Lori Calabrese, MD

Author: Lori Calabrese, M.D.

CT doctors using new nasal spray to treat severely depressed patients

By Peggy McCarthy, Conn. Health I-Team Writer Published 11:51 am EDT, Tuesday, August 13, 2019

Some Connecticut hospitals and doctors and a clinic are starting to treat severely depressed patients with a new nasal spray called Spravato, touted as the most significant federally approved depression medication since Prozac was approved in 1987.

Spravato, which received Food and Drug Administration (FDA) approval in March, has raised hopes for preventing suicides and relieving depression after other treatments have failed. But there are concerns about possible side effects, including drug abuse, elevated blood pressure and heart rate, sedation, and hypersensitivity to surroundings.

The nasal spray is prescribed for treatment-resistant depression after at least two other antidepressants haven’t worked and is given with an oral antidepressant. It is only administered in restrictive clinical settings to reduce potential for abuse and side effects.

Nationally, of the 17.3 million adults with depression, one-third are treatment-resistant, increasing their risk of suicide.

Yale New Haven Hospital, the Institute of Living, UConn Health John Dempsey Hospital, Wheeler Clinic, VA Connecticut Healthcare, and Dr. Lori Calabrese in South Windsor report that they have either started or are planning to offer the fast-acting medication whose chemical name is esketamine. It is designed to show results in hours and days compared to the weeks and months it takes for traditional antidepressants to work.

Dr. Jayesh Kamath, director of the mood and anxiety disorders program at UConn Health, has conducted esketamine studies for Janssen, its manufacturer. “I want to make sure people hear the positives and the negatives of this medication,” he said.

While he said that “it is changing how we treat depression” and shows promise for enabling severely depressed people to function, he added that “the results are concerning about side effects.”

Janssen, a Johnson & Johnson subsidiary, is charging $590 to $885 for the medicine, depending on dosage. This does not include costs charged by providers for administering it. Veterans who receive it at the VA will not be charged. Medicaid and Husky will cover it, according to the state Department of Social Services.

A Janssen spokesperson said insurance companies are starting to cover it and Janssen is providing help, such as co-pay coupons.

Janssen refused to provide a list of Spravato-certified treatment centers and applicants in Connecticut but said that nationally about 1,600 sites have been certified. Restrictions imposed on Spravato sites include: prohibiting it from being sent home with patients; requiring patients to remain at the site for at least two hours and not drive for another day; and specifications for dosages, screening and monitoring patients, and labeling and handling of the medication.

Dr. Michael Twist, Wheeler Clinic’s medical director, said Spravato can be a replacement for electric convulsive therapy. “This is going to be a way of getting someone much better much quicker,” he said. “It’s huge.”

Esketamine: A derivative of ketamine

Esketamine is a derivative of ketamine, an anesthetic that has been abused as a party drug called Special K. Yale School of Medicine pioneered research on ketamine for depression starting in 1995. It has not been approved by the FDA to treat depression because as a generic drug, it doesn’t have the profit-making potential to attract research funding, several doctors said.

Ketamine is FDA-approved as an anesthetic administered intravenously or by intramuscular injections. The chemical difference between the two drugs is that ketamine is comprised of two mirror-image molecules and esketamine (Spravato) is comprised of one of those molecules.

Some doctors, including Calabrese, provide it intravenously “off label” for depression treatment, a legal use of a non-approved medication that is usually not covered by insurance.

Calabrese, a psychiatrist, said she will continue to offer intravenous ketamine in addition to Spravato. She said an analysis of 144 of her suicidal patients showed 68 percent no longer had suicidal thoughts after ketamine treatment and 82 percent had diminished suicidal thoughts. She said there were no suicide attempts, emergency room visits, or hospitalizations from the time of treatment through follow-up four weeks later. She charges patients $502 for ketamine.

Dr. Vincent Carlesi, an anesthesiologist and pain management specialist in Stamford and Ridgefield, is among other physicians who offer intravenous ketamine. Patients with depression are referred by psychiatrists, said Robin Asken, the practice’s manager. She wouldn’t provide numbers, but reported seeing “a marked improvement in quite a few of the patients.” The charge is $850 per infusion, which is typically not reimbursed by insurance, Asken said.

Dr. John Krystal, psychiatry chairman of the Yale School of Medicine, said that “it is very moving to hear the stories of people who have been depressed for many years, who have tried multiple treatments without success, and then to hear how they had their first good clinical response to ketamine, often within 24 hours of their first doses.”

He said people have told him it saved their lives.

Yale medical school’s first ketamine study was at a clinic it ran at the Connecticut VA in 1995 and 1996. Five years ago, it established a ketamine clinic at Yale New Haven Hospital and last year, it opened a new ketamine program at the VA, Krystal said.

This story was reported under a partnership with the Connecticut Health I-Team, a nonprofit news organization dedicated to health reporting.

[Read the Original Post Here]

August 16, 2019
Nasal spray Spravato, offering fresh hope for severely depressed patients, arrives in Connecticut

Spravato, which received Food and Drug Administration (FDA) approval in March, has raised hopes for preventing suicides and relieving depression after other treatments have failed. But there are concerns about possible side effects, including drug abuse, elevated blood pressure and heart rate, sedation, and hypersensitivity to surroundings.

The nasal spray is prescribed for treatment-resistant depression after at least two other antidepressants haven’t worked and is given with an oral antidepressant. It is only administered in restrictive clinical settings to reduce potential for abuse and side effects.

Nationally, of the 17.3 million adults with depression, one-third are treatment-resistant, increasing their risk of suicide.

Yale New Haven Hospital, the Institute of Living, UConn Health John Dempsey Hospital, Wheeler Clinic, VA Connecticut Healthcare, and Dr. Lori Calabrese in South Windsor report that they have either started or are planning to offer the fast-acting medication whose chemical name is esketamine. It is designed to show results in hours and days compared to the weeks and months it takes for traditional antidepressants to work.

Positives and negatives

Dr. Jayesh Kamath, director of the mood and anxiety disorders program at UConn Health, has conducted esketamine studies for Janssen, its manufacturer. “I want to make sure people hear the positives and the negatives of this medication,” he said.

While he said that “it is changing how we treat depression” and shows promise for enabling severely depressed people to function, he added that “the results are concerning about side effects.”

Janssen, a Johnson & Johnson subsidiary, is charging $590 to $885 per dose for the medicine. This does not include costs charged by providers for administering it. Veterans who receive it at the VA will not be charged. Medicaid and Husky will cover it, according to the state Department of Social Services.

A Janssen spokesperson said insurance companies are starting to cover it and Janssen is providing help, such as co-pay coupons.[Health] State’s first pediatric dialysis center will open soon at Connecticut Children’s »

Janssen refused to provide a list of Spravato-certified treatment centers and applicants in Connecticut but said that nationally about 1,600 sites have been certified. Restrictions imposed on Spravato sites include: prohibiting it from being sent home with patients; requiring patients to remain at the site for at least two hours and not drive for another day; and specifications for dosages, screening and monitoring patients, and labeling and handling of the medication.

Dr. Michael Twist, Wheeler Clinic’s medical director, said Spravato can be a replacement for electric convulsive therapy. “This is going to be a way of getting someone much better much quicker,” he said. “It’s huge.”

Diminished suicidal thoughts

Esketamine is a derivative of ketamine, an anesthetic that has been abused as a party drug called Special K. Yale School of Medicine pioneered research on ketamine for depression starting in 1995. It has not been approved by the FDA to treat depression because as a generic drug, it doesn’t have the profit-making potential to attract research funding, several doctors said.

