Month: July 2022

Ketamine is an unusual type of psychedelic drug — called a dissociative — that is undergoing a resurgence in popularity. Originally derived from PCP, or “angel dust,” ketamine has been used in hospitals and veterinary clinics as an anesthetic for decades, and has been cited as a drug of misuse under the moniker “special K.”

It is the effects that ketamine reliably produces that underlie both its medical and recreational uses: pain control, forgetfulness, intoxication, disassociation, and euphoria. Recently, it has been used more widely due to its approval for treatment-resistant depression (TRD) — that is, severe depression that has not improved via other therapies, including people who are experiencing suicidal thoughts.

Evidence of the benefit of ketamine

A prescription version of ketamine called esketamine (Spravato), given through a nasal spray, was approved in 2019 by the FDA for TRD; however, according to the guidelines, it is only to be used “under the supervision of a health care provider in a certified doctor’s office or clinic.” That means medical professionals need to watch you use it, and then follow you after you’ve taken your dose, checking your vital signs and how you are doing clinically.

The effectiveness of ketamine for TRD was first demonstrated for short-term treatment in research that resulted in clinically and statistically significant decreases in depression scores for ketamine versus placebo (In both groups in this study, the patients continued with their regular antidepressants because of concern of not treating TRD in the placebo arm.) Nasal ketamine was shown to have longer-term efficacy, in a study where ketamine (plus the regular antidepressant) helped people stay in stable remission 16 weeks into treatment.

Relief from TRD with ketamine happens rapidly. Instead of waiting for an SSRI to hopefully provide some relief over the course of weeks, people who are suffering under the crushing weight of depression can start to feel the benefits of ketamine within about 40 minutes.

Is ketamine the right treatment for you?

This is a discussion that should include your primary care doctor, your mental health provider, and any other health care professionals who care for you. It’s important to remember that ketamine isn’t a first-option treatment for depression, and it is generally used only when other, more longstanding treatments haven’t been effective. It is not thought to be curative; rather, it improves symptoms for a certain amount of time. It is easier to say who isn’t appropriate for ketamine treatment, based on the side effects.

Should you go to a ketamine clinic for treatment?

Independent, outpatient ketamine clinics are popping up all over the place. It is estimated that there are currently hundreds to thousands of these clinics — almost all of which were established in 2019 when ketamine was approved for TRD. Typically, these clinics are for-profit enterprises that are staffed by some combination of either a psychiatrist or an anesthesiologist (who can administer the infusion), a nurse, a social worker, and (of course) the businesspeople who make it all work.

In writing this piece, I called several ketamine clinics, posing as a patient, to investigate what would be involved in receiving ketamine therapy. Most of them seemed as if they would provide ketamine for me without any major hurdles, after an introductory medical interview by a nurse or a social worker. A few clinics required communication or a diagnosis from my psychiatrist — and this seemed quite sensible.

The clinics operate on a fee-for-service arrangement, so you would pay out of pocket, as insurance rarely covers this treatment. In the Boston area where I live, the ketamine infusions cost about $600 each, and a course of six infusions and a clinical re-evaluation are typically recommended. (I should note that the ketamine clinics affiliated with medical academic institutions seem to have more safeguards in place, and they may also be enrolling people in clinical trials.)

Are ketamine clinics safe?

These ketamine clinics raise many questions — namely, what does one look for in a reputable and safe ketamine clinic? Currently, we don’t yet have definitive answers to that question. One wonders if a ketamine infusion, which can cause a profound dissociation from reality, would be better controlled in a hospital setting, where there are protocols for safety in case anything goes wrong. It was unclear (in part because I didn’t actually go through with the therapy) how much communication, if any, there would be between the ketamine clinic staff and your health care providers, and typically the treatments you receive would not be included in your primary electronic medical record.

What are the side effects?

Ketamine is generally considered safe, including for those who are experiencing suicidal ideation (thoughts or plans for suicide). The main side effects are dissociation, intoxication, sedation, high blood pressure, dizziness, headache, blurred vision, anxiety, nausea, and vomiting. Ketamine is avoided or used with extreme caution in the following groups:

• people with a history of psychosis or schizophrenia, as there is concern that the dissociation ketamine produces can make psychotic disorders worse
• people with a history of substance use disorder, because ketamine can cause euphoria (likely by triggering the opioid receptors) and some people can become addicted to it (which is called ketamine use disorder)
• teenagers, as there are some concerns about the long-term effects of ketamine on the still-developing adolescent brain
• people who are pregnant or breastfeeding
• older adults who have symptoms of dementia.

More detailed research needs to be done on the longer-term benefits and side effects of ketamine treatment, and on its safety and effectiveness for teens and older adults, as well as for the emerging indications of ketamine therapy for PTSD, OCD, alcohol use disorder, and other mental health conditions.

Finally, there is some concern that, with repeated dosing, ketamine can start to lose its effectiveness and require larger doses to produce the same effect, which is not sustainable.

Ketamine could provide hope for people with serious depression

Serious, treatment-resistant depression can rob people of hope for the future and hope that they will ever feel better. Ketamine can provide help and hope to patients who have not found relief with any other treatments. Given its efficacy in people considering suicide, it is plausible that ketamine may be lifesaving.

As we learn more from research on ketamine and from people’s experiences in newer clinics, we will be better able to answer the questions of ketamine’s longer-term effectiveness and what safeguards are needed for treatment. We may also learn who is most likely to safely benefit from ketamine therapies, and the best method of administration: intravenous infusion, a nasal spray, or a pill.

