Category: Esketamine

Esketamine Nasal Spray from Lori Calabrese, MD | The Ketamine Blog

We provide these articles about esketamine nasal spray, known by the brand name Spravato, to inform… and explain the similarities and differences between esketamine and ketamine, the compound esketamine was derived from.

Racemic Ketamine and Its Twin Molecules

As a compound made of two mirror-image molecules, racemic ketamine performs with extraordinary and robust antidepressant strength. We call those mirror-image molecules enantiomers. So, the word “racemic” simply means a compound made of right-handed and left-handed molecules.

You probably notice that identical twins look not so much exactly the same, but rather, they look like mirror images of each other. This phenomenon occurs all through nature. And you see it on the cell level, too.

The fact that these molecules are mirror images of each other doesn’t mean they’re identical. They’re similar…and have similar properties. Sometimes you see this with identical twins. For instance, one twin shows empathy, compassion, and introversion, while the other fills a room with laughter and friendliness.

In the same way, these molecules act differently also, with one showing stronger properties of one kind and the other showing stronger properties of another. It’s the synergy between the two that creates the characteristics of the full racemic compound.

The ketamine compound dynamically illustrates this. Each enantiomer behaves in some ways like the other, and behaves differently from the other in other ways.

We recognize the left enantiomer molecule s-ketamine…”s” being an abbreviation for the latin term for “left.” We recognize the right one r-ketamine, which is much easier to remember, right? So, with this in mind, they created a name that uses the “s” or the “r” phonetically. So these enantiomers enjoy the nicknames of esketamine and arketamine. Clever-ish…maybe?

Creating a NEW Medicine with an Old Molecule

Researchers hoped that by separating the left mirror-image molecule from the right-side one, they could produce an antidepressant with fewer side effects and less addiction risk. They knew they needed an entirely new compound. Because they needed the financial benefits of a patent to pay for the extensive research and testing that would be required to receive FDA approval.

It turned out that their new medicine required the aide of a newly initiated anti-depressant to perform as an antidepressant effectively. But with that antidepressant added, it showed some promising ability for erasing suicidal thinking and lifting depression.

Unfortunately, life in the laboratory behaves a lot like life everywhere else. It can be unpredictable. During the trials required for FDA approved, esketamine performed like a champ in some trials, and failed rather miserably in others.

At a time when the suicide rate rises higher and higher, psychiatrists need medicines that erase suicidal thinking. As a result, the FDA approved this new medicine along with its specially designed spray in March 2019. They took precautions, however.

They imposed safeguards. One such safeguard required that doses be restricted to administration in the office under medical supervision. Another one required that the doctor hold the patient for observation in the office for 2 hours after each dose, in case of side effects.

A Ketamine-Derived Medicine Covered by Insurance?

Janssen, a company owned by Johnson&Johnson which developed this medicine, promises that esketamine nasal spray will be covered by insurance. So, we’re waiting to hear what the coverage will be.

Will Spravato replace IV ketamine treatment? Probably not.

While esketamine may not be as effective as ketamine and is more expensive to administer. Does it have a place in treatment of depression and suicidal thinking? We certainly hope so. The fact that insurance companies plan to provide coverage for it will hopefully make it available to patients who find IV ketamine treatment is out of reach financially.

Because of the way the media promoted Spravato (esketamine), most people think that ketamine nasal spray was approved by the FDA. Esketamine isn’t ketamine, but it IS derived from ketamine. It performs with some of ketamine’s traits, but not others.

At Innovative Psychiatry, we embrace treatments that may help. And we hope esketamine will help some who haven’t been helped by traditional antidepressants or anxiety medicines. As you read these articles about esketamine nasal spray, remember this is a new medication and we’ll know more as we use it to treat the conditions it’s been developed to relieve.

How What You’re Eating Affects Your Depression

We’ve talked before about how your diet affects your microbiome, and how your microbiome affects your mood.

We’ve also talked about how eating foods rich in fatty acids helps your brain function. Since we know that your eating affects your depression—we know that… and you know that—let’s talk today about how other foods impact your mood, to either fight depression or invite it.