Ketamine is FDA-approved as an anesthetic administered intravenously or by intramuscular injections. The chemical difference between the two drugs is that ketamine is comprised of two mirror-image molecules and esketamine (Spravato) is comprised of one of those molecules.

Dr. John Krystal, psychiatry chair of the Yale School of Medicine.

Some doctors, including Calabrese, provide it intravenously “off label” for depression treatment, a legal use of a non-approved medication that is usually not covered by insurance.[Health] Bristol Hospital opens emergency center for patients in mental health crises »

Calabrese, a psychiatrist, said she will continue to offer intravenous ketamine in addition to Spravato. She said an analysis of 144 of her suicidal patients showed 68 percent no longer had suicidal thoughts after ketamine treatment and 82 percent had diminished suicidal thoughts. She said there were no suicide attempts, emergency room visits, or hospitalizations from the time of treatment through follow-up four weeks later. She charges patients $502 for ketamine.

Dr. Vincent Carlesi, an anesthesiologist and pain management specialist in Stamford and Ridgefield, is among other physicians who offer intravenous ketamine. Patients with depression are referred by psychiatrists, said Robin Asken, the practice’s manager. She wouldn’t provide numbers, but reported seeing “a marked improvement in quite a few of the patients.” The charge is $850 per infusion, which is typically not reimbursed by insurance, Asken said.

, said that “it is very moving to hear the stories of people who have been depressed for many years, who have tried multiple treatments without success, and then to hear how they had their first good clinical response to ketamine, often within 24 hours of their first doses.”

He said people have told him it saved their lives.

Yale medical school’s first ketamine study was at a clinic it ran at the Connecticut VA in 1995 and 1996. Five years ago, it established a ketamine clinic at Yale New Haven Hospital and last year, it opened a new ketamine program at the VA, Krystal said.

This story was reported under a partnership with the Connecticut Health I-Team, a nonprofit news organization dedicated to health reporting. (c-hit.org)

[Read the Original Article Here]

August 16, 2019
Nasal Spray Offers Hope For Severely Depressed Patients

By Peggy McCarthy August 13, 2019

Originally published in Connecticut Health I-Team on C-Hit.org.

Some Connecticut hospitals and doctors and a clinic are starting to treat severely depressed patients with a new nasal spray called Spravato, touted as the most significant federally approved depression medication since Prozac was approved in 1987.

Spravato, which received Food and Drug Administration (FDA) approval in March, has raised hopes for preventing suicides and relieving depression after other treatments have failed. But there are concerns about possible side effects, including drug abuse, elevated blood pressure and heart rate, sedation, and hypersensitivity to surroundings.

The nasal spray is prescribed for treatment-resistant depression after at least two other antidepressants haven’t worked and is given with an oral antidepressant. It is only administered in restrictive clinical settings to reduce potential for abuse and side effects.

Nationally, of the 17.3 million adults with depression, one-third are treatment-resistant, increasing their risk of suicide.

Yale New Haven Hospital, the Institute of Living, UConn Health John Dempsey Hospital,Wheeler Clinic, VA Connecticut Healthcare, and Dr. Lori Calabrese in South Windsor report that they have either started or are planning to offer the fast-acting medication whose chemical name is esketamine. It is designed to show results in hours and days compared to the weeks and months it takes for traditional antidepressants to work.

Dr. Jayesh Kamath, director of the mood and anxiety disorders program at UConn Health, has conducted esketamine studies for Janssen, its manufacturer. “I want to make sure people hear the positives and the negatives of this medication,” he said.

Spravato, a nasal spray, is prescribed for treatment-resistant depression.

While he said that “it is changing how we treat depression” and shows promise for enabling severely depressed people to function, he added that “the results are concerning about side effects.”

Janssen, a Johnson & Johnson subsidiary, is charging $590 to $885 for the medicine, depending on dosage. This does not include costs charged by providers for administering it. Veterans who receive it at the VA will not be charged. Medicaid and Husky will cover it, according to the state Department of Social Services.

A Janssen spokesperson said insurance companies are starting to cover it and Janssen is providing help, such as co-pay coupons.

Janssen refused to provide a list of Spravato-certified treatment centers and applicants in Connecticut but said that nationally about 1,600 sites have been certified. Restrictions imposed on Spravato sites include: prohibiting it from being sent home with patients; requiring patients to remain at the site for at least two hours and not drive for another day; and specifications for dosages, screening and monitoring patients, and labeling and handling of the medication.

Dr. Michael Twist, Wheeler Clinic’s medical director, said Spravato can be a replacement for electric convulsive therapy. “This is going to be a way of getting someone much better much quicker,” he said. “It’s huge.”

Esketamine: A Derivative Of Ketamine

John Krystal, Psychiatry Chair, Yale School of Medicine

Esketamine is a derivative of ketamine, an anesthetic that has been abused as a party drug called Special K. Yale School of Medicine pioneered research on ketamine for depression starting in 1995. It has not been approved by the FDA to treat depression because as a generic drug, it doesn’t have the profit-making potential to attract research funding, several doctors said.

Ketamine is FDA-approved as an anesthetic administered intravenously or by intramuscular injections. The chemical difference between the two drugs is that ketamine is comprised of two mirror-image molecules and esketamine (Spravato) is comprised of one of those molecules.

Some doctors, including Calabrese, provide it intravenously “off label” for depression treatment, a legal use of a non-approved medication that is usually not covered by insurance.

Calabrese, a psychiatrist, said she will continue to offer intravenous ketamine in addition to Spravato. She said an analysis of 144 of her suicidal patients showed 68 percent no longer had suicidal thoughts after ketamine treatment and 82 percent had diminished suicidal thoughts. She said there were no suicide attempts, emergency room visits, or hospitalizations from the time of treatment through follow-up four weeks later. She charges patients $502 for ketamine.

Dr. Vincent Carlesi, an anesthesiologist and pain management specialist in Stamford and Ridgefield, is among other physicians who offer intravenous ketamine. Patients with depression are referred by psychiatrists, said Robin Asken, the practice’s manager. She wouldn’t provide numbers, but reported seeing “a marked improvement in quite a few of the patients.” The charge is $850 per infusion, which is typically not reimbursed by insurance, Asken said.

Dr. John Krystal, psychiatry chair of the Yale School of Medicine, said that “it is very moving to hear the stories of people who have been depressed for many years, who have tried multiple treatments without success, and then to hear how they had their first good clinical response to ketamine, often within 24 hours of their first doses.”

He said people have told him it saved their lives.

Yale medical school’s first ketamine study was at a clinic it ran at the Connecticut VA in 1995 and 1996. Five years ago, it established a ketamine clinic at Yale New Haven Hospital and last year, it opened a new ketamine program at the VA, Krystal said.

[Read the Original Post in Connecticut Health I-Team on C-Hit.Org]

August 15, 2019
Buy Esketamine Online..? Get Real.

The news outlets, journals, and lifestyle magazines have been chock-full of articles about ketamine treatment for depression the last few years, with sprinklings about esketamine from time to time…

Then, this past March, esketamine received FDA approval for depression and suicidal ideation under the name Spravato. Developed by Janssen, owned by Johnson & Johnson, esketamine nasal spray won approval packaged in an innovative spray dispenser that metes out a precise dose in each spray. And literally — within just a few months — people are already looking to buy esketamine online.

Unbelievable, right?

Michael Thase, M.D., an investigator of intranasal esketamine during FDA trials, noted that “this treatment has addiction liability — it is a Schedule III controlled substance in the eyes of the Drug Enforcement [Administration]. It’s identical to the parent drug, ketamine.”