About the Author

Peter Grinspoon, MD, Contributor

Dr. Peter Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital; an instructor at Harvard Medical School; and a certified health and wellness coach. He is the author of the forthcoming book Seeing … See Full Bio View all posts by Peter Grinspoon, MD

The wait is finally over: after 40 weeks of medical appointments, nursery planning, and anticipation, your baby has finally arrived. She is perfect in your eyes, healthy and adorable. Yet over the next few weeks, your initial joy is replaced by all-consuming worries: Is she feeding enough? Why is she crying so often? Is something medically wrong with her? These worries are constant during the day and keep you up at night. You feel tense and irritable, your heart races, and you feel panicky. Your family members start to express their concern —not just about the baby, but about you. You wonder whether your anxiety is normal.

Baby blues, postpartum depression, or postpartum anxiety?

Chances are, you have heard about the baby blues or postpartum depression. You may have even filled out questionnaires about your mood during your postpartum doctor’s visit. The baby blues are a very common reaction to decreasing hormone levels after delivery, and may leave you feeling sad, weepy, and overwhelmed. However, these symptoms are mild and only last for a couple of weeks. When the symptoms persist and become debilitating, something else could be going on.

Many symptoms overlap between postpartum depression and postpartum anxiety (such as poor sleep, trouble relaxing, and irritability). Mothers experiencing postpartum depression commonly experience symptoms of anxiety, although not all mothers suffering from anxiety are depressed. Establishing the correct diagnosis is important, as women with postpartum anxiety may not respond as well to certain treatments for depression, such as interpersonal psychotherapy or medications such as bupropion (Wellbutrin).

Similar to postpartum depression, postpartum anxiety may spike due to hormonal changes in the postpartum period. It may also increase as a response to real stressors — whether it’s the health of the baby, finances, or in response to navigating new roles in your relationships. A history of pregnancy loss (miscarriage or stillbirth) also increases your risk for developing postpartum anxiety. If you have a history of anxiety before or during pregnancy, postpartum anxiety symptoms may also return after delivery. Anxiety and sadness may also appear after weaning from breastfeeding due to hormonal changes.

Some women experience panic attacks or symptoms of obsessive-compulsive disorder (OCD) in the postpartum period. Panic attacks are distinct episodes of intense anxiety accompanied by physical symptoms including a rapidly beating heart, feelings of doom, shortness of breath, and dizziness. Obsessions are intrusive, unwanted thoughts and may be accompanied by compulsions, or purposeful behaviors to relieve distress. These symptoms may be frightening to a new mother, especially when these thoughts involve harming the baby. Fortunately, when obsessions are due to an anxiety disorder, mothers are extremely unlikely to harm their babies.

What are the treatments for postpartum anxiety?

In general, postpartum anxiety is less studied than its cousin postpartum depression; however, it is estimated that at least one in five women has postpartum anxiety. We do know that therapies such as cognitive behavioral therapy (CBT) are excellent treatments for anxiety disorders, including OCD. For some women, medications can be helpful and are more effective when combined with therapy. Selective serotonin reuptake inhibitors (SSRIs) are generally the first-line medications (and the best studied medication class) for anxiety disorders, whereas benzodiazepines are rapidly acting anti-anxiety medications that are often used while waiting for an SSRI to take effect.

Should you take medications when breastfeeding?

Breastfeeding provides many benefits to the baby: it’s the perfect nutrition, it helps build a baby’s immune system, it may help prevent adulthood obesity, and it provides comfort and security. Breastfeeding also provides benefits for the mother: it releases prolactin and oxytocin (the love and cuddle hormones), which help a mother bond with her baby and provide a sense of relaxation. When considering whether to start a medication, it is important to be aware that all psychiatric medications are excreted into the breast milk. Your doctor can help you think through the risks and benefits of medications based on the severity of your illness, medication preference, and previous response, as well as factors unique to your baby, such as medical illness or prematurity.

What non-medication strategies are helpful in decreasing postpartum anxiety?

• Cuddle your baby (a lot). This releases oxytocin, which can lower anxiety levels.
• Try to maximize sleep. Although the baby may wake you every three hours (or 45 minutes) to feed, your partner should not. Sleeping in separate rooms or taking shifts caring for the baby may be necessary during the first few months. Aim for at least one uninterrupted four-hour stretch of sleep, and be mindful about caffeine intake.
• Spend time with other mothers. Although you may feel like you don’t have the time, connecting with other mothers (even online) can do wonders in lowering your fears and validating your emotions. Chances are you are not the only one worrying up a storm.
• Increase your physical activity. In spite of the physical toll that pregnancy, delivery, and milk production take on your body, physical activity is one of the most powerful anti-anxiety strategies. Activities that incorporate breathing exercises, such as yoga, may be particularly helpful.
• Wean gradually. If you are breastfeeding and make the decision to wean, try to do so gently (when possible) to minimize sudden hormonal changes.
• Ask for help. Caring for a baby often requires a village. If you are feeding the baby, ask someone else to help with household chores. There is an old saying “sleep when the baby sleeps.” You may prefer “do laundry when the baby does laundry.”

And finally, give yourself a break — after all, you just had a baby. Postpartum anxiety is common, and in many cases, it will pass with time.

About the Author

Stephanie Collier, MD, MPH,

Contributor; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Stephanie Collier is the director of education in the division of geriatric psychiatry at McLean Hospital; consulting psychiatrist for the population health management team at Newton-Wellesley Hospital; and instructor in psychiatry at Harvard Medical School. … See Full Bio View all posts by Stephanie Collier, MD, MPH