We see a lot of patients with chronic disease in clinic. Most of our patients have depression as well, that they attribute to their chronic disease. We are not psychiatrists, and don’t manage antidepressants, but we do have to be aware of side effects and potentially dangerous drug interactions with medications we may prescribe or procedures we perform.
We do have patients that report stable mood on their medication regimen; however, more often than not, the medications our patients are on don’t seem to work, cause weight gain, insomnia, constipation, decreased libido or other undesirable side effects. Despite these adverse effects, they stay on these drugs for years, and there is no plan to stop in the near future. Many times, patients report going to their doctor and just getting refills, because they don’t know what else to do.
A study from 2015 showed that depression is a major public health problem associated with functional disability and mortality, and that the consequences of
major depression exceeded $200 billion dollars in 2010. Depression has increased over time and has more than doubled from the early 1990’s to the early 2000’s per cross-sectional survey.
We have noticed that most, if not all, of our patients have work related stress. Burnout is a common term that is used these days, but at RevIVe Wellness we are going away from this term. Why? Burnout suggests that people are not resilient or efficient enough to handle their work, implying it is their fault. Moral injury is a phrase that has been suggested instead as it occurs when we witness or fail to prevent an act that goes against our moral grain. To put this in context, this act is caused by trying to keep everyone happy in the workplace- the customer, the boss, the company as a whole, and any other entity attached to the business. We tell our patients it’s not possible to make everyone happy as it can jeopardize their happiness. Once that occurs, it begins a potentially downward spiral.
To combat stress and decreased mood, patients take antidepressant medications. Antidepressants come in a variety of forms and have varying mechanisms of action, the most common being selective serotonin reuptake inhibitors (SSRI). As we said before, patients stay on antidepressants for a long time, often times for years or longer. Major depression has a high recurrence rate, as there is a 40% chance of recurrence over two years following one episode of major depression, and a 75% chance of depression after two episodes of depression.
The United States is the largest users of anti-depressants in the world, with 11% of Americans over the age of 12 being on an antidepressant. A meta-analysis from Lancet in April 2018 compared the efficacy of 21 antidepressants for the acute treatment of major depressive disorders. Fluoxetine, also known as Prozac, was shown to have low efficacy in the treatment of depression. Drugs like amitriptyline (Elavil), duloxetine (Cymbalta), and venlafaxine (Effexor) had the highest drop out rates due to side effects.
Adherence is also an issue. According to a questionnaire study from 2017, 60 people on antidepressants were studied, with 78% being women. 68% of women were non-adherent, with 82% of housewives being non-adherent. The conclusion of the study was that most patients were non-adherent to their regimen, with the main reason for non-adherence being forgetfulness.
A common issue we hear about in clinic is that when a patient sees their primary care doctor and explains the (sometimes multiple) issues they are having, the doctor spends just a few minutes with them and gives them a medication for each complaint. This leads to poly-pharmacy and potentially dangerous drug-drug interactions. A Johns Hopkins study from 2015 showed that 69% of anti-depressant users did not even meet criteria for a diagnosis of major depressive disorder (MDD).
Intravenous ketamine infusions are a viable option for major depressive disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and for patients who have had a history of suicidal thoughts. A series of six infusions for forty to sixty minutes over a 2-3 week period is what has been traditionally used, and at RevIVe Wellness, we stress to our patients not to change their antidepressant regimen unless instructed to do so by their psychiatrist or prescriber. We have observed that patients who have started with ketamine infusions feel like they need less antidepressants by the end of the treatment series. In fact, most of our patients have reported being on less antidepressants at follow up after their six infusions.
Ketamine has been especially useful for those who want a rapid treatment for depression, as anti-depressants can take many weeks to months to take effect.
According to a consensus statement on the use of ketamine in the treatment of mood disorders, the strongest data supporting ketamine’s clinical benefit in psychiatric disorders are in the treatment of major depressive episodes without psychotic features. The consensus statement also strongly discourages use of self-administration of ketamine at home. This is likely why esketamine nasal spray will have to be done in a physician’s office and having to be observed for two hours. Dissociation is the most common adverse effect associated with esketamine, another reason why self-administration can be potentially dangerous. There are guidelines for the use of ketamine in acute and chronic pain written by academic anesthesiologists, which is a major reason why anesthesiologists should be involved in patients undergoing administration of ketamine.
There are over 50 academic papers that have shown that ketamine can improve symptoms of depression, including treatment resistant depression. It has also been shown to be helpful in patients who have suicidal ideations and PTSD. Ketamine is a controlled medication, and should be administered under the vigilant watch of a board-certified anesthesiologist, who has the experience and training to manage any potential side effects of the drug and for patient safety.
If you live in the Chicago area and have a diagnosis of depression or PTSD, book a preliminary consultation for a ketamine intravenous infusion with ReVive Wellness on (847) 213-0990 or email us at [email protected] and take charge of your health.