When he said that esketamine is identical to its parent drug ketamine, he was referring to its controlled substance rating. Both drugs are Schedule III.

And even though there were 3 suicides during the trials, Dr. Thase pointed out that during the follow-up phase of the study, no one experienced craving or abuse among the subjects who received esketamine.

He continued that it’s important to have a 2-hour observation period in the office after each dose. And went on to say that esketamine nasal spray treatment is “administered twice a week in clinical practice.”

As we now know, esketamine was FDA approved with stipulations that it must be provided with an antidepressant, in a doctor’s office (or medical setting like a hospital), and the patient must be monitored for 2 hours.

So, during that 2-hour observation time, they monitor the patient’s blood pressure and watch for signs of sedation and dizziness or other adverse reactions. And, not surprisingly, sometimes patients need kind, warm support from someone to help them get through an unpleasant psychoactive experience.

Clearly, it’s not an at-home medical treatment.

So here’s something to think about.

With all that said, more and more people are looking for ways to buy esketamine online...

It’s not a good idea.

Before we had internet, if you got sick, you went to the doctor. The doctor examined you, figured out what was wrong, and took care of it… maybe sent you home with a prescription. If your pipe sprung a leak, you called a plumber who came out and fixed it.

People depended on experts to fix their problems.

But since search engines took center stage, everybody’s a DIYer. Just google what you need to do, order what you need online, find a YouTube video that shows you exactly what to do, and — do it yourself. Everything from erecting a power pole and replacing spark plugs to folding sheets the right way to … treating your own maladies.

And THAT MAY WORK FOR YOU as long as you stick to relatively low-risk problems. But when it comes to treating your own illnesses with medicines acquired from a questionable source, you can really set yourself up for a life-threatening – or fatal – disaster.

Serious Consequences When You “Treat” Yourself, Like If You Buy Esketamine Online

We talked in the past about the danger that arises when club goers use ketamine to get high, and try to “treat” their own depression in the process. There are substantial risks. When ketamine is used in high doses and way too often, addiction raises its ugly head. But beyond the risk of addiction lies the risk of serious damage to the bladder.

Someone who has been dosing himself with controlled substances for entertainment might consider himself an “expert” in using those substances.

However, a hazard looms with such practices. It works like this: during ketamine or esketamine treatment, some people experience a pleasant floating sensation as it’s working in the circuitry and structures of the brain. Others, however, experience a stronger sensation we call dissociation. A feeling that you’re detached from your body, or detached from yourself…or maybe even in another place. For some, this is a bit unpleasant. And it passes. But for others…and here’s where it can get slippery…this can be a very appealing experience. And for those, it’s disappointing when the treatment ends, and those feelings dissipate.

But what happens if you have a bagful of ketamine on the table? Do you think you would just put it away?

Not likely. Not likely at all.

Because along with this experience, you’ve also lost a lion’s share of your inhibitions, too. So why not just dose up again? Keep the good times rollin’, as they say?

Someone who would have received 0.5 mg/kg or a bit more over 40 or 50 minutes under a doctor’s supervision might take 5 times, 10 times, 20 times, or more than that amount on his own.

This is how addiction is born. And how bladders are destroyed.

Then tomorrow, he’s ready to buy esketamine online, again.

Controlled Substances Require a Physician’s Supervision for YOUR Safety

Controlled substances are controlled to protect you from the dangers of over use, from side effects, adverse reactions, and from overdose. When you defy those safety measures, you put yourself at extreme risk.

So let’s talk now about esketamine.

We don’t know a lot about esketamine so far. It hasn’t been widely used yet. But a wise person recognizes that since the FDA stipulated approval of esketamine in the presence of specific parameters, it’s a safe bet they need to be followed.

First, it must be administered in a registered medical office or hospital/clinic under strict guidelines.

Second, you must remain in the office for observation for a full 2 hours after administration, and a safety report has to be sent in to an oversight safety monitoring program every time you come into the office.

It must be administered along with an antidepressant.

And finally, esketamine nasal spray may not be taken home or out of the office.

This assures that the medicine is not overused, or given to someone else. The medication from the pharmacy is pure — it hasn’t been tainted or adulterated with anything.

What IF You COULD Buy Esketamine Online?

Would that be a DIY Solution or a DIY Tragedy?

Hint: Some things should be left to the experts.

Now, let’s picture what it would be like if you actually found an online source for esketamine. It might be produced in a developing country, or by a chemist prodigy with questionable integrity, and shipped out in a little baggie… and without FDA restrictions.

While we recognize the FDA isn’t a perfect institution, its requirements do set restrictions that help keep consumers safe. Or at least saf-ER. Without that protection, you have no idea if the esketamine you might receive would destroy your organs, cause blindness, trigger psychosis… or worse.

Any chemical or pharmaceutical treatment for brain or behavior disorders has the power to incapacitate or disable you if it’s not pure, well tested, and administered with precision.

So often we talk about the delicate brain systems and the precision and care necessary to treat disorders with a medication like ketamine — and we administer it IV because of the precision, flexibility and responsiveness that the IV route allows in psychiatric treatment. It’s just as critical when treating with esketamine. Just as vital that a psychiatrist is supervising the treatment — and your response to it — expertly.

It’s all about you, and your improved life.

So you can experience a truly therapeutic dose that can help you feel more balanced and better, function better, and live a happier, more fulfilling life.

There are no shortcuts to reaching that goal.

No bargains.

No fun “trips” killing two birds with one stone.

And if you were able to find esketamine in bulk form, without that innovative sprayer..well you’re taking your life and your health in your hands.

DIY Brain Surgery

So let me ask you this. Let’s say your PCP referred you to a brain surgeon. You call and make the appointment, then on the designated day you appear in his office. He looks at your x-rays and scans, and tells you he agrees with your PCP that you need surgery. You meet with the scheduler to schedule it.

Then a few days later, you get the call and find out the cost of the surgery…and the amount you’ll have to pay as a co-insurance payment.

WHAAA???

You could pay off your house for that!!

All you can see is white. Shocked. Stunned. There is just no way. You’re not going to pay that.

So you get to thinking. You know… it can’t be that hard… You start looking on YouTube for DIY brain surgery… It’s hard to find much. So you keep trying different key words. Then you drive to the University Bookstore and ask for a textbook for neurosurgeons… You know you can always close the incision with staples. That’s what they use in the hospital right..?

Ok, I’m pulling your leg. Who would do that? Ever?? Now, there are some unusually determined people out there who go over the line. All the time.

But NO ONE would attempt surgery on his own brain. Why? Because it would more than likely cause brain damage, or worse. Because it would destroy your ability to think, to walk, to speak, to see. And that’s if you were lucky.

It’s for this reason you need to leave treatment of brain and behavior disorders to an expert in brain and behavior disorders. To avail yourself of the expertise and experience required to effectively treat the most delicate and most central managing system of your very life.

Brain Treatment is for the Experts

If you’re looking for a shortcut to health and well-being, put your doctor’s appointment setter on speed-dial. How’s that for a shortcut?

Meanwhile, if you struggle with depression that hasn’t responded to treatment, symptoms that persist no matter what you do, suicidal thoughts that return again and again … if medicines aren’t helping, just call us. Give yourself the advantage of deep psychiatric expertise, patient and skillful dose titration (with IV ketamine), and quick response to reactions and needs.

We offer comprehensive evaluations to determine if IV ketamine infusions or esketamine nasal spray could be an appropriate and effective treatment for you.

