For severe intractable depression, bipolar disorder, migraines, PTSD and CRPS or RSD we offer Ketamine Injection therapy.
Who Can Benefit From Ketamine Therapy?
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Persons with resistant Depression, Bipolar disorder, PTSD, OCD, Migraine
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Persons with neuropathic pain that is not well controlled with injections, nerve blocks, or prescription pain medication. Examples of this kind of pain are trigeminal neuralgia, complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy (RSD), phantom limb pain, diabetic and other neuropathies, post-herpetic neuralgia, and some headaches.
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Persons with chronic back and neck pain no longer responsive to any form of treatment.
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Persons with debilitating fibromyalgia.
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Persons with other debilitating musculoskeletal and joint pain.
Ketamine and Depression
Periods of depression are common mood disorders that most people face from time to time. They follow life events and disappointments that impact us deeply. These kinds of depression are generally short lived and respond to psychotherapy, conventional drug therapy or simply tincture of time. They are not crippling. But, lifelong major depressive disorders (MDDs) are something different, and are more likely associated with suicidal thoughts and attempts.
Patients who have been diagnosed with treatment resistant depression are candidates for ketamine therapy. This includes patients with major depressive disorders, post-partum depression, bipolar depression and severe anxiety states. When a patient has not responded to inpatient therapy, medications or other forms of treatment, Ketamine should be considered as the next step.
Ketamine therapy is not for those with mild depression, situational depression, or mood swings. Severe depression is often the result of Post-Traumatic Stress. This stress does not have to be the result of “war wounds”, but can arise from neglect, abandonment, bullying, sexual abuse, or severe depravity during the developmental years. The depression is often not manifest for a decade or more following the trauma. Ketamine therapy can successfully treat post-traumatic stress and subsequent depression.
Patients with recurrent thoughts of suicide, who need immediate mood stabilization, will most often benefit from Ketamine therapy.
If you are visiting this page you are most likely dealing with a major depressive disorder (MDD) that has not responded to other medications. Many of you will have had trials of all the available antidepressants. Some of you have had ECT (electroconvulsive therapy) and /or TMS (transcranial magnetic stimulation) with no significant improvement in your condition. Chances are that you can no longer function at home, work or school, and find even small tasks, like showering, insurmountable.
Many of the patients with MDD that I encounter are survivors of childhood trauma. They are actually suffering from post-traumatic stress disorder (PTSD). Childhood trauma can arise from a variety of causes; abject poverty, physical, mental or sexual abuse, neglect, parental divorce, disabilities, and bullying, to name some. All of the above result in stress, anxiety, pain and feelings of low self-worth. It is these feelings that morph into MDD, beginning as early as the late teens and continue thereafter. The cause is a change in brain chemistry brought on by childhood stress, with subsequent changes in brain anatomy that are difficult to repair.
Brain Derived Neurotropic Factor (BDNF) is an important brain chemical. It is responsible for the maturation and maintenance of the neuronal dendrites and synapses that are necessary for normal brain connectivity. That is, in order to have a normal mood, the neurons in various parts of your brain need to be able to connect to each other via their dendrites and their synaptic contact. Childhood stress and anxiety inhibit the production of BDNF, leading to visible changes in neuro-anatomy and subsequent serious mood disorders such as MDD, PTSD, obsessive compulsive disorder (OCD), and anxiety.
Over the past five decades, antidepressant research and medications have revolved around the regulation of three neurotransmitters; serotonin, dopamine and norepinephrine. Together, they represent about 15% of the brain’s neurotransmitters. Much more prevalent is the neurotransmitter glutamate, which has only recently begun to receive attention as instrumental in treating mood disorders. It is via the glutamate system and two important receptors, NMDA and AMPA receptors, that ketamine works to relieve depression. It does so by turning back on BDNF production. The BDNF then leads to repair of the damaged neurons with regrowth of the important dendrites and synapses needed to achieve a normal mood. Animal models show us that the repair can begin in a matter of hours after the administration of ketamine. This process of brain repair is called neuroplasticity, and ketamine facilitated neuroplasticity offers great hope for patients with MDD who have not responded to other treatments.
Bipolar Manic State
There is a lot of research showing ketamine is effective for bipolar patients. But some researchers say bipolar patients get good results only when their therapy happens during a depressed state, not manic. If you are bipolar and are in a manic state on the day of your appointment, make sure the doctor is aware. Together we may decide it’s better to postpone until you cycle back to depression.
