychologists that can provide comprehensive psychological and neurocognitive testing when needed.
A diplomate of the American Board of Psychiatry and Neurology, Dr. Goldman is also certified in Clinical Psychopharmacology by the American Society of Clinical Psychopharmacology. He currently is an Adjunct Clinical Professor at the University of Texas at Arlington, co-founder of the Northeast Tarrant County Mental Health Professionals, and a member of Mensa.
Dr. Goldman may be reached at 817-329-3300.