Neither treatment can give you a sure-fire guarantee. No treatment can. But when ketamine is administered properly, our patients often enjoy an amazing improvement. For many, it’s fast, and it’s robust … with IV ketamine, the improvement can begin within just a few hours.

Your life is too precious to wreck. Don’t search for ways to buy esketamine online… or ketamine either, for that matter. It can lead to a slippery slope of abuse, addiction, and worse. You’re just too valuable to miss the relief and wellbeing proper treatment can provide.

Your life is yours to live, and we want to help you gain the opportunity to live it well. With joy, loving relationships, and accomplishments.

You really can be the best you can be.

To your best self in the months ahead,

Lori Calabrese, M.D.

August 12, 2019
Ketamine isn’t an opioid and treats depression in a unique way, says Johns Hopkins expert

In scientific journal letter, Hopkins psychiatrist Adam Kaplin disputes a study claiming ketamine is an opioid.

Ketamine has gotten a bad reputation as an opioid—when there’s plenty of evidence suggesting it isn’t one, say Johns Hopkins experts. They believe this misconception may prevent patients from getting necessary treatment for the kinds of depression that don’t respond to typical antidepressants.

In a letter to the editor published in the American Journal of Psychiatry, the researchers clarify how ketamine works in hopes of restoring the therapy’s standing among health care professionals and the public.

“A study done late last year delivered a black eye to ketamine, and as a result of the coverage, there was a wholesale acceptance by both potential patients and physicians that ketamine is an opioid,” says Adam Kaplin, Assistant Pofessor of Pychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. “This is most worrisome if people continue to think this way, particularly in the wake of the opioid epidemic; clinicians won’t refer patients for a treatment, despite that it has been shown to be incredibly effective for many patients with treatment-resistant depression.”

In late 2018, researchers at Stanford University and Palo Alto University showed that naltrexone—a drug used to reverse accidental opioid overdoses by binding to opioid receptors in the brain—also blocks the antidepressant effects of ketamine, which led them to propose that ketamine must also bind to the same opioid receptors and thus concluded that ketamine must be an opioid. Kaplin says that there’s plenty of contrary evidence demonstrating that ketamine sticks to an entirely different receptor on brain cells: NMDA receptors, which are involved in learning and memory.

These NMDA receptors are found together with the opioid receptors on brain cells, and Kaplin says it’s no surprise that their components can meddle with one another, like interference picked up on a phone call or on the radio. “This interference and cross-talk does not mean that ketamine is an opioid, and to wrongly label it as such could eventually keep patients from essential antidepressant medications that could make a huge difference in their quality of life,” says Kaplin.

In March of this year, the U.S. Food and Drug Administration approved ketamine as a nasal spray to treat depression, specifying that ketamine is to be administered under the watch of physicians in small doses and in a health care setting to minimize any chance of abuse. The drug works much faster than other traditional antidepressants on the market, sometimes even after one or two uses.

Kaplin and his team are in the process of setting up their own ketamine clinic at Johns Hopkins, which they anticipate will be opening within the next year.

[Read the Original Post Here]

August 5, 2019
The Pain and Marginalizing of Stigma

Stigma Isolates, Humiliates, and Separates

As I think about what to write today, my thoughts are filled with a comment I received from a man who’d read last week’s blog, which you can read here. He wrote that he also suffers from bipolar 1 disorder and was upset and hurt by the description of the young man in the story who showed signs of violence. For him, a description like the one I wrote perpetuates stigma because it portrays someone suffering from a psychiatric disorder as a “dangerous” person.

Pause. Deep breath here. Not what I intended.

My concerned reader made the point that he takes medication to manage his symptoms and works hard to keep them from dominating his life. He emphasized that he had never thrown a lamp or a table (like the young man I’d described) … which is often the case. Most of the time, mood dysregulation is not accompanied by physical explosiveness or violence. He was right.

And he felt that last week’s blog misrepresented him and others like him.

It was heartbreaking to me that this reader felt hurt by my story. I never want to cause pain to anyone with my writing. But it can be hard to prevent. My readers come from a wide variety of backgrounds and experiences. My practice, on the other hand, consists primarily of the most ill, treatment-resistant patients for whom medications have failed.

So today, I want to go a little deeper and talk about stigma and the damage it causes.

And I want to explain why I write the accounts I do of severely ill patients and how they suffer.

The Pain and Marginalizing of Stigma

So what is stigma anyway?

We get the word “stigma” from the ancient Greeks, who used it to describe a mark made on the body that signaled to others to avoid or shun the bearer of the mark. And, we use it the same way today. Except in our present culture there’s no need for a mark on the body… with our words we make a mark on the soul.

Stigma creates shame, disgrace, humiliation…and the bad reputation that goes with certain things in our society. It’s associated with anything in someone’s life that labels them. A label that results in judging someone by the label rather than on their own merits.

Labels like this separate people from the group just as lepers were separated from the city in ancient times.

An example might be the experience of prison. When someone breaks the law and is sentenced to prison, that label hangs over them, as much within themselves as from the outside. This person might feel they’re “less than” others, that they deserve less respect. And they’ll almost certainly run into narrow minded people who will hold that fact from their past over them… impose upon them the pain and marginalizing of stigma to bring them shame and humiliation.

But the fact is, that some of those who spend time in prison continue a lawless lifestyle and others use the opportunity to improve their lives and accomplish great things. Still, it’s fair to say that improvement isn’t easily won. That person has to work very hard to rise above the experiences from his or her past.

Another example of stigma seems to accompany psychiatric disorders. There are those in our society who still associate the need for psychiatric treatment as a sign of weakness, “craziness,” and/or questionable character.

Working to Reduce Stigma and Increase Enlightenment

As we work to reduce stigma, and open conversations about brain disorders, behavior disorders, and the medications we use to manage them, we have to look honestly at individuals, and who they are. And we need to try to understand each other.

Because not all diabetics are alike. Not all the people with bipolar disorder are alike. Not all the people with PTSD are alike. Each one is an individual — with their own unique needs, symptoms, challenges, and vulnerabilities.

Most of us know someone who suffers from diabetes, either Type 1 or Type 2. There is some amount of stigma associated with diabetes. If you’re well informed about this condition, you know that while diet and exercise can help improve the condition for people with Type 2 diabetes, there is nothing someone with Type 1 can do to make this condition go away.

It’s pretty short-sighted of anyone who tells a person who suffers from this disease that they just need to stop being so sloppy about how they take care of themselves.

While it’s true that diet and exercise can improve their control of symptoms, it’s a disease that progresses and is not preventable.

Words can cut deeply … and we never really know the story that people keep hidden in their hearts.

In both cases, diet and exercise help in its management, but that’s true in a wide variety of illnesses. People with coronary artery disease, arthritis, hypertension, asthma, obesity, as well as depression, bipolar disorder, PTSD, and more…all can enjoy improved symptoms through diet and exercise. Improvement. Not cure.

The cruelty of stigma lies in the cutting words and attitudes the “unenlightened” use to build a box around an individual without knowing his story.

Pain and Marginalizing of Stigma ISOLATES

Disorders like bipolar I disorder, bipolar II disorder, major depressive disorder, PTSD, substance misuse, dependence and addiction, eating disorders, OCD, panic disorder, ADHD — are not understood…and are not familiar….to a very broad segment of society. And what human nature doesn’t understand, human nature too often misjudges.

But what we DON’T want to do is marginalize individuals no matter what their experience is.

And just what do I mean by “marginalize” exactly? I mean that I don’t want anyone to feel shut out, alienated, trivialized, or ignored in any way by my words or actions. Whether you use all your strength to hold your symptoms under control or whether your medication helps you do that, your experience is important. You are important. And you matter.