Response of Depression to Ketamine
About 70% of patients with treatment-resistant depression (including bipolar patients) experience rapid relief after a low-dose ketamine treatment. Results can be immediate in some patients with refractory depression. Similar success rates have been seen in returning combat veterans suffering from PTSD. These patients’ cases are the worst of the worst, lasting years or even decades, and which have not responded to any other treatments. Many have hovered on the verge of suicide for years, many have actually attempted suicide, and all have endured a very poor quality of life. Before ketamine therapy, there was virtually no way to substantially improve the condition of patients like these. The fact that ketamine works rapidly on 70% of them is astonishing, and its discovery has profoundly changed depression research, and our understanding of the very nature of depression.
The National Institutes of Health has been studying ketamine’s effect on depression for more than ten years. There is serious scholarly research behind this treatment, which means controlled, double-blind, peer-reviewed studies at major institutions. Researchers at Yale pioneered this research nearly 20 years ago and published the first major study in 2000. Since then, dozens more ketamine studies have been conducted at Yale and other major institutions including NIH, The VA, Harvard, Johns Hopkins, Mt. Sinai Medical School, Oxford University, and many more around the world.
It’s important to keep in mind, however, that the degree of relief can vary among patients. Some sufferers get only partial relief, some do not get relief until a second or third treatment, some feel a gradual sense of well-being not directly related to the treatment, and some do not respond to ketamine at all.
Consider relief to be a spectrum of results. The very best outcomes might include a rapid, obvious reduction of symptoms; increased function and productivity; significant improvement in mood; and a massive positive shift in the patient’s fundamental thinking that persists even after relapse. Not everyone will experience this best-possible case. But to patients who’ve suffered years in acute agony, even partial relief can be miraculous and life-changing. Most first-time ketamine patients are desperately craving relief. They can’t help but pin all their hopes on this new option. It’s completely understandable for someone who’s suffered for years, maybe decades, where no treatment has ever helped. When the stakes are so high, expectations can run wild.
We want to be blasted with relief, instantly. We might fantasize that it will arrive in dramatic fashion, with an incredible electric sensation, and gasps from spectators. Relief rarely comes in that packaging. It’s usually much more subtle – but just as gratifying. Many patients get incredible, life-changing relief without pyrotechnics. It is important that your expectations are realistic, and you ask any questions prior to starting the treatment.
Getting the most out of treatment: If you’re going to spend money and pin your hopes on being a ketamine responder, you should do everything in your power to get the most out of the treatment. At first you may not feel your treatment was successful, but later you may note solid improvement. There are things you can do before, during, and after treatment to maximize your chances of a good outcome. Keep in mind that some patients do not respond to ketamine, and here we are only talking about those who do.
Rest Up: Try to be well-rested before the ketamine treatment. If you have a morning appointment and are worried about being able sleep the night before, ask your ketamine provider if it’s ok to take a sleep aid. Some patients feel their treatments are less effective when they are sleep-deprived.
Relax & Empty your bladder: The ketamine when administered as an infusion only puts a few ounces of fluid into your body. But many patients feel like their bladder is full as soon as the infusion is over or soon after the injection. Make sure it’s completely empty before the infusion starts or the injection is given, to buy yourself time at the end of the treatment before you have to make your way to the bathroom. We realize this is easier said than done for some patients, but try to be in a relaxed state before the treatment. Patients who are very tense when the treatment starts are more likely to have brief moments of unpleasantness. If caffeine makes you jumpy, maybe skip your daily cappuccino or wait until after your appointment. Obviously, you may be pinning a lot of hopes on the treatment and that can make you anxious. Arming yourself with knowledge about the treatment and setting realistic expectations can help you relax when you get there. Do not take a benzodiazepine to relax before your appointment! See below.
Ask If Your Current Meds Will Interfere Make sure your ketamine provider is aware of every drug you are currently taking, whether it’s a psychotropic med, heart medication, cough syrup, an illegal substance, etc. Some substances can interact with ketamine or interfere with its action in the brain. For example, high doses of benzodiazepines seem to reduce ketamine’s antidepressant effect. If you are taking a daily high dose of benzodiazepines, we might recommend reducing it before your treatment. Other medications that can impact ketamine’s efficacy include lamotrigine [Lamictal], memantine, and any drug that affects NMDA receptors. Don’t hold anything back from the doctor. There’s no point investing your money and hopes unless you’ve disclosed everything and the doctor is satisfied nothing will interfere with the ketamine.
