Ketamine in Psychiatry

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Ketamine has been used since 2011 by psychiatrists and others for untreatable depression. Soon after it was seen to be used for post, traumatic stress and anxiety disorders and suicidal ideation.

Dr. Richman certified by the ASKP3, the American Society of Ketamine, physicians, practitioners and psychotherapists. Ketamine does not belong to any group of physicians, particularly. Anesthesiologists utilize ketamine to prepare patients for surgery and some radiology procedures. Some psychiatrists may understand ketamine for use with psychiatric conditions. In our office we are familiar with decades of psychiatric patients, neurologic patients such a dementia and migraines, as well as pain patients with various types of pain.

We like to start many patients with an intramuscular injection, using an insulin syringe for a very precise dosing. This is less traumatic for patients and more cost-effective initially. When patients become more comfortable, they frequently like to go to a syringe pump. This is how we deliver intravenous dosing. The syringe pump gives extremely accurate dosing. We may use a cream to “numb” your skin prior to the IV catheter.

**leave room for more copy.y.

Treatment resistant depression is considered when two prior treatment failures of antidepressant medication, using adequate dosing and duration occur. As patients we see with depression or actually treatment resistant depression as long as there’s no schizophrenia or liver disease we are pretty safe to move forward after evaluation. Patients do extremely well with ketamine here.

Bipolar depression 

Some terms to understand. 

Mania is a state of extreme elation, euphoria, or irritability lasting for at least one week. Characterized by inflated self-esteem, decreased need for sleep, racing thoughts, impulsivity, and reckless behavior. 

Hypomania is an a form of mania that can last for at least four days. This has the same symptoms, but less severe does not cause significant impairment. =——==========

Bipolar disorder type 1 requires at least one manic episode. Depressive episodes may also occur, but not necessary for diagnosis.

Bipolar disorder type 2 shows at least one hypomanic episode and at least one major depressive episode. 

Bipolar 1 is considered more severe than 2 as being more intense and longer lasting manic episodes. 

Bipolar 2 tends to have more frequent and severe depressive episodes. 

Bipolar 1 typically has an earlier age of onset. 

It is thought, although seemingly less than severe bipolar 2, bipolar  type 2 could be much more dangerous as someone suffers with severe depression, sometimes unrelenting, which can lead to suicide. 

Of interest, it could be said that many patients with treatment resistant depression are really bipolar 2 who have failed 2 antidepressants or more and not clinically labeled. 

Regarding treatment with Ketamine, many experts say one must be careful with Bipolar disorder as ketamine may cause more mania. 

A recent article in the journal Brain Science in June 2023 stated ketamine infusions did not appear to result in a higher rate of manic/hypomanic induction, dissociation or psychosis when compared to persons with major depressive disorder.

So, game on!

Post traumatic stress disorder occurs with exposure to trauma with the result of patients avoiding the triggering stimuli or thought of triggering stimuli as well as changes in mood and thought processes and changes in arousal. Patients are feeling always on the alert.  Patients are successful with ketamine .

Substance use disorder does not need an explanation. It’s important to understand. The patient was such as used disorders do not have a drug problem. They have a “hug problem.” people self treat undiagnosed psychiatric problems, feelings of shame and guilt, and many of other problems what could be more properly fixed if found earlier.  

We find patients who receive a light dose of ketamine by intramuscular route do not need Suboxone opiates or benzodiazepines for a number of days. Weaning off in this manner should be discussed with your physician. We are using this to get people off Suboxone, opiates and benzodiazepines. This can happen simultaneously while treating anxiety disorder, PTSD, substance use disorder, etc..

ADD and anxiety disorders should be at the top of the list as far as far as how often it seen affecting individuals.

When seeing patients with anxiety and depression and even manic behaviors is important to rule out ADD. Otherwise they are doomed to failure with SSRI such as escitalopram as we see all the time. ADD is not attention deficit but attention inconsistency. Patients may be very smart, but may not seem so because of their attention variability. Things they like they are extremely fascinated by. They’re extremely skillful at these things. They also procrastinate as there is a fear and subconscious thought of failure so they avoid it. There is also a great deal of volatility and they can be upset over things not going as planned. When we hear anger management we think ADD.

A very high percentage of patients seen with addictions are coming in for medical cannabis cards and actually have ADD. Avoid stimulants due to tolerance and teeth, decay. Other medications include atomoxetine and bupropion.

That being said the ADD brain does amazingly well with Ketamine. The ADD brain has problems in the prefrontal cortex where executive function is performed. This can be rewired with Ketamine. 

Other causes of anxiety need to be ruled out. This includes personality disorders, such as borderline personality disorder. This is where individuals have a strong fear of rejection leading to frantic efforts to avoid abandonment. They have symptoms of intense, anger and difficulty controlling anger. Paranoid thoughts and feelings during stressful situations and may feel detached from reality perform self harm. Suicidal thoughts may be seen and it is important the person is properly diagnosed and treatment should include a psychiatrist. ketamine may have some benefit depending on the psychiatrist.