What is ketamine?

Ketamine is a drug that has been used for many years in anesthesiology. It is a general anesthetic used for brief diagnostic and surgical procedures that do not require skeletal muscle relaxation. It blocks glutamate (a neurotransmitter), which causes synapses to not transmit excitatory information, while the nervous system enters a relaxed state.

Since 2014, it has also been used off-label at lower doses to treat depression refractory to standard forms of pharmacotherapy and psychotherapy. Ketamine is a dissociant, which is a substance that reduces or inhibits the signals sent from the brain to consciousness. Feelings of unrealness, lightness, or daydreaming are cited as effects of dissociatives. Its hallucinogenic properties cause changes in one’s body perception.

How is ketamine supposed to help with depression? In people with the established chronic form of this disease, nervous system changes are observed. Among other things, ketamine is precisely the substance that contributes to the reconstruction of damaged areas of nerve tissue. When used for medical purposes under medical supervision, it is safe.

Who can benefit from ketamine and esketamine treatment? Indications for therapy

Ketamine and esketamine therapy is primarily recommended for people struggling with depression accompanied by feelings of sadness, anxiety, insomnia, loss of appetite, lack of motivation or apathy. It works well in the case of drug resistance, or in a situation in which pharmacotherapy has not had the desired effect or the effect was unsustainable. Drug-resistant depression is referred to when two or more antidepressant treatments from different drug groups have been used for treatment, and they have lasted for a reasonable amount of time.

It is not uncommon for drug-resistant depression to be caused by a misdiagnosis, so it is important to re-verify the diagnosis before starting ketamine or esketamine therapy. Disorders such as Asperger’s syndrome or various types of addictions can adversely affect the anticipated effecacy of treatment.

Advantages of ketamine treatment

Effecacy

Ketamine works well when treatment with antidepressant pills doesn't help. In 30% of people diagnosed with depression, standard treatment with antidepressant medications does not work, even though different types are used in sufficient dose and duration. Therapy with ketamine gives a chance for remission in these situations (70%).

Short-term side effects

Side effects, if they occur, often subside soon after the procedure is completed. After a good night's sleep, the patient usually no longer feels any unpleasant discomfort.

Quick response

The visible effects of the therapy are already visible after the first 3-6 infusions, although significant improvement is often achieved just after the first session.

Remission of depression

Although studies on disease remission after ketamine and esketamine therapy are still ongoing, current data suggest that they are effective in preventing relapse.

What does ketamine therapy consist of?

Do not eat food for about 2h before the procedure to avoid nausea after the drug is administered. However, you can drink water for up to 30 minutes before the treatment begins.

An intravenous port is placed by a doctor on the upper limb and is removed after the procedure. The rate of ketamine infusion is gentle and may be slowed or accelerated depending on patient preference and condition. Patients respond to ketamine very individually, so it is important to determine the optimal regimen during initial treatments. The position during the treatment is horizontal, it is a good idea to bring your favorite relaxing music and a blanket/pillow. The office is equipped with high quality soundproofing headphones to ensure that the patient can relax as much as possible and be cut off from external stimuli.

The patient’s vitals are monitored before and during the procedure. Ongoing support from an experienced psychotherapist (accessory) and medical care is also provided. When unusual experiences occur during treatment or when therapeutic insight is unlocked, it is possible to collect these experiences and then use them in psychotherapy sessions between treatments.

Compared to other antidepressants, esketamine/ketamine is distinguished by its very rapid onset of action – clear effects are seen after 1-6 treatments. The optimal ketamine treatment regimen is to administer 6 doses of the drug over a 3-week period, followed by weekly or once every two weeks maintenance therapy.

In my experience so far, the drug is effective in about 70% of patients.

During the procedures, the patient should continue treatment with an oral antidepressant.

In our clinic, we use a regimen based on administering 6 doses of the drug over a 3-week period, followed by weekly or once every two weeks maintenance therapy.

After 80 minutes, the dissociative state usually passes and the patient can leave the clinic. It is strictly prohibited to drive or operate machinery after treatment until the next day after a restful night of restorative sleep.

Contraindications to ketamine treatment include:

  • conditions that may pose a risk for increased blood pressure (arrhythmia, unstable angina, recent myocardial infarction or ischemic stroke, history of hemorrhagic stroke, aneurysm),
  • mania,
  • psychosis,
  • glaucoma,
  • porphyria,
  • other unstable somatic conditions.

They are mostly limited to the procedure itself. They usually subside during or soon after its completion. The most important include dissociation, sedation, and increased blood pressure. Ketamine is a narcotic, so its use theoretically carries a risk of addiction.    

The cost of ketamine administration is 700 PLN.

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What effects does ketamine have in psychiatric treatment?

As many as 15% of patients with depression have drug resistance. Unless patients in this group opted for electroconvulsive therapy, until some time ago, medicine offered them no other solution.

Ketamine has an effect on the body just a few hours after administration. Based on patient observations, we estimate the effectiveness of the therapy to be about 70%. A similar result was obtained in a Randomized Controlled Trial (RTC) published in Translational Psychiatry.

Studies related to remission of depression after administration of ketamine or esketamine are still ongoing.

Safety of ketamine and esketamine therapy

Treatments are performed under constant medical supervision under controlled conditions. Side effects are usually limited to the procedure itself and resolve soon afterwards. Only some people experience dissociation, that is, changes in what the patient sees, hears, and feels. It is described as a dream-like state and a sensation of distortion of time and space.

Although ketamine is a narcotic, and therefore theoretically carries a risk of addiction, clinical trials of esketamine (which contains ketamine) did not find that patients abused the drug or experienced unpleasant withdrawal symptoms.

There are contraindications to both therapies, so it is important to answer the doctor’s questions in detail in the qualifying history for the treatments.