Randy Dotinga Clinical Psychiatry News
Ketamine, once best known as a pet anesthetic and party drug, is taking the United States by storm. Dozens of ketamine treatment centers are operating from coast to coast.Big cities like Baltimore, Boston, and Phoenix have them. So do Charleston, S.C., and Boise, Idaho. Two such clinics are in sparsely populated New Mexico. And one national chain went from a pair of clinics to 10 in fewer than 2 years.

Dr. Jeffrey Lieberman New York State Psychiatric Institute

Dr. Jeffrey Lieberman

“There’s been a mad rush on the part of desperate patients to seek care,” said ketamine researcher Jeffrey A. Lieberman, MD, chair of the psychiatry department at Columbia University, New York; director of the New York State Psychiatric Institute; and a past president of the American Psychiatric Association.

Never mind that these expensive treatments for conditions like depression are not covered by insurers or approved for this use by the Food and Drug Administration. Other questions also persist. “There is a considerable body of evidence that proves it really does work,” Dr. Lieberman said. “But we don’t know the extent of the range of conditions for which it might be effective, what the optimal frequency and concentration for dosing is, and what the long-term consequences are.”To make matters more complicated, it’s anesthesiologists – not psychiatrists – who are leading the way toward a ketamine-infused future.

Dr. Gerard Sanacora of Yale

Dr. Gerard Sanacora

“This was a truly novel breakthrough in the field, but we have to be careful. We have to develop this rationally,” said ketamine researcher Gerard Sanacora, MD, PhD, lead author of an APA consensus statement published in JAMA Psychiatry (2017;74[4]:399-405) urging caution on use of ketamine for mood disorders, and professor of psychiatry and director of the Depression Research Program at Yale University, New Haven, Conn.For now, however, hundreds and perhaps even thousands of patients are serving as ketamine test cases with psychiatrists only assisting remotely, if at all.

A stunningly rapid rise

Sara M. Markey, MD, is one of the rare psychiatrists in the United States who’s fully embraced ketamine treatment for mental illness.

She recalled first hearing about ketamine as an anesthetic in medical school. Best known as an anesthetic in animals, it’s also occasionally given to children and adults, although the drug’s dissociative properties have prevented widespread use.

Dr. Sara Markey of Denver

Dr. Sara Markey

In 2006, word spread about ketamine’s use as a painkiller. “I also began hearing and reading about its potential use/efficacy in treatment-resistant depression,” said Dr. Markey, who practices in Denver. “It was difficult to find information about ketamine, and many of my colleagues were hostile to the idea of using ketamine in clinical practice.”

She persisted, however, and prescribed intranasal and oral ketamine to depressed patients with “mild success.” She also saw patients whose psychiatrists refused to consider ketamine.

In early 2016, with Steven P. Levine, MD, a New Jersey psychiatrist who pioneered ketamine use for depression, Dr. Markey opened a ketamine infusion clinic in the Mile High City.

At at that time, it was only the second in a national chain called Ketamine Treatment Centers. Now, not even 2 years later, the chain has a new name – Actify Neurotherapies – and a total of 10 clinics from San Francisco and Beverly Hills, Calif., to Palm Beach, Fla.; Raleigh, N.C.; and New York City.

“It is wonderful,” she said, “to have an opportunity to provide a medication to people that does not cause weight gain, has very few medication interactions, and which is well tolerated and generic.”

Big short-term benefits

Treatment outcomes with ketamine – which is thought to act on glutamate and N-methyl-D-aspartate receptors – can be dramatic. “Some patients describe the ketamine treatments as life saving,” said Allison F. Wells, MD, an anesthesiologist who runs a clinic in Houston.

Dr. Allison Wells Houston anesthesiologist

Dr. Allison Wells

One depressed young man who tried ketamine at a Phoenix clinic in 2013 reportedly told the news site vice.com that he “felt good for a week” after his first treatment: “Not the kind of bipolar ‘good’ where I’d be manic. I just felt pleasant, and not crazy or compulsive. I felt normal for the first time in a long time.” Another depressed patient told National Public Radio that ketamine transformed his life: “I remember I was in my bathroom, and I literally fell to my knees crying because I had no anxiety; I had no depression.”

Enrique A. Abreu, DO, an anesthesiologist who offers ketamine therapy in Seattle and Portland, Ore., said he’s seen anxiety relief and a decrease in rumination in these patients. “They’re able to go back to work; a lot haven’t been able to work for a long time. And motivation is a big thing. They’re able to do things they haven’t been able to do.”

In addition, ketamine can reduce suicidal thinking, Dr. Markey said. “I am continually astounded to hear patients who come in with acute or chronic suicidal thinking report that those ideas and/or intrusive thoughts have disappeared. When they are absent, people need to be reminded of when they had them. They seem to have forgotten about them.”

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