Does it matter if I get ketamine therapy from an anesthesiologist or psychiatrist?
This is a question that is surrounded by some controversy, and deserves examination.
Ketamine is a medication. It has historically been used as an anesthetic. It is a popular medication in third world nations and in the war/ battlefield environments because it is an extremely safe medication that does not require many of the complex and expensive monitoring techniques that modern western medicine utilizes (see safety section for more information).
There are many medications that cross between medical specialties. For example, Depakote is a medicine used by neurologists as an anti-seizure medication, but is also used by psychiatrists to treat bipolar disorder. Another example would be botox. Botox is used by dermatologists to lessen wrinkles, neurologists to treat migraine headaches, and urologists to treat overactive bladder. Each of the mentioned specialties are adept at utilizing the same medication and use it safely. However, not all specialties are adept at treating the same diagnosis. One would not want a heart doctor to treat their seizures any more than they would want a seizure doctor to perform their cardiac bypass surgery.
Anesthesiologist are trained in the art of sedation and many aspects of pain control. Their primary specialty training does not include the proper diagnosis, treatment, or management of depression or any other mental health issue. Anesthesiologists are extremely adept at ensuring safety for their patients during surgical procedures, both in and outside the hospital. Anesthesiologists sometimes also get additional training to work as pain specialists. Ketamine therapy delivered by an anesthesiologist is likely to feel similar to a medical procedure that you might undergo in a hospital, but in the outpatient setting.
Psychiatrists spend the entirety of their medical specialty training learning how to properly diagnose, treat, and manage the full range of mental health issues in adults such as depression and ptsd. Extra training is required for certification to treat children and adolescents. Patients dealing with treatment-resistant depression are some of the more complex and challenging patients that psychiatrists work to assist. Understanding the many nuances and the various medications involved with treating depression, both past and present, is an area where a psychiatrist would have more expertise and training than an anesthesiologist.
As a psychiatrist, I have spent nearly two decades solely dedicated to helping patients who suffer from depression and other mental health concerns. My education, training, and career have been aimed in this direction from the beginning. The field of psychiatry is always searching for new and innovative ways to treat depression. I am happy that ketamine therapy is an option that is becoming increasingly available to those struggling with depression and other mental health issues. The increased availability is largely due to both specialties providing treatment. Both specialties offer safe treatment with ketamine. Each type of provider will offer the same type of treatment but in a modified form based on their medical specialty and personality. Properly educating yourself on the particular type of experience you desire from your physician and the type of experience you desire from treatment should ultimately guide your decision.
Is there good, sound research to support the use of ketamine?
The short answer to this question is “yes,” and a lot of it. Please visit the research section of this website for links to some of the significant and impactful research being done in this area. There, you will find links to articles from studies at Yale, the National Institute of Mental Health, Mayo Clinic, Mt. Sinai, and other reputable resources
What do Ketamine Infusions treat?
Ketamine has been shown to effectively treat depression, the depressive phase of bipolar disorder, and PTSD. Ketamine has been shown to be particularly effective in treating forms of depression that have not responded to other medication interventions (treatment resistant depression). Of particular note is that it has been shown to have benefit in its impact on suicidal ideation (Murrough et al, 2013). Research involving ketamine is robust. It is now being shown in the research literature to positively impact such psychiatric issues as Obsessive Compulsive Disorder and Substance Abuse Disorders. Ketamine infusions have also been shown to treat some chronic pain syndromes like CRPS.
Ketamine is NOT indicated in the treatment of any psychiatric disorder with a psychotic component such as schizophrenia.
What is the response rate to ketamine infusions?
Current research and clinical practice support an approximate 50 to 70% response rate.
How long does ketamine take to work?
Amazingly, ketamine’s effect can begin to take place anywhere between 1-12 hours after the infusion. Most patients feel some effect by the day after the infusion. Patients may continue to have bad periods of time either during or after the course of ketamine infusions, but the overall trend of mood symptoms tends to be in a positive direction following serial ketamine infusions.
How long do the positive effects of ketamine last?
Outcome data differs among patients. That being said, serial infusion can provide relief anywhere from a few weeks to several months. Even after patients report the lessening of some of the positive effects of ketamine, many feel like there overall abilities to cope and adapt are improved in comparison to before treatment.
While complete remission has been observed, it should be considered an exception and not the rule. This is unfortunately the case with most all psychiatric interventions. However, ketamine infusion treatment allows for an individual to acutely become “unstuck” in rigid negative thought patterns and behaviors, and facilitates them reengaging in life, therapeutic processes, and allows time for other psychiatric medications to begin to have an effect.
What is an infusion?
An infusion is the administration of a medication via an intravenous line over a certain period of time. Ketamine infusions typically last approximately 40 minutes.
How many infusions will I need?
There is not yet a standard established regimen for ketamine infusion delivery. That being said, there have been some consistent themes that have developed from ongoing ketamine research, studies, and clinical practice.
Serial infusions have been shown to be more effective in sustaining clinical response in comparison to singular infusions. The most common number currently established through the research and literature is a series of six infusions spaced out over a two week period. This is found to maximize new dendrite and synapse growth. Some individuals choose to have “booster” infusions over time. Because each individual’s response varies to some degree, we try our best to get to know the individual patient and their response so that we may deliver the most personalized care.