Tell Your Loved Ones to Hold Their Questions
Easy to ask, hard to answer. Ask your friends and family not to bombard you with questions after the treatment. They will naturally want to ask “Did it work?” or “Do you feel better?” But the effects can be extremely subtle at first and many patients have trouble putting the experience into words. You may need time to process it. Even those who can sense an immediate change often find it impossible to articulate at first. When people ask those questions it can make you feel pressured not to disappoint them. To them, these seem like easy questions, but to you the answers may be complicated in ways you can’t explain. Let them know ahead of time that you’ll talk about it when you’re ready, which might take a few days. Don’t Stress Out Waiting for a “Blast” of Relief – Remember Function Often Improves Before Mood. Don’t forget that successful patients often begin functioning better before they feel better.
Do NOT forget this fact while you wait for relief to reveal itself. You might be inclined to find an isolated place, close your eyes, block out all noise, and concentrate hard to measure your mood, searching for any tiny changes. It’s perfectly understandable why, but doing that won’t actually help you. Instead, try to go about your daily routine. You may gradually realize that it’s easier than before. Even if your daily routine was nothing but lying in bed wishing you could get up, you may start noticing small things becoming easier, like putting on clothes, brushing your teeth, etc. These improvements can snowball in ways you don’t expect. Many patients look back later and recognize small improvements like these as the first signs of relief, even if they didn’t seem momentous at first.
Put Your Improved Function to Use – Right Now! If you respond to ketamine, you will be able to function better than before. Put that ability to use! Don’t wait, even for a minute. If you’re able to socialize, go do it right now, instead of just patting yourself on the back for feeling able. If you’re able to clean your house or organize your finances, do it right now, instead of feeling satisfied that you could do it. The more you exercise your improved function, the more your mood will lift. Imagine you had a muscle-wasting disease instead of depression, but there’s a treatment that can quickly repair the damage. If you don’t put those newly-repaired muscles to use, your treatment was wasted.
But if you lift weights and focus on building new muscle mass, you’ll be much more able to deal with the condition if it returns, literally from a position of strength. Successful ketamine therapy gives you the ability to build new “muscle” in the form of better function, improved habits, etc. – and the improved mood that comes with those things. This combination can give you an entirely new power: resilience. If your depressive symptoms return, your new strength and resilience can help you withstand those symptoms better than ever before. Most responders do not sink all the way back to their old baseline.
The likelihood of permanent baseline improvement is directly related to how much you exercise your improved function while the relief holds, regardless of whether it lasts one week or six months. Build on Your Relief to Make Lasting Emotional Gains. When a patient experiences relief like we’ve described, they can often make huge sudden leaps forward in their emotional healing. Many patients say they suddenly “get” what their therapists have been saying for years. Take advantage of this state and find a competent therapist who can help solidify your benefits into lasting emotional gains. Many patients find these improvements persist even if their symptoms return, giving them resilience, they never had before.
Ketamine Side Effects
Ketamine treatment is generally well tolerated, and few patients need to terminate treatment because of side effects. Still, ketamine is a derivative of phencyclidine (PCP) a known psychedelic and if not combined with sedation can cause hallucinations in some patients. Other possible side effects include nausea and rarely a headache. Following treatment, patients will be tired for several hours and need to be accompanied home by a responsible adult. There are no long-term side effects associated with Ketamine in the relatively low doses used to treat chronic pain. Ketamine is a potential drug of abuse and dependence and tolerance can occur.