When someone suffers from one of these disorders, but has no outward symptoms — because of medication or their own unique disease process — they can feel blocked out and unheard…misunderstood and not represented.

(By the same token, if you only know someone who takes medication that’s working, and never has any symptoms that show, it’s super easy to think that people with psych disorders should have their symptoms under control. Nothing should show.)

Maybe you know someone with kidney disease who looks and acts like anyone else. And maybe I know someone with kidney disease who is thin, pale, with only patches of hair. When I meet your friend I may believe there is no way your friend is ill. And you may believe that my friend has something much worse than kidney disease because she looks so terribly ill.

But in fact, they both have the same disease but it differs in severity.

Why Assume Everyone’s the SAME?

This is the case with disorders that are related to the brain. Why is a disorder more severe in one person than another? I don’t know. I may know some factors that could affect its severity, but I don’t know why one person has bipolar I disorder and another has bipolar II, or a third person has cyclothymic disorder.

None of these three got off scot-free. They all suffer.

And why does one person respond to medication and another doesn’t? If I knew the answer to that, I’d go on vacation more often! These are questions I’ve been studying to find answers to all the years I’ve been a psychiatrist.

For those who respond to medications, I’m very glad and thankful. For those who don’t, I search and read and research and seek hope for those patients. And when I write about people with severe cases of their illness, it’s to show others who suffer in this way that they aren’t forgotten. That there is no shame in their symptoms. Because in their case, the medicines aren’t working. And the symptoms run rampant.

It can be devastating.

Don’t Misinterpret Symptoms: Hollywood vs. Reality

And I want to add –quickly– that a table or chair that is flung out the window is not necessarily a sign of danger to others. It signals dysregulation, sure, and warrants a very careful assessment. Because often, even someone who is markedly dysregulated can draw the line between hurling an inanimate object and hurting another person.

Hollywood has a way of exploiting the human suffering of mental health problems, to intensify fear. That’s Hollywood. Get to know individuals and take note of how they differ from what you see on the big screen.

Coronary Artery Disease

One of my neighbors has coronary artery disease. He took medications, but eventually had to have open heart surgery. Does that mean that everyone with coronary artery disease needs open heart surgery?

No. In fact, I have a relative who has coronary artery disease, who manages to live a full life with medicines, diet, and exercise and has never needed surgery.

These individuals tell their own personal stories. And report their own personal symptoms.

Words can be so hurtful even when they’re not intended to be. We’ve all done it. Without realizing someone’s personal story we tell the story of someone else that’s too close to their own…and it sounds to them like we’re judging them.

Pain and Marginalizing of Stigma… is Cruel

By the same token, when a treatment or clinic pops up that seems to promise a world of wonder to everyone, (which nothing can do, by the way), people can feel trivialized and ignored. Because they may not fit in that “slot” for a variety of reasons.

Let’s put up our antennas and notice when the pain and marginalizing of stigma has someone walled off from the world. Alone. Isolated.

Psychiatric disorders marginalize people, and we marginalize them, too. Every doc-in-a-box or one-size-fits-all protocol marginalizes your individual experience of suffering by suggesting there is a panacea.

Of course, there’s no universal cure, but there IS hope in a jar. Remember that story?

That was the story of ketamine treatment as a medicine prescribed “off label” because of its unique healing abilities in addition to the purpose it was FDA-approved for.

One Size Fits Some

ONE SIZE DOES NOT FIT ALL. Each patient needs to be custom treated for his own individual version of disorders. Each person also needs to be ACCEPTED and supported for who he is, and what he manages in life.

Let’s vanquish the pain and marginalizing of stigma. Let’s stop leaving people isolated in their suffering. And let’s look people in the eye and seek to understand their struggles.

If you don’t know what he manages, ask him. Let’s try harder to get to know each other, and respect each human for the life he or she manages.

And you know what? If you suffer greatly, or if your struggles are partially managed by medication, I want to hear from you. Not that I can solve your challenges, but you matter to me. And you matter to a lot more people than you may be aware. You are included here. And your experience can help someone else feel less alone in the world. Please share your comments below.

And if you’ve read about ketamine treatment and you want to see if it can help you, call us.

We want to help you experience some degree of relief from your symptoms, whether it be a little or a lot.

To the recovery of your best self,

Lori Calabrese, M.D.

August 5, 2019
Evidence shows ketamine is not an opioid and can treat depression easily

Ketamine has gotten a bad rap as an opioid when there’s plenty of evidence suggesting it isn’t one, Johns Hopkins experts say. They believe this reputation may hamper patients from getting necessary treatment for the kinds of depression that don’t respond to typical antidepressants.

In a new paper, the researchers clarify the mechanism behind ketamine’s mechanism of action in hopes of restoring the therapy’s standing among health care professionals and the public.

In March of this year, the U.S. Food and Drug Administration approved ketamine as a nasal spray to treat depression.

A study done late last year delivered a black eye to ketamine, and as a result of the coverage, there was a wholesale acceptance by both potential patients and physicians that ketamine is an opioid. This is most worrisome if people continue to think this way, particularly in the wake of the opioid epidemic; clinicians won’t refer patients for treatment, despite that it has been shown to be incredibly effective for many patients with treatment-resistant depression.”
Adam Kaplin, M.D., Ph.D., Assistant Professor of Psychiatry and Behavioral Sciences at The Johns Hopkins University School of Medicine

The researchers published their viewpoint and explanation of the alternative mechanism as a Letter to the Editor in the May 1 issue of The American Journal of Psychiatry.

Naltrexone — the drug used to reverse accidental opioid overdoses — binds to opioid receptors on the surface of brain cells and prevents opioids like morphine or heroin from sticking to them and acting on the brain, preventing the high.

In late 2018, researchers at Stanford University and Palo Alto University showed that naltrexone also blocks the antidepressant effects of ketamine, which led them to propose that ketamine must also bind to the same opioid receptors and thus concluded that ketamine must be an opioid. Kaplin says that there’s plenty of contrary evidence demonstrating that ketamine sticks to an entirely different receptor on brain cells: the NMDA receptors — involved in learning and memory — instead of the opioid receptors.

He proposes how this works:

Normally, NMDA receptors get turned on when the chemical messenger glutamate binds to them. Turning on the NMDA receptors turns off a master control switch in the cell called mTOR, which ultimately results in learning a behavior or forming a new memory.

Ketamine can also bind to the NMDA receptors, but it has the opposite effect of glutamate, in that it turns these receptors off. Turning off the NMDA receptors turns on the master control switch mTOR, which is required for ketamine’s antidepressant properties.

Separately, says Kaplin, opioid receptors are normally turned on at low-levels all the time, even without opioids to turn them on all the way. This low activity of the opioid receptors normally suppresses the level of another chemical messenger called cyclic AMP (cAMP). When the overdose drug naltrexone is administered, it sticks to the opioid receptors, turning them completely off, which releases the brakes on cAMP.

This increase in cAMP is what then interferes with the master switch mTOR, shutting it down. When ketamine is taken, it turns on the master switch mTOR to enable antidepressant effects, [emphasis mine] but if naltrexone is given on top of that, naltrexone obstructs and shuts off the mTOR again. It is through cAMP that naltrexone overrides and extinguishes the antidepressant effects of ketamine.

These NMDA receptors are found together with the opioid receptors on brain cells, and Kaplin says it’s no surprise that their components can meddle with one another, like interference picked up on a phone call or on the radio.

