Ketamine For Depression Confirmed

Press release by A. Shah from Baylor College confirms that ketamine works well for depression. Press release makes a statling comment: “Prozac and other treatments each improve conditions for only about 30 to 40 percent of the patient population, barely outperforming placebos; meanwhile, a single infusion of ketamine washes away the symptoms of 80 to 90 percent of patients who try it, Shah said”

WARNING at end

Is Club Drug ‘Special K’ a Quick Fix for Depression?

(Not listed in pubmed so may not be actual study?)

Doctors -take note: article in rheumatology new states one doctor in the US commits suicide each day so this IS important just for our own…

Each Day, One Doctor Dies by Suicide in U.S.

re Ketamine – This is not new for me – I’ve written:

Depression is a Form of Pain and Ketamine May be a Cure if One Can Make It Last

and

No Need to Fear Suicidality – Rapid Relief of Suicide Intent With Ketamine

I have been using it and come to certain insights:

1) Titrating dose has eliminated dysphoria and hallucinogenic concerns:

  • Give 10 mg subcut first time
  • Give 10 mg IM deltoid every 15 min 2-3 X while monitoring effect – if not feel well – don’t give next dose. Medication is rapidly absorbed and people feel effects within 5-10 minutes.
  • Have relative stay with (will probably need someone to drive unless willing to stay 1/2 hour + after last shot).
  • Have oximetry on subject if becomes drowsy (better make sure no nail polish or you will be putting it on a toe…)
  • work up gradually to 15 mg every 15 min IM deltoid if patient wishes.

2) One has to be committed to giving meds 2-3 time a week and no point in starting if no committment there.

Unfortunately, there is a serious (tongue in cheek) side effect of patients rapidly deciding to go back to work – in which case doctor has to be committed to giving shots after work hours – I have arranged for wednesday nights and saturday mornings though I must say,  I’ve got to be crazy doing it… it is hard.

3) A local psychiatrist, Dr. Messer, has expressed concerns about inducing psychotic symptoms in unstable patients. This has not been seen in pain and depression treatment literature and was mentioned in a case given general anesthetic doses – much higher –  where it was used in anesthetic induction. Nonetheless, I have not used it in anyone I would consider unstable (with schizoid tendencies for instance).

4) Ketamine can be abused and hence not great choice for people with drug dependencies (maybe check a urine?). Having said that, a Russian group has been using ketamine to treat alcoholism and claims to reduce recurrence from 65.8 to 24%:

Ketamine Psychedelic Therapy (KPT): A Review of the Results of Ten Years of Research
E. M. Krupitskya & A. Y. Grinenkoa
Journal of Psychoactive Drugs  Volume 29, Issue 2, 1997 pages 165-183  abstract here

5) The big question is how long one maintains the ketamine – lets face it, people are on anti-depressants for years.  It may be important to have a back up plan – one lady I did was waiting to have ECT and the shots just got her through to it. Having said that, there are cases that have never responded to antidepresssants. However, I am amazed how quickly some people could put their lives back to order and go back to work – that lifestyle improvement has got to have a beneficial effect.  I still do not have the answer there…

6) Chronic continuous use (mostly abused unclean drug) is associated with small bladder syndrome – having to pee frequently – so if a subject already has such issues don’t go there. Still ,a warning for others maintained on it long, would be useful.

I was told to be quiet at a family practice meeting on depression when I brought this up; and was only annoyingly allowed to mention it, for treatment of suicidality, at a cognitive depression course.  I find physicians very intolerant to anything new and hope they can embrace this.

 Addendum – getting more credence with a Scientific American article on its use March 2010, 306(3), 66-71.  Lifting the Black Cloud;  R. Henig.  Discusses rapid growth of synapse connections starting as neuronal spines:

Great article with other interesting tidbits…

Still dealing with:

1) Needing to see patient 3 times a week initially and then twice weekly as improve. – There has to be commitment  of patient to come in or they will complain bitterly how YOU failed them….

2) Commitment on your part to see twice weekly after hours once they have returned to work (hard – but why should I be the only one to suffer?).

3) Having a women come solo –  creates an issue for me – during day I have female staff around but after hours I can’t always have my wife coming… This unfortunately creates an issue for women who cannot bring a chaparone. This unfairly effects who I will accept but can’t be helped.

4) This drug is not covered by any health plan and so I have been giving the drug out free to poorer patients (costs me $7.00 a visit). The pharmacy must think I’m a druggy… Have gotten other patients to buy their own at around $70.00 for a 50 mg/ml 10 ml bottle.