Frequently Asked Questions
Concerns Regarding Ketamine
1. Consequences of long-term use have not been studied yet. That statement is true. There are no studies on long-term repeated ketamine treatment for depression. And there probably never will be. There is simply no way to turn ketamine into a big moneymaker, so no one is going to fund that research. Instead of researching long-term ketamine use, or trying to find the most effective dosage and treatment schedules, much of the research is heading in a different direction. The search is on for other drugs that are similar to ketamine, but different enough to be patented. In other words, ketamine-like drugs that could become blockbuster moneymakers. If such a drug is found and obtains FDA approval, it will quickly become one of the top 5 or 10 bestselling drugs in the world, even if it proves less effective than ketamine. Some of the research remains focused on the underlying ketamine mechanisms of action, but enough effort has shifted towards profit to dilute the resources available for fundamental science. Bottom line: we’re not aware of a single study, current or planned, that looks at potential consequences of long-term ketamine therapy – there is simply no appetite for this research. Even though there are no formal studies on long-term ketamine therapy, there is actually quite a lot of good clinical data available. For 20 years, ketamine infusion has been the most effective treatment available for Chronic Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD), an extremely painful neuropathic condition. The ketamine dose in a typical CRPS infusion is between 2x and 10x that of a depression dosage. And they are much more frequent, sometimes with multiple treatments per week, where a depression patient may get 1-2 treatments every few months. Yet after 20 years of routine CRPS use there is no clinical evidence of negative side-effects from repeated ketamine treatments. Can’t wait for long-term study of life preservers. Let’s talk about what we do know. Ketamine has a 50-year track record as a safe anesthetic, and a 20-year history as a safe long-term CRPS treatment. It’s proven to rapidly relieve depression/bipolar/PTSD symptoms in about 70% of treatment-resistant patients for whom no other treatment works. Most importantly, we know the awful consequences when patients like this can’t get relief. Finally, substantial research has shown that living with severe depression causes measurable physical injury to the brain. Every day that passes without relief means additional harm to the brain. With ketamine treatment, there’s a chance of relief. Without it, there’s guaranteed continued suffering. Patients must be entitled to weigh the risks for themselves.
2. The relief is not permanent, and depressive symptoms will return for most patients. This statement is true. But so what? Do psychiatrists discourage patients from taking SSRIs because a single dose can’t permanently extinguish their symptoms? Taking a single dose of insulin doesn’t cure diabetes, but is that a reason not to take it? No one is hawking ketamine as a cure. It’s a treatment. An intervention. That’s why it’s called “therapy,” not a “permanent fix.” Yes, the patient will usually relapse, at least partially. But most find additional treatments will restore the relief. Ketamine can have lasting benefit even after relapse occurs. When ketamine relieves their symptoms, many patients find they are suddenly able to achieve rapid, profound emotional healing, and break out of negative behaviors and thought loops that were previously inescapable. When the symptoms begin to return, the emotional healing can persist. It can make the patient more resilient, and better able to withstand the pain caused by the symptoms.
3. Dissociation is an unacceptable side-effect. Is puking violently for days an acceptable side-effect of lifesaving chemotherapy? What about losing your hair for a year? Who decides? Is 40 minutes of mild dissociation an acceptable side-effect of lifesaving ketamine therapy? Again, who decides? Many medical treatments have truly awful side-effects, yet they are universally embraced because the benefits dwarf the side-effects. Chemotherapy and radiation treatment are two examples. Ketamine therapy is like that too, where the magnitude of the dissociative side-effect is trivial compared to the life-changing relief it provides many patients. Unlike chemo or radiation, this side-effect is brief, disappearing completely fairly quickly before you leave the office. Moreover, ketamine patients usually experience dissociation as a pleasant side-effect, not negative. To declare it an “unacceptable” or “negative” side-effect is to pass a moral judgment, and that is outside the jurisdiction of researchers. Doctors, pharmaceutical companies, and other parties also have no business telling patients which side-effects are acceptable in exchange for relief. Patients must be entitled to decide for themselves which side-effects are worth the potential payoff. There’s simply no way to argue that this patient’s misery is preferable to a brief dissociation. “We give chemotherapy for cancer and there are side effects with chemotherapy, but we give it anyway, because people need it to get better from cancer. Ketamine does not have the side effects chemotherapy does, yet we’re using it for a disease that has a defined mortality; there is a suicide rate associated with severe depression.” Dennis Charney Co-author of the original Yale study and Dean of Icahn School of Medicine at Mt. Sinai.
4. Injectable treatments are too much of a hassle. Patients need something that is easier to administer. Of course, it would be preferable to have something simple like a pill. But until the research produces something easier to administer that is just as effective as ketamine, what’s the alternative? Remember we’re talking about patients who respond to no other treatment. They’ve already exhausted the usual options, and they deserve a lifeline. The right to decide whether ketamine is worth the trouble lies solely with the patients.