This interference and cross-talk does not mean that ketamine is an opioid, and to wrongly label it as such could eventually keep patients from essential antidepressant medications that could make a huge difference in their quality of life.”
Adam Kaplin, MD, Ph.D

The FDA specified that ketamine is to be administered under the watch of physicians in small doses and in a health care setting to minimize any chance of abuse. The drug works much faster than other traditional antidepressants on the market, sometimes even after one or two uses.

Kaplin and his team are in the process of setting up their own ketamine clinic at Johns Hopkins, which they anticipate will be opening within the next year.

Mike Wang was also an author on the paper.

Wang and Kaplin received grant funding from Janssen.

Kaplin is the co-founder of Reward Pathways and a consultant for Biogen, EMD Serono and Pear Therapeutics.

Source:

Johns Hopkins Medicine Journal reference:

Wang, B. & Kaplin, A. (2019) Explaining Naltrexone’s Interference With Ketamine’s Antidepressant Effect. The American Journal of Psychiatry. doi.org/10.1176/appi.ajp.2019.19010044

August 2, 2019
Family: Suffering Together With Psychiatric Disorders

“I don’t care what the &%@!* you think!! It’s all your fault!! I’m outta here!!!”

With that, Ben picked up the massive carved oak coffee table and threw it at the window. It hit the window and the wall with a thud, pushing the window frame in a contorted mangle of metal and glass out toward the garden, knocking a gash into the wall with the impact. Families that are suffering together with psychiatric disorders know this scene so well…

The table fell to the floor, unaffected by its collision, except for a few paint scrapes off the wall. The wall, however, didn’t do so well.

By then, Ben had already grabbed a china lamp and slung it toward another window. The shattering glass of the window and the shattering china in the lamp base formed a tinkling wind-chimes sort of symphony as they fell.

Ben beat his face with both fists, cursing his life.

Suffering Together

Little 6-year-old Sara shrank back into the shadows of the hallway. She knew not to cross her big brother at times like this. He was her hero and had been her best friend ever since she was born. He was kind, patient and included her even though he was 7 years older.

It scared her when he got like this, but she also instinctively knew he just couldn’t help it. She knew he’d probably cry again after this rage subsided, because he felt so helpless to control it and so sad about hurting the family.

She slipped back into her room and quietly closed the door to play with her dolls…and try to not hear what was happening.

Then her mom’s gentle voice sounded soothing and reassuring. She was helping him calm down, like she had so many times before. After 30 minutes or so (it was hard to tell time, but especially when every second seems like an eternity…) she heard Ben trying to talk through sobs… she knew what he was probably saying, and she wanted to go hug him. But she thought it was better to let mom do that right now. He might be embarrassed to know she heard all of that.

Each One Copes in His Own Way

Sara felt confident the “storm” had passed, but then the front door slammed so hard the house seemed to crack. She quietly opened her door to look and listen. Ben and Mom were talking in low tones in the living room…but she could see her older brother’s door was open.

Then a car started and screeched away outside.

Ohhhhh. I guess Ben’s episode made Gregory mad again. (Huge sigh) I wish everyone could just be happy. We must be the only family that goes through this..

Out of nowhere Scruffy, their mixed breed little dog, scooted between Sara’s legs and into her room for safety. She picked him up, and could feel him trembling…

Hugging Scruffy close to her, Sara withdrew back into her room and ever-so-quietly closed the door.

Quiet Distractions Provide Solace

She set up a tea party in her closet where it would be extra quiet… and brought in Baby Alive and Jenna to share it with her. hmmm….we need one more, she thought. She reached under her bed and pulled out Timothy, her cream-colored teddy bear…and took him into the “tea room” in her closet floor. With the light turned on, she pulled her closet door shut.

Shame Torments

Ben had stopped sobbing by now…and was looking at his feet. It’s never going to stop, he thought. What’s wrong with me?? I always ruin everything. I’m the black sheep of this family.

Why can’t I be like everyone else…? I’m so worthless, stupid, bad, and rotten to the core. I should never have been born… I’ll probably end up being a criminal…

“Whatcha thinking, Ben?” Ben’s mom waited patiently for Ben to gather his thoughts.

While Ben was searching for words, the front door opened.

Learning to Support Each Other In the Family

His dad was home from work. Ben tried to look pleasant.

“Hi Dad…”

“What’s going on…? Has something happened…?” Ben’s dad spotted the bashed windows and looked worried. Then his eyes fell on Ben’s swollen red face. Ben felt humiliated and didn’t know what to say.

“Hi Bill. How was your day?” Ben’s mom hated to bombard him with the latest family crisis when he’d just walked in from a stressful day. And she also hoped to give Ben a break from his dad’s scrutiny.

“It was fine, Lil. Is everything ok?”

The air in the room hung heavy with tension. But they were a family, and they needed to face times like these together, so Lily spoke up.

“Everything’s fine, honey. Ben had another episode today. It was terrible for him…well, for all of us. He’s feeling pretty discouraged right now. We were talking about what we could do to find a doctor that might help more than Dr. Mendolssohn has. Someone maybe who specializes in adolescent bipolar disorder?”

Ben focused on the pet hair on the rug. Bill nodded and stared at his feet, hands in his pockets. Lily stroked the sofa cushion. When a family is suffering together with psychiatric disorders…well, each one harbors his own secret pain.

A big part of that pain is helplessness.

Bill spoke first. “I noticed the car is gone…did Gregory leave?”

Ben sighed. Lily nodded.

“And Sara…?”

The NON-Squeaky Wheel Needs Attention, Too

Lily sprang up from the sofa and headed for Sara’s room. Her little girl had been so quiet…and with all the turmoil, she forgot to check on her. Guilt swelled up and threatened to choke her.

Tap, tap, tap. “Sara? May I come in please?” Lily tried to sound cheerful.

Tap-Tap-Tap. “Sara?”

Lily opened the door and didn’t see Sara.

“Sara??”

A tiny muffled voice squeaked, “yes, Mom?”

Lily got down on her knees and looked under the bed. Nothing.

She looked on the other side of Sara’s bed. Nothing but a couple stuffed animals.

“Sara? Where are you?”

The closet door opened. Sara’s hair was disheveled and the rims of her eyes were red. She’d been crying. Lily rushed over to her and swooped her up in a hug.

“Whatcha doing in your closet..?”

“Tea party…”

“Wanna help me cook supper?”

“Yeah!”

She swung Sara onto her hip and off they went to the kitchen, chattering about the tea party.

With Psychiatric Disorders, Symptoms Can Look Like Bad Behavior

Bill was sitting with Ben, helping him with his algebra homework. He knew a lecture about behavior wasn’t what Ben needed. He needed acceptance and support. Bill had made plenty of mistakes while he learned how to provide what his family needed in times like this.

So.

Another day. Once again they’d survived another major bump in the road. Tomorrow they’d call the insurance company about the damaged windows. But for now, they were thankful for peace.

He and Lily did their best to try to help Ben’s self-image remain strong…though they knew all too well that their best efforts might not be enough. They also tried to be sure Gregory had their time, support, and attention, too. It was easy in this household to be overlooked.

They were learning to avoid reacting with even more conflict or criticism. But rather to choose words and tone that soothed. Everyone needed it. And they believed their reactions were improving.

Family: Suffering Together with Psychiatric Disorders

Which brings up little Sara. They worked hard to try to protect her innocence and sweetness. But they couldn’t protect her from the frequent upheavals in her own home.

They also knew they had to be sure to communicate and make time for their relationship with each other. That was usually the first to be sacrificed.

Most of the time they were both stretched pretty thin.

