How does Ketamine work for Depression?

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Research is ongoing into the mechanism of action for ketamine having an anti-depressant effect. Although the exact mechanism for its anti-depressant effect is not delineated, ketamine is known to act at the NMDA, AMPA, and opioid receptors in the body which have been the basis of its understanding and use in anesthesia and pain relief. Studies have also demonstrated that ketamine therapy can modify and increase connectivity in parts of the brain implicated in mood control. 

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How effective is Ketamine for Depression?

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For patients that will respond to ketamine therapy, symptom relief can often be observed before the first dose is complete (within the first hour). Studies are ongoing but several have shown that more than 50% of patients with treatment resistant depression who receive ketamine have an improvement in their mood while placebo arms in those studies only saw about a 2% mood improvement. This means that not everyone will see a benefit from ketamine therapy, but many will. For those that don't respond during their first dose, studies have shown they may respond during a subsequent dose. Additionally, studies have shown that for patients with suicidal ideation, ketamine can be effective at reducing ideation with improvement occurring within 1 hour of starting treatment and typically lasting for at least one week. For patients with treatment resistant depression and suicidal ideation ongoing surveillance by your psychiatrist is vital. 

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When should Ketamine be used for Depression?

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Ketamine therapy should only be initiated when deemed appropriate by your psychiatrist. It should be used for those who do not have adequate mood control when traditional treatment modalities have been tried for an appropriate period of time (traditional anti-depressants, psychotherapy, others). Ketamine may be considered before ECT ('electro convulsive therapy') given the invasive nature of ECT treatment. Additionally it can be used following ECT therapy if patients have ongoing mood concerns. Additionally, ketamine therapy has shown to have a strong effect at reducing suicidal ideation in patients with ongoing depression. 

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Who is involved in Ketamine therapy?

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Safe and appropriate usage of ketamine therapy involves a team approach between two physician specialties. Firstly a psychiatrist is needed for long term care of a patient's mood condition and to determine a patient's eligibility and likelihood of them benefiting from ketamine therapy. Secondly an anesthesiologist is needed to determine a patient's eligibility to receive ketamine therapy based on their medical history, to administer the medication, and to monitor and treat any side effects. Anesthesiologists are physicians who specialize in providing anesthesia for surgeries and have vast experience with using ketamine and monitoring patients. It is critical that both physician specialties work together to ensure the best possible outcome for patients and as such our centre ensures a collaborative relationship is established with your psychiatrist and that appropriate follow up to monitor your mood is in place following ketamine therapy. 

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How long does Ketamine help Depression Symptoms?

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Research is ongoing into the duration and durability of depression symptom relief following ketamine therapy. To date studies have demonstrated variable lengths of mood improvement  but several have demonstrated up to several weeks of symptom relief after an initial course of ketamine therapy for those that respond. Additional maintenance doses of ketamine therapy can be prescribed if deemed appropriate by your managing psychiatrist based on the progression of your symptoms and response to your initial treatment. Additionally, some studies have shown that using a course of ketamine therapy followed by continuing traditional anti-depressants leads to better long term mood management than using traditional anti-depressants alone. 

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How is Ketamine administered and monitored?

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Intravenous (IV) ketamine is administered intravenously. To do so, a small IV cannula is placed into a vein in a patient's arm through which ketamine is infused using a medical infusion pump. An infusion of ketamine (typically 0.5mg/kg) is given over ~1 hour and the patients vital signs are monitored throughout where heart rate and rhythm, blood pressure, and oxygen saturation levels are monitored. Patients are monitored for an additional hour after completing the infusion. One of the advantages to using IV ketamine when compared to intranasal ketamine, is that being an continuous infusion, it can be stopped at any point if side effects are experienced before the full dose is administered. 

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Esketamine (Spravato) is ketamine that is given intra nasally using the included dispenser. It comes as a 28mg nasal spray and the amount of individual dispensers needed is determined by your body weight. Many patients will require more than one dispenser per treatment. Once applied intra nasally using the spray applicator, patients needs to be monitored for 2 hours, identical to IV ketamine. Unlike IV ketamine, once administered the full dose is given and cannot be stopped early.  

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How many doses of Ketamine are needed?

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We will work with your psychiatrist to determine how many ketamine doses are needed during your initial treatment. For IV Ketamine, typical regimens are 4 to 8 doses administered once to twice a week. Additional maintenance doses may prescribed as determined by your mood and discussions with your psychiatrist. 

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For esketamine (Spravato), the recommended initial dosing is 2 doses per week for 4 weeks (8 total). Following this the maintenance dose can be prescribed based on your psychiatrists recommendation with a dose every 1 to 2 weeks. 

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What are the potential complications and risks of Ketamine therapy? 

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Short term ketamine use is generally safe and well tolerated with most side effects having peaked by 2 hours. The most common side effects from ketamine include sedation, elevated blood pressure, head ache, nausea, anxiety, and dissociation (a state of sedation and decreased awareness). This is why it is important to be appropriately monitored by an anesthesiologist who is available to treat intolerable side effects like excessively high blood pressure, excess sedation, or dissociation. Long term complications (bladder dysfunction, liver injury) are very rare particularly with short duration of use. Additionally there is a low risk of addiction and dependence with short term use.

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Is Ketamine for depression OHIP covered? What is the cost? Does insurance cover it?

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Currently OHIP only covers ketamine therapy for chronic pain conditions and not for treatment of mood symptoms. When referred to our clinic by a physician your initial intake consultation will be covered by OHIP. Cost per IV ketamine dose is $375 and includes the cost of the pre and post treatment assessments, the medication and infusion, and monitoring for 2 hours. Some private insurance plans may cover IV ketamine therapy for depression but this is on a plan by plan basis. 

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For patients using esketamine (Spravato), the prescription must be filled at a designated pharmacy and delivered to our clinic before your appointment date. If you require assistance getting or filling an esketamine prescription please contact us and we can help to facilitate the process through one of our collaborating pharmacies. The cost of esketamine is not currently covered by OHIP. Some private insurance plans may cover the cost of the esketamine. Cost for 2 hours of monitoring and administration is $250 (not including the cost of the esketamine). 

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How do I get a referral?

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Please see our Referral Section. 

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