- Ketamine is a very powerful anesthetic drug
that's made its way into psychiatry.
I'm gonna talk about what it does and what it doesn't do.
I'm Dr. Tracey Marks, a psychiatrist.
And this channel is about
mental health education and self-improvement.
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Ketamine is known on the street as Special K.
It's a hallucinogen and induces dissociation,
which is detachment from your environment.
In clinical medicine, the drug is primarily used
to start and maintain anesthesia.
It's a dissociative anesthetic, which means
it makes you immobile, it makes you forget,
but it doesn't completely make you unconscious.
And so, that's why its usually used
in conjunction with another anesthetic agent.
It's one of those medications that
gives you that floating feeling.
Chemically, it's an NMDA receptor agonist.
NMDA stands for N-methyl-D-aspartate.
How it treats depression is still unclear,
but the latest thought is that it's through
a metabolite or breakdown product of ketamine.
At lower doses than we use for anesthesia,
ketamine does have anti-depressant effects.
In fact, not only does it improve depression,
but it removes it quickly, and it's the best drug
we have so far to treat suicidality,
even better than lithium.
In 2000, the first randomized control trial showed that
ketamine produced rapid improvement in depression.
It's not FDA approved yet for the use in depression,
but it's gonna need more studies,
and we need more answers on longterm safety.
So how does it work and what's the catch?
Ketamine is infused through an IV, usually over 40 minutes.
During and after the infusion,
you can experience hallucinations
and a feeling of depersonalization or derealization.
You can feel unreal or like things around you aren't real.
But these effects are only temporary, and go away within
minutes to hours of receiving the infusion.
You can feel better within 24 hours, but here's the catch.
The antidepressant effect only lasts
about five to seven days, but you can get
some lower level of improvement that lasts
maybe a week or two from that single infusion.
So to extend the effect,
people will administer multiple infusions.
How many infusions it takes for the person
to get better and stay better is individual,
and we don't have a set protocol for that.
Some people have gotten one or two infusions
and then are maintained on antidepressants,
maybe at a lower dose than they were
before they started the infusions,
or some people will get a few infusions
and then are maintained on ketamine nasal spray.
Currently to get the nasal spray, you have
to go to a compounding pharmacy to have it made for you.
A compounding pharmacy is a specialty pharmacy
that makes preparations to fit a specific medical need.
So in this case, nasal ketamine
is not commercially available,
so a compounding pharmacy will make the product.
But, esketamine is a commercial formulation
that's still in the approval phase
to be used for treatment-resistant depression
and depression with imminent risk of suicide.
So, if and when that medication is approved,
it will be sold by Janssen Pharmaceuticals
under the brand name Spravato.
And that will eliminate the need
to go to a compounding pharmacy.
Newsflash, since I made this video,
the FDA has approved Spravato.
(people applauding) Yeah, that's right.
But before you get too excited,
here's a few nitty gritty details.
For the first four weeks you do two treatments a week,
then from week four to eight,
you do a treatment once a week.
Then after eight weeks, you can go
either weekly or every two weeks.
You can't just go pick it up
from the pharmacy and do it yourself.
You have to go to your doctor's office,
and that doctor has to be registered
within this monitoring system.
Also, once you go and get the treatment,
there's certain rules or procedures you have to follow.
It's similar to going and getting a colonoscopy.
You can't eat or drink for a certain
period of time beforehand, and you're required to sit
in the doctor's office for two hours after you do the spray.
You do the spray yourself,
but then you have to wait there for two hours,
and you're instructed to have someone drive you home.
So that's a pretty big time commitment.
Probably not much more than
if you were getting the infusion,
but I think because it's the spray
that it's just implied or people automatically think
that it's gonna be a whole lot easier.
But it's still very well managed as far as the protocol
and the rules to follow and all of that.
Also, when you go to the doctor's office twice a week,
are you gonna be charged for those appointments?
You don't really have to see the doctor,
but there's gonna need to be a dedicated person
who does all of the monitoring
and checking you in and all of that.
So the answer is probably yes.
It may be a nurse's visit or a medical tech visit
or something, but I doubt that they'll be
no charge for you to show up and get your spray.
So despite all these little nitty gritty details,
this is still a breakthrough
in the treatment of treatment-resistant depression.
(static crackling)
What are the downsides?
Well, as for side effects, you have the dissociation
that I mentioned, and then other common side effects
are things like nausea, dizziness, and drowsiness.
But another practical issue is cost.
Here in Georgia, it could run you $250 to $300 per infusion.
And since this is not FDA approved,
it probably won't be covered by your insurance.
So if you need several insurance,
then you're talking about spending about $1,000.
And then on the maintenance,
the nasal spray can run you anywhere between $45 to $125
depending on how often you use the spray.
Some people may only use it once a week,
but some people could use it three times a week.
Then there's the issue of finding a provider.
I'm in a metropolitan area where there's a few
major providers who have people who are
trained in the use of anesthesia doing the infusion.
But if you don't have that,
then you have to find a psychiatrist
who is comfortable putting a needle in your arm
and running an infusion and giving you anesthesia.
I have a feeling the nasal spray
won't have as dramatic an effect
or may not last as long as the infusion.
Because there's just no substitute for putting something
directly into your bloodstream.
But, it can still make a huge difference
in how we treat people with suicidal depression
and treatment-resistant depression.
Check out my video on treatment-resistant depression
to get a better sense of the obstacles
that we face in the current treatments that we have,
and share this video with others.
See ya next time.