Breathe.

Got anyone in your family with a psychiatric condition? It might be an eating disorder, bipolar disorder, severe depression, social anxiety (yes…that’s a disorder too), addiction, PTSD… there are lots of possibilities.

No matter what the condition, and whether it’s you or someone else, a family with a psychiatric disorder suffers together, feels helpless together, gets frustrated together… no one escapes.

And while it’s easy to blame, that doesn’t accomplish much, does it? It just makes the wounds infect.

When it gets right down to it, there is likely some genetic connection that links you all to the disorder. In this family, Ben drew the short straw. And bears the stigma.

But just as Bill isn’t to blame for the high blood pressure he inherited from his grandmother, and Lily isn’t to blame for her kidney stones, Ben inherited the tendency to develop his condition before he was ever born.

To try to manage his blood pressure, Bill either jogs or takes a brisk walk every night after work while Lily cooks dinner. Lily is careful to stay hydrated to avoid more stones. Ben tries to get out and play football in the afternoons and they work together to see that he eats balanced meals and gets to bed early. And they all take medication for these health problems.

When The Brain is Disordered, It Can Be Hard to Maintain Order At All

Not just for the person with the condition, but everyone close to him, too.

So don’t be fooled. The family tries to maintain these routines, but that’s not as easy as it sounds. It takes a concerted effort, and they try to support each other and understand when things don’t go as planned. Because, when a family is suffering together with psychiatric disorders, everything is more complicated, it seems.

Families like this have plenty of bad days. More days than they care to admit actually… where all the opportunities to manage their collective health slip through their fingers.

But they do try. And when things fall apart, they help each other get up and try again. Or at least they try to. Sometimes everyone just gets sick and tired of it all. So they retreat into their corners to recover a bit, then come together and face their life together again. At least that’s their intention.

Life Is Challenging on Some Level for Us All

If you don’t have a person in your family who has a health condition, maybe things go smoothly for you…? But I bet they don’t go as smoothly as you wish. Nobody’s life is perfect.

Still, if you do have one or more family members who endure chronic illness, (the genetics often strike multiple times in a family) you probably feel like no one can imagine what it’s like. You likely feel isolated and alone. Maybe you feel embarrassed, because your life isn’t perfect. And you’re right to some degree. No one knows what it’s like to live your life. But you don’t know what it’s like to live someone else’s either.

I can say this however… that if your family suffers with a member who has a brain or behavior disorder, we know it impacts the whole family. And our hearts are with you.

Is Your Outpost Suffering Together with Psychiatric Disorders?

Family is our most important outpost of support. No matter what the challenges a family faces, they don’t manage them well all the time. In fact, it’s fair to say there are LOTS of times the whole family seems to implode.

Some families have financial struggles. Other families have marriage struggles. And still other families have health struggles. But whatever the challenges, pulling together is the best way for everyone to come out in the best shape possible.

But then, that’s life, isn’t it?

It’s for you we work at Innovative Psychiatry to find better solutions, more effective treatments, and the compassion and support you need. And we’ve found extraordinary results for families like yours with ketamine treatment. You may have a family member with bipolar disorder, major depression, or PTSD. If so, call us.

She just might be a candidate for IV ketamine treatment. That also goes for social anxiety, addictions…and of course suicidal thoughts. ALWAYS take suicidal thoughts seriously. And let us help.

But don’t forget to take note of other family members who may be suffering in addition. They may need treatment, too, so they have the energy to conquer the days, weeks, and months of stress at home.

There is help available for your family. To feel better, with restored hope, and more harmony.

To the fresh emergence of your best selves,

Lori Calabrese, M.D.

July 29, 2019
Are There Biomarkers for PTSD and Suicidal Thinking?

Know someone who’s suicidal? Or…how about this? Do you know someone you think might be?

Is there someone in your life who’s always down, irritable, short-tempered… even jumpy, maybe? Maybe you wish they’d adjust their attitude, or take a chill pill. Sometimes, people can be like this and the problem is that they might be depressed. Or they may suffer from PTSD and even be suicidal. There are some researchers at Yale who are trying to identify biomarkers for PTSD and suicidal thinking. More about that in a moment, but first let’s talk about PTSD.

Some 8% of people will meet criteria for PTSD at some point in their lives. Those who have fought in active combat have roughly a 40% likelihood of receiving a PTSD diagnosis. But there are other life events that can also lead to PTSD such as sexual assault, domestic violence, cancer treatment, a child’s devastating illness, or a serious transportation accident, for example.

The DSM-5 sets the criteria for diagnosis of psychiatric disorders. It says there are several criteria required to diagnose someone with PTSD:

First, you must have been exposed to the threat of death or serious injury or sexual violence directly, or by witnessing it, or learning someone close to you experienced it. Or by indirect exposure as a first responder.

Second, you have to re-experience this traumatic event by reliving memories, or in nightmares, or maybe you suffer distress when you’re faced with a traumatic reminder of what happened.

Third, you likely make effort to avoid situations that would remind you of the traumatic event, or to think thoughts that pull you back into the painful memories of it.

Fourth, you have negative thoughts or feelings that resulted after the trauma. Like blaming yourself or others, shaming yourself, holding a negative attitude, and isolating yourself. You have lost interest in doing things you used to enjoy or getting out with friends. Does any of this sound familiar? Stay with me…because there’s hope coming…

Further, you find that you react to things that happen differently than you used to. Like you feel irritable and aggressive, or you may embrace high risk activities, or you may feel hyper-vigilant…always on edge for something to happen. Plus it’s hard to sleep or stay asleep, and it’s hard to concentrate. You’re likely to experience depression, anxiety, possibly substance abuse in an effort to avoid thinking about the traumatic experience.

Obstacles to Functioning

And all these things often result in problems with friends, with family, with your job, your education…and even with taking care of yourself and your own needs.

If you’re diagnosed with PTSD, these symptoms have lasted awhile and your doctor must know that you haven’t used other medications or illicit drugs that could have caused this.

PTSD isn’t just feeling bad about something that happened. It’s a reaction inside you to something terrifying that changes the way you think and feel and respond to life. It changes your body… and your environment. Because it changes the way your mind interprets what you see, smell, hear, taste, and feel.

How Fear is Connected to Suicidal Thinking

The Brain and Behavior Research Foundation recently offered a webinar about the work they’re funding with regard to PTSD, suicidality, and IV ketamine treatment. Lynnette A. Averill, Ph.D., Assistant Professor of Psychiatry at Yale University, explained the link between the fear and anxiety people with PTSD have and how it’s connected to suicidal thinking.

Three Regions of Your Brain are Key

So let’s talk about your brain, and how PTSD affects it. There are multiple parts of your brain that play a role in your experience as part of this disorder. And the trauma that caused this disorder triggered multiple changes in your brain. The prefrontal cortex, the amygdala, and the hippocampus are the primary areas involved, and what Dr. Averill’s team focused on.

The prefrontal cortex regulates our emotions and helps us make decisions related to them. The amygdala helps us with fear processing. And the hippocampus helps us interpret emotional context.

These three regions aren’t the only regions involved in PTSD, but they’re the most consistently significant.

The hippocampus loses volume when you’re traumatized. So as PTSD increases and its symptoms increase, too, the volume of the hippocampus decreases.

The prefrontal cortex thins in the presence of trauma. In fact, the more severely traumatized you are, the thinner the tissues in the prefrontal cortex. It makes the decision whether you’ll fight, run, or chill.