You mentioned maintenance. How often would that be?
Length of response can vary from person to person. To use an example, let us suppose that Erik successfully treated his depression with ketamine infusions. Every 5 months, however, Erik begins to feel his depressive symptoms coming back. Were ketamine to be considered to be an appropriate treatment, Erik might get a booster infusion every four and a half months to stave off the relapse of symptoms. This type of maintenance program has been shown to be an effective treatment of depressive symptoms that would otherwise impact Erik’s life in extremely detrimental ways.
Once a patient has completed the initial series of six ketamine infusions, it is often the case that they would only need one infusion to serve as a booster each time symptoms of depression reoccurred.
Please explain the process of getting a ketamine infusion?
You will arrive at our office, check in, and then fill out appropriate scales and forms. An IV is started and the infusion will begin. The total time of the actual infusion will be approximately 40-45 minutes. Patients typically do not feel anything different for the first 10-15 minutes. After that time, you will begin to feel effects that are typically described as being “unusual,” “odd,” and almost always “interesting.” Patients report experiences of infusions being dreamlike, feeling like you are floating, feeling disconnected from one’s body or the physical space. Patients may feel more introspective. Perceptions can become distorted and sometimes seem more intense. The experience ramps up in intensity and then begins to subside after the 40-45 minute mark.
Less common side effects include nausea and anxiety. If bothersome for the patient, those can be treated during the treatment with fast acting IV medications. All infusion related experiences cease approximately 10-15 minutes after the infusion is completed. Patients relax in our office for an additional 20 minutes to an hour, and are then driven home by a trusted prearranged driver or loved one.
Please note that expectations do affect your infusion experience. You will feel different or “weird” during the transfusion. It is best to know this and accept it as part of the ketamine infusion process. You should also know, however, that you will feel like yourself shortly after the transfusions ends with the exception of hopefully being left with a sense of newfound hope, optimism, and less feelings related to depression.
What will I feel like during the ketamine infusion?
The best thing that you can do during the ketamine infusion experience is to sit back and relax. Our staff will do everything possible to create a comfortable and relaxing environment for the infusion. Tasks such as being on your phone are discouraged as ketamine can sometimes temporarily blur vision and affect thinking during the treatment. We recommend listening to calming music, such as the type you might hear at a spa or while receiving a massage. Most patients find this type of music to be anchoring and relaxing. We typically recommend for patients to simply close their eyes, kick back, relax, listen to the calming music, and allow us to care for you. You will be awake throughout the infusion as the low dose of ketamine delivered does not produce the “going under” effect of ketamine when used for general anesthesia. Our staff is present to speak to you if you would like to process the experience during or after.
Below is additional useful information describing the infusions experience from the very informative website Ketamineadvocacynetwork.org :
“Your experience may include something called a dissociative effect, or dissociation. Dissociation is a kind of out-of-body experience, where you partially lose awareness of your body. You can often reduce the effect simply by opening your eyes. Again, it can be weird, but most find it to be a pleasant sensation. Dissociation does not happen to every patient. Some just feel extreme relaxation.
Your mind will be very active during the infusion. In a state of deep relaxation, you may find that you’re able to reflect on past traumas or current anxieties in a very calm, matter-of-fact way – with zero emotional pain. Most patients find this very satisfying, but a small percentage may find it uncomfortable. Many patients prefer to simply let their thoughts wander, without trying to steer them in any particular direction. We suggest using whatever approach maximizes your sense of calmness and relaxation, as long as your doctor agrees.
Although most patients find the experience relaxing and pleasant, some can have brief moments of fright. Patients who begin the infusion in a state of high anxiety seem most susceptible to this. Many are desperately pinning all their hopes on ketamine to relieve their suffering, which is totally understandable but can amp up their anxiety. Some patients get very tense at the thought of not being in total control of their thoughts or body. Try your best to relax before the infusion begins.
We think it’s important not to obsess over the infusion experience. The research indicates that depression relief is produced not by the strange infusion sensations, but by physical changes in the brain that remain after the infusion ends. Yes, you might feel odd for 40 minutes or so while the ketamine is in your system. But those effects are merely a consequence of delivering the drug to its destination – they are not the cause of the depression relief.
You may have heard the term K-hole. The massive doses taken by recreational abusers can cause effects far more intense than an infusion. This can cause dissociation so strong that it becomes frightening: a K-hole. This phenomenon does not occur in the low-dose, slow-rate infusions used for depression.
How much does each infusion cost?
The cost of the initial infusion is $600. This fee is inclusive of the medication, the nursing staff, as well as the psychiatric staff’s time. Each infusion thereafter costs $550. In order to maximize the effects of Ketamine treatment in “responders,” we ask that individuals commit to our clinic’s standard protocol of six infusions in order to maximize the sustainability of response. Payment is expected to be made on the day of the appointment in the form of credit card or cash.
We are typically able to determine whether someone will be a “responder” or not sometime after the second infusion. If you do not experience beneficial effects from ketamine treatment, you will not be charged for the infusions you do not have but will be responsible for the cost of infusions you have already had.