WARNING:

Recent studies have suggested urinary symptoms may be a problem (they asked users online if they EVER had a problem (what EVER that means))

BJU Int. 2012 Mar 14. doi: 10.1111/j.1464-410X.2012.11028.x. [Epub ahead ofprint]
The prevalence and natural history of urinary symptoms among recreational ketamine users.
Winstock AR, Mitcheson L, Gillatt DA, Cottrell AM.  abstract here

It has also been suggeested that there are cognitive concerns but I think the cognitive concerns of unremitting depression and pain are probably worse.
There are also concerns of liver damage so blood tests would have to be done:
Curr Opin Support Palliat Care. 2012 Mar 20. [Epub ahead of print]
Ketamine for chronic noncancer pain: concerns regarding toxicity.
Bell RF.   abstract here

To this end I have devised a simple urinary questionnaire that should be filled every 2 weeks – if there are any yeses (that weren’t there before then maybe stop the drug

Name______________________________________      Date_____________

Do you have any discomfort in the lower abdomen?         N    Y   
Does it burn or sting to pass urine?                     N    Y   
Do you find you need to pass urine more frequently?      N    Y 

Do you go:      
< every 2 hours                               N    Y                                        
< every hour                                  N    Y
Do you have to get up at night to urinate?    N    Y    _______ Times
Have you had any leakage of urine?            N    Y 
Have you had any blood in urine               N    Y

I have gotten 4 of these on one word page and will get them to fill consequetively so can see the difference. Each sheet should have one liver function result on.

can get 4 on a page in word here

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6 Responses to Ketamine For Depression Confirmed

  1. Mark Samuelson says:

    Have you considered trying to switch any of your patients to intranasal or oral routs to allow for self-administered treatment at home? While differences in pharmacokinetics may affect efficacy, it seems like finding a rout and dose schedule that allowed for at-home treatment would be a big win in terms of cost and convenience.
    Two reasons though I am not sure how valid they are:
    1) I am not sure you could achieve the same blood levels without having to snort an inordinate amount which patient (and their nose)would not like.
    2) At home, I would not be there to deal with a dysphoric derealization “bad trip” – only saw it once when I gave a larger dose all at once – never happened with divided doses. However, the one case I had , I gave IV Midazolam and it settled. BTW, I always make sure a woman is present in the office when I do women. I think things do go better with people there.
    3) I do not think my Medical College would approve of dispensing such an agent – In office settling I can avoid any potential abuse. – Though I am unaware of abuse in a clinical setting.
    4) Any doctors using it should be aware it does require some sacrifice – These people get better and go back to work and need to be seen after hours and on weekends – 30 min for the 3 shots and perhaps 1 hour to recover after. Weaning the dose could occur alot faster if it didn’t take 6 month+ to get a shoulder labral tear dealt with…

    Anyone had experience with intranasal?

    • Mark Samuelson says:

      (FYI – your reply got appended to my comment above)

      1.) I would note that ketamine is available in 100mg/ml concentrations if anyone is interested in trying it. This would give you 10mg/spray in a 0.1ml sprayer. I’m not sure of intranasal bioavailability, but it seems like the doses you are giving would be in reach, particularly if both nostrils are used. (and don’t forget PO as an option)

      2.) Re dysphoric derealization – it sounds like (based on your experience and that of various studies), that for a patient that has been titrated in-office, subsequent risk would be quite small. Also, while it is surly comforting to be able to manage these effects quickly via IV, perhaps a benzodiazepine PO could be substituted. (Taken in divided doses, I presume any dysphonic effects would gradually increase with each dose administered, allowing a patent to stop and take a benzodiazepine PO if needed. Note: this study found that ketamine’s “psychedelic effects” varied linearly with plasma concentration. http://www.ncbi.nlm.nih.gov/pubmed/9447860.)

      3.) This is mainly the ketamine-squirm factor, right? Consider opioids. The abuse potential is presumably many times higher, but the cost and convenience of at home treatment clearly wins out. Moreover, doesn’t at home use of similar doses of ketamine for pain, of which there are both informal and published reports, provide some cover in trying it for depression?

      Thank you for your comments! I read your link about how linear side effects are to blood levels. It is a relief to find with titration like I am using, you can avoid taking patient to the dysphoric/psychedelic doses – by following thier response to each shot, one can stop giving the next does in time to avoid side effects.

      My cases were already tried opioids and either didn’t handle side effects or didn’t find they worked well.
      I think the results of injectable ketamine are similar to my results with IV lidocaine:
      – small does not disoiented – good for the day
      – small-moderate dose – some disorientation for short period – better 2-3 days relief
      – moderate dosage run over 1 hour – significant disoientation – 5 – 7 days some relief (I don’t do that in my office)

      As with the lidocaine, there are 2 factors – severity of disorientation and length of period;
      – Initial studies on depresssion gave an IV infusion over 40 min. I suspect 3 shots at 0, 15 and 30 minutes mimics the IV infusion duration.
      – The degree of disorientation achieved by injection could not be well achieved orally and if it was, it would probably last for hours which could be very unsettling – injectable fast in, higher peaks, and fast out – people are good within the hour and less if their wife is willing to drive…

      However, I haven’t tried it so don’t know for sure. – and yes, I do suffer from squirm factor..