And the amygdala hyper-reacts. So it goes like this. Let’s say a T-Rex stomped down your street and through your yard. You look out the window and see his knees. Immediately, your amygdala sends out the alarm and calls upon adrenalin to scream, “FIGHT or FLIGHT!!”

PTSD Changes Brain Function

The job of the prefrontal cortex (PFC) is to call up the amygdala on speed dial…and tell him “Nothing’s wrong... It’s a hologram. Go back to your cable show… Everything’s ok.” And the amygdala settles back into his recliner.

Because PTSD doesn’t just change the way the brain areas look, it also changes the way they function…and so, in turn, the way YOU function.

Now here’s the thing. People who are suicidal have impaired executive function. This means that the organization, ability to focus and pay attention to others, as well as regulating emotion and disciplining yourself in a way that helps you meet goals…well, none of that is working well enough.

It means you’re likely scattered, and probably unpredictable. Maybe impulsive. The impairment of these abilities sets you at greater risk for making a tragic and impulsive final decision.

Is Suicide Rare?

Suicide is the 10th leading cause of death in the US across all age groups. To make that a little easier to grasp, think of it this way: 129 people take their own lives every single day in this country.

In 2016, suicide was the 2nd leading cause of death for people aged 10 to 24. More than leukemia, or fire, or overdose.

This is aside from the numbers for middle aged adults or the elderly. This includes children only 10 years old! And we need to better understand any biomarkers that can help us identify those who are at higher risk to even attempt suicide.

And it gets worse. Veterans are 1.5 to 2 times at higher risk for suicide. Sexual minorities are also at increased risk for suicidal thoughts and behaviors. The numbers include those individuals who suffer from bipolar disorder and have a 5 times greater risk for suicidal behaviors.

So this brings up this point. We need something to point to that’s common to all these conditions. Dr. Averill believes the link is synaptic growth.

Actually, it makes sense, doesn’t it? When synaptic growth stops, and synapses break down and thin out, you’re more likely to experience depression, anxiety, and PTSD along with other disorders that are stress-based. And when you treat this synaptic deficit, the symptoms of these disorders tend to dissipate.

Ketamine Treatment Restores Synaptic Growth and Just May Be a Biomarker for PTSD and Suicidal Thinking

The most effective treatment for these disorders is likely something that restores synaptic growth. Furthermore, that something needs to act rapidly, because there is the risk these patients may make suicidal attempts.

It just stands to reason, doesn’t it?

Well, it so happens that IV ketamine treatment does just that, and fast.

It switches on mRNA which turns on DNA to turboboost brain-derived-neurotrophic-factor (BDNF) to rapidly proliferate new synapse connections with their dendrites and dendritic spines all through the brain. It also slides the G proteins off their lipid rafts in the brain cell membranes, so they can productively go to work enhancing signaling along these new synapse connections. And within 24 hours you can feel amazingly better. Or it might take you a few days depending on your brain and genetic makeup.

But traditional antidepressants take weeks or even months… in many cases it can be three or four. And far too many people struggling with intrusive suicidal thoughts have ended their lives by then. That’s why it’s so extraordinary that ketamine is a RAAD (rapid-acting-antidepressant) rather than a SAAD (slow-acting-antidepressant).

Ketamine treatment is life-saving for a LARGE percentage of treatment-resistant cases. Ketamine doesn’t work for everyone, but we’re learning every day how to help more people benefit from it’s restorative actions.

At Innovative Psychiatry, we work with people who suffer from PTSD and with people who suffer from suicidal thoughts. We’ve been so gratified to watch them walk out of the office with a smile, and energy, and a joy for living.

If you suffer from PTSD, depression, bipolar depression, social anxiety, addiction, or other disorders that make life seem hopeless, or if you have thoughts about ending your life, call us. Let’s work together to help you find your joy, your hope, your fulfillment, and your relationships again.

We want you to see how appealing life can be.

To the emerging of your best self,

Lori Calabrese, M.D.

*****If you or someone you know is contemplating suicide, call the National Suicide Prevention Lifeline at 800-273-8255. There’s someone available to listen 24 hours every day.*****

July 22, 2019
Ketamine Tied to Remission from Suicidal Ideation for Most Patients

BY M. ALEXANDER OTTO

REPORTING FROM APA 2019

SAN FRANCISCO – Serial ketamine infusions eliminated suicidal ideation in more than two-thirds of patients at a psychiatry office in Connecticut but at significantly higher doses than those recently approved for Janssen’s new esketamine nasal spray (Spravato). The patients were treated by Lori V. Calabrese, MD, at Innovative Psychiatry, her private outpatient practice in South Windsor. She presented her first 235 IV ketamine cases at the American Psychiatric Association annual meeting. It was likely the largest real-world series to date of ketamine infusions for treatment-resistant depression and suicidality.

The patients, 14-84 years old but mostly middle aged, received six infusions over 2-3 weeks, starting at 0.5 mg/kg over 40-50 minutes, then titrated upward for dissociative effect to a maximum of 1.7 mg/kg. Subjects filled out the nine-item Patient Health Questionnaire (PHQ-9) at baseline and before each in- fusion. Item nine – “thoughts that you would be better off dead or of hurting yourself in some way” – was used to gauge suicidality. That item has been validated as a predictor of suicide risk.

Among 144 patients (62%) who were markedly suicidal, ketamine infusions were tied to diminished ideation in 118 (82%) and eliminated ideation in 98 (68%). They were severely depressed at baseline; PHQ-9 scores fell in 127 (89%), and depression went into remission in 89 (62%). There were no suicide attempts, ED visits, or hospitalizations during treatment and at 4-week follow-up.

“Even if they had been suicidal for a long time, been hospitalized, and made suicide attempts, 68% had full remission of suicidality. This is a life-saving treatment, a breakthrough option for psychiatrists,” Dr. Calabrese said.

Lori Calabrese MD

The results are “fabulous,” said Jaskaran Singh, MD, who said he was clinical leader of the esketamine program at Janssen. “You prevented hospitalizations and saved lives,” Dr. Singh said. “This is a marvelous study that we should have done.”

Dr. Calabrese’s report, however, raises the question of whether the nasal spray will be potent enough to achieve the same results. She found that cessation of suicidal thoughts required an average dose of 0.75 mg/kg IV ketamine, which is higher than the 0.5 mg/kg used by many ketamine infusion programs in the United States. It’s also significantly higher than Spravato dosing. The spray was cleared by the Food and Drug Administration in March for use with an oral antidepressant for treatment-resistant depression.

Esketamine is approved in doses of 56 mg, which works out to almost 0.2 mg/ kg, and 84 mg, which works out to less than 0.4 mg/kg. Dosing is twice weekly at first, then weekly or biweekly for maintenance. When asked whether he thought those doses would be enough to prevent suicide, Dr. Singh said his company has finished two trials in suicidal patients and would present results later in 2019.

Dr. Singh

Dr. Calabrese, meanwhile, plans to incorporate intranasal esketamine into her practice, but will continue to offer ketamine infusions. “How can I not? I’ve seen how effective they are,” she said.
Insurance companies have sometimes covered them for patients with a history of psychiatric ED visits and hospitalizations, on the grounds that infusions will prevent future admissions. But patients have to fight for coverage – and feel well enough to do so.

That’s the main reason Dr. Calabrese plans to start offering Spravato; coverage will likely be less of a hassle for patients once Janssen works out the insurance issues. Spravato has been reported to cost about $600-$900 per treatment session.

Posted with permission from the July 2019 issue of Clinical Psychiatry News ® Copyright © 2019 IMNG/Frontline Communications Medical Group LLC. All rights reserved.

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July 19, 2019

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