For more information about the cost of ketamine treatment, click here.
Are Ketamine Infusions covered by insurance?
At this time, ketamine infusions for the treatment of psychiatric conditions are not covered by insurance. While ketamine is an FDA approved anesthetic medication, it is not recognized at this time by the FDA for the treatment of depression or other psychiatric conditions.
What are the common side effects?
Most individuals undergoing ketamine infusions have little to no side effects. Those that do may experience mild nausea, drowsiness, blurry vision, dizziness, and sometimes a temporary increase in blood pressure. These side effects can be treated during the infusion process if they become too bothersome. To note is that ketamine stays in your system for a very brief time. Nearly all infusion side effects disappear within 10-15 minutes of the infusion being over. Less common side effects include vivid dreams, mood swings, or agitation.
Will I become addicted to ketamine?
If receiving care in the hands of a trained psychiatrist and other medical professionals, the answer is no. Like many other medications used initially to treat legitimate medical conditions, ketamine does has a history of being abused in the “Club Drug” or “Rave” scenes. Ketamine used in those arenas is typically used at much, much higher doses. Even at those doses, however, ketamine does not create physical dependence. The amount used to treat depression is approximately 8% to 12% of that used when used as a club drug and an even smaller fraction of that used during anesthesia.
Is Ketamine dangerous?
Ketamine has now been used for over five decades as an anesthetic for both adults and children. In fact, it one of the most popular medications used by physicians for anesthesia in pediatric emergency rooms. Although ketamine is not FDA approved as an antidepressant, it is FDA approved to be used as an anesthetic at approximately 20 times the doses used to treat depression. In addition, ketamine is a unique anesthetic in that it does not suppress the gag reflex nor does it reduce an individual’s respiration rate. As a result, it is considered to have a very wide safety margin. Ketamine is listed as a top 10 medication by the World Health Organization. The reason is that ketamine is used as an anesthetic by many third world nations because its wide safety margin does not necessitate the use of many of the expensive monitoring devices and techniques used in western medicine.
Are there any reasons that would prevent me from receiving a ketamine infusion?
There are very few conditions that would rule an individual out from being able to receive a ketamine infusion. Some such conditions include uncontrolled high blood pressure, hyperthyroidism, persistent pulmonary issues, and seizure disorders, Those with cardiac problems, uncontrolled high blood pressure, or pulmonary problems should be thoroughly cleared by their treating primary care physicians before receiving ketamine treatment. Those with bad glaucoma also should not take part in ketamine infusions.
Do I have to stop taking my medications and can I stop taking my medications?
You should not stop taking psychiatric or other medications at the time of your infusion unless told to do so by Dr. Barton. You should not adjust your dose or frequency of use of any medication without first consulting your prescribing physician. There are a small number of medications, however, that should cause one to avoid receiving an infusion. Patients taking aminophylline for asthma or COPD may be at greater risk for developing seizures if they receive ketamine. There are also a few medications, such as lamictal or the class of benzodiazepines that MAY possibly affect the dose of ketamine or the schedule of infusions. Please make sure to tell your evaluating psychiatrist all of the medications that you are taking.
-Lamictal (lamotrigine) patients should allow 12 hours between taking lamictal and the start of their infusion. They should wait 6 hours after their infusion before resuming lamictal.
-Patients cannot take any MAOIs within 2 weeks of an infusion.
-Patients taking large doses of benzodiazepines may have a reduced response to ketamine. This does not mean that you cannot receive ketamine infusions while taking benzodiazepines, but your response may vary and your dose may need to be adjusted.
-SSRIs and Tricyclic antidepressants do not interfere with ketamine and should be continued as prescribed.
Do I stop seeing my psychiatrist or therapist?
No. You will be under the care of Dr. Barton and the staff of the Nashville Ketamine Center for the purposes of the ketamine infusions only. We will assist you in developing a maintenance plan should you desire to do so. However, you should remain under the care of your referring psychiatrist, therapist, and/or primary care physician during and after your treatment for ongoing medical and mental health needs.
Are there special instructions for the appointment that I need to know about?
-You will not be allowed to drive yourself home. Please make arrangements accordingly. We advise you to not drive or operate heavy machinery until the morning after the infusion. We also advise you not to make any “significant life decisions” like signing a binding contract until the morning after an infusion.
-Please abstain from eating beginning 4 hours prior to the appointment. You may have clear liquids up to two hours before the appointment.
-Expect the entire process from stepping in the door to leaving to last approximately 1.5 – 2 hours per infusion. The initial appointment and infusion may take a bit longer. Please plan accordingly.
Is there an age limit in regards to ketamine treatment?
There is not a formal age limitation. We recognize that depression is not something that only happens to adults. Dr. Barton is a licensed and double board certified child, adolescent, and adult psychiatrist. In addition to the adult population, he possesses a comfort level treating patients under the age of 18 as well. Treatment will ultimately be decided on a case by case basis.
How soon can I begin ketamine infusion treatment?
Most patients are able to be scheduled and seen within one week of their initial contact with our clinic, assuming your case is an appropriate referral.