  2. Has there been any long term affects for the Ketamine?
    I did discuss ketamine long term effects here:
    http://painmuse.org/?p=1420
    (near end)
    Concerns I have:

    1) Bladder issue – constant use – particularly as a dirty street drug is associated with a small bladder syndrome, initially reversable but later permanent. I would not suggest it for people with bladder frequency issues.
    2) Over-extending onself physically and emotionally and then needing the shot to carry on. My cases quickly return to work and then I found myself committed to continuing the shots to help maintain their work- Extending times from 3 time a week to twice weekly is a start and I hope over time the work hardening has kicked in and helped. Mood also improves once one is working and has money in one’s pocket… I just hope the necessity of shot will gradually wane…
    3) There is no literature on ketamine being habit forming when given clinically. I have had no one wanting desperate escalation of their dose and frankly don’t see people enjoy being disoriented for the hour they are on it.
    4) Had one funny guy reading the reader digest while having shots and then repeating the joke later without remembering where he read it (his wife had to tell him it wasn’t his idea – he got it from reader’s digest…so funny)

  3. Paula says:

    I received Ketamine infusions through a clinical trial and it produced ‘the miracle’. I had forgotten how smart and optimistic I used to be, it’s been 17 years since depression ruined my life. I am an RN on disability, have tried 6 jobs in the 6 years since disability, due to cognitive issues I was fired from each one.

    I plan to do whatever it takes to get my hands on some medical-grade K, I know the dosing and I know it is safely being administered IM.

    This drug should be made available, especially for people like me, for humanitarian reasons. I was 35 when this torture started and I am now 53. I don’t have 10 more years to waste when I know what will cure me.

  4. Brian Murphy says:

    are there any people out there who have had success with the .5mg/kg ketamine injections, and who once the effects wore off, just continued gettting more injections. i realize the financial cost is generally outrageous, and this keeps most from being able to do this. but are there any out there with chronic major depression and/or anxiety, ptsd etc, who have regularly had the injections for a year or more? and if so, has the ketamine (at the same dose, and at the same frequency of injection) maintained its efficacy? perhaps there’s someone out there who either can financially afford this, or who has special circumstances allowing for regular injections, who could answer this? my example would be that say if ketamine injection works well for 10 days, but by day 11 it generally starts losing its effectiveness for someone, and so then the person uses this as their schedule of injection (.5mg injection every 10 days); does the drug tend to maintain its efficacy? or do people generally need higher doses or more frequent shots over time? or perhaps the opposite; as synapses form and neurons repair (and whatever else the apparrent NMDA antagonism /glutamate modulation etc does), perhaps people over time began to build cumulative, sustainable lasting benefits from the ketamine, and can then began spacing out injections or titrating off until it’s no longer needed? this would of course be the ideal. does anyone know of cases where the drug atleast maintains its efficacy over a year or longer with regular scheduled injections? i am told by a reputable psychiatrist that this can very well be the case. and that it’s only the cost, inconvenience, and potential discomfort (hallucinatory etc) of the injection administration that keeps this from being performed. he tells me that at this dosage and at no closer than 10 days between shots, there is NO reported lab abnormalities, bladder or kidney problems,,,and that the drug generally keeps its efficacy indefinitely (for those who it works for initially). is there anyone out there who could confirm this, or provide any info of known cases that supports this as true? i already know that of course ketamine doesnt work for everyone, but for those who it does help……any data on above questions? any patients recieving regular longterm injections out there??

    The initial study was with ketamine TWO shots – a week apart and got a 70% response rate. Cost of injection – an 11 dose bottle cost $70.00 so less than 7 dollars a shot – some poorer cases I just use my stock meds for free. It works best if they bring someone to monitor them and drive them home afterwards. In Canada, we do not get paid for administering the shot; there is just the inconvenience of subjects being in an extra office for 1 hour+ and maybe needing an oximeter if drowsy. Giving the dose divided into 3 separate shots 15 minutes apart prevents any nasty depersonalization effects as if they start feeling funny – they just don’t get another dose. The cases I am doing, have a combination of mood issues and severe pain (one is at 9/10) – they would not be able to function without the shots and are having to wait forever for surgery. Those cases need shots 2- 3 shots a week to function which means I do not get a free weekend…

    Pure depression might get away with 1/week but during the period they are better, they have to take that opportunity to make changes in their life for the better. It is called the pursuit of happiness for a reason. One of the foremost causes of persistent depression is overconcern re depression. One of the most influential sayings I can across I modified to say:
    ” one of my happiest moments – the moment I was most happy – was when I realized I did not have to be happy TODAY…
    Good luck

  5. Brian Murphy says:

    Also, I have had one ketamine (.5mg/kg body weight) injection, and felt no better the day after, or since. Is it reasonable that perhaps it may require a cumulation for it to be effective? My thought is perhaps to have these .5mg/kg injections 3 times a week for 2 weeks to see if this brings any noticeable effects. If not, then I would discontinue and acept ketamine is not right for me. But if it did help after these 6 injections (intramuscular) so close together, then perhaps I could begin to spread out to twice a week and then once a week or every ten days or whatever seems to be my relapse time. Does this sound like a reasonable approach? Does anyone have any experience and success doing it this way? I want to give ketamine a full chance before dismissing it, and it seems from what I’ve read in a few studies that these 3 a week for 2 weeks injections have longer lasting success with patients. Maybe this is because it takes some close together injections to really achieve the ‘reboot’ effect for people who have had chronic major depression, anxiety, trauma (all of which is me) ?? Any and all answers or comments would be appreciated. Thanks, Brian

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