While we all know that sugar isn’t that healthy for you, do you know why? Do you know what it does to your frame of mind and emotions?

Inflammation

We’ve talked about inflammation before, and how it contributes to depression, and even suicidal thinking. Sounds like a dull subject? Well, look at it this way. Self indulgences like desserts, soft drinks…even the unsweetened ones…and blueberry muffins with your coffee, are making you more depressed.

Is that close enough to home?

Did you know that sugar contributes to inflammation? And if you think you’re avoiding inflammation by reaching for a diet drink, think again. Artificial sweeteners also contribute to inflammation.

Sugar and Sugar Substitutes Increase Risk of Depression

A meta-analysis by Xiaoming Bian, et al., published in Frontiers in Physiology in July 2017, showed that long term use of sucralose, which is the most widely used artificial sweetener, alters the bacteria in the microbiome. For the microbiome to function in support of your mental health, the “good” bacteria needs to be strong enough to hold the “bad bacteria” in balance.

Your eating affects your depression. And when you use Splenda, you’re actually fueling the mechanism that makes you depressed, or makes your depression worse.

And there’s more.

Sugar and sugar substitutes also increase your likelihood of developing schizophrenia. In 2004, the well-known British psychiatric researcher Malcolm Peet discovered two mechanisms where refined sugar can potentially have a toxic impact on mental health.

Sugar Interferes with Production of BDNF

To begin with, sugar stifles the activity of an extremely important growth factor in the brain, the brain-derived-neurotrophic-factor (BDNF). Now we know from our discussions of ketamine treatment that BDNF stimulates the growth of synaptic connections in the brain, which improves communication signals. And the more connections there are, the sharper your mind, the richer your associations, the brighter your mood.

However, if you’re eating a lot of sugar, the production of BDNF is reduced, which in turn reduces the growth of synapse connections, dendrites, and dendritic spines, which causes the information highway in your brain to grow darker and darker…then the signaling slows down…and your mood tanks.

We know that in depression and in schizophrenia, the BDNF level is very low. When the BDNF level remains low for an extended period of time, important brain regions begin to shrink. So it’s not too hard to connect the dots and see how you can eat a lot of sugar as a habit, and find yourself more and more depressed.

There’s a vicious cycle there. It may be tempting when you’re feeling low to eat chocolate, or cookies, or cake to cheer yourself up. But after the initial jolt of increased blood sugar, you find yourself feeling worse and worse emotionally. At which point you may be inclined to repeat the sweet treats.

Then add to that the effect of crackers and bread. These are simple starches, which saliva breaks down to sugar. And you experience the same deteriorating mood you did with all that sugar, because it’s just more of the same.

Your Eating Affects Your Depression: Sugar Consumption Stimulates a Chemical Domino Effect

In addition, when you eat lots of sugar..and in the western world the majority of us do…a domino effect of chemical reactions is instigated that leads to chronic inflammation. And that brings us full circle to the destructive force of chronic inflammation in our bodies and our minds.

If you have a history of depression or anxiety, it can be remarkably helpful to keep your microbiome balanced and strong, and to keep inflammation under control. Because you know that once symptoms emerge and increase, it can be so difficult to find the energy and initiative to take the necessary steps to get these components under control again.

And this includes processed meats. Because they’re also packed with sugar and chemicals that trigger inflammation. The safest food for strengthening your microbiome and holding inflammation at bay is to eat whole food as it’s grown naturally.

Ideally? No More Sugar Than 25 Grams/Day.

Sounds crazy? It’s so doable.

But Rome wasn’t built in a day. Baby steps. Every week, you could reduce your daily sugar intake by 1 teaspoon. Little by little. But try to be consistent. You may be flabbergasted six months from now by the difference you’ve made in the way you feel.

A study in London led by Anika Knuppel focused on 5000 men over five years who consumed over 67 gm/day of sugar. They found that these men were 1/5th more likely to develop anxiety and depression than their counterparts who consumed less than 39.5 gm/day.

So even though we all know that consuming too much sugar increases our risk for obesity, Type 2 diabetes, and cancer, it also increases our risk for psychiatric disorders, too.

More than you know, your eating affects your depression and overall wellbeing.

Nutrient Deficiencies Can Lead to Depression, Too

Things like omega 3 fatty acids, B vitamins, magnesium, and Vitamin D are all needed to maintain well being. Certainly, there are multiple factors that contribute to symptoms of disorders, including genetics, environmental factors, stress, and more. So there is not much you can do to completely prevent depression and other disorders.

But there are foods you can eat to improve your chances of staying healthier, reducing symptoms, or possibly avoiding them altogether.

The Bees

Well, ok, not the bees, or the bees knees. But rather the vitamin Bs, like B1, B2, B3, B6, B9, and B12. When your diet is low in folate (which is a B vitamin), it can increase your risk of depression and other disorders by a whopping 304%!

In 2017, a study was conducted in suicidal teens, and it happened that most of them were deficient in cerebral folate. And listen to this: all of them improved when they were treated with folinic acid.

You brain needs B vitamins. So make them part of your daily regimen to improve your mood and outlook. Because your eating affects your depression and other disorders. It just does.

Omega-3 Fatty Acids

Another thing you brain needs is omega-3s. Get it from eating wild caught Alaskan salmon, sardines, herring, mackerel, and anchovies. If you can, request an omega-3 index test to find out where you stand. In general terms, you’d like that to show 8% or higher.

Magnesium

To keep your thinking clear, your memory sharp, and your outlook bright, include a magnesium supplement that crosses the blood brain barrier. Magnesium is good for your whole body. So eating walnuts, avocados, legumes, dark chocolate, tofu, and seeds can help keep your whole body in better working order. But symptoms of depression need magnesium L-threonate. Some neuroscientists at MIT and Stanford developed that one, and it’s far more effective for your brain than nuts and chocolate.

Vitamin D

This one is needed for most chemical reactions throughout your body. In fact, vitamin D3 is especially in demand. And while you can take supplements for it, your best source for vitamin D is regular, sensible exposure to sunshine. Thirty minutes a day during mid-morning can be an effective way to build your vitamin D stores.

A double-blind randomized trial published in Y 2008 stated in conclusion that supplementing with high doses of vitamin D seems to “ameliorate symptoms indicating a causal relationship.”

It’s wise to request a vitamin D test twice a year to make sure you’re vitamin D level is 60-80 ng/ml. Tell your doctor that you know your eating affects your depression and you want to stay on top of the details.

For decades, our western society has dismissed the vital role nutrients play in our physical and mental wellbeing. At the same time, processed foods have played a larger and larger role in our overall diet primary for the sake of convenience.

But it hasn’t been without a high price. Depression has sky-rocketed in prevalence. Obesity and diabetes have almost become the norm. Only you can recover your dietary fuel by eating whole foods and paying close attention to including foods we’ve listed here, and avoiding processed foods, sugar, sugar substitutes, and fatty meats.

A Thought…

Think about this: What if treatment resistance is related to diet? Just think how much better you might feel by fueling your brain with what it needs!

At Innovative Psychiatry, we encourage our patients to give their brain the best possible opportunities to improve. With nutrients, rest, exercise, relationships, and doing things they enjoy.

And if medicines aren’t helping, if nutrients and exercise don’t help enough, we consider whether a patient is a candidate for IV ketamine treatment. Ketamine treatment isn’t for everyone, but it is effective for the majority of patients who need it. And it’s so remarkable, it can reverse their suicidal thoughts in a few hours, restore their energy for relationships, for investing in their jobs, and enjoying their hobbies. It can replace despair with hope in a big way.

If you feel like you’ve done all you know to do, including a couple or more antidepressant prescriptions for at least 3-4 months each, then call us. You just might be a candidate for ketamine infusions. And if you are, chances are that this treatment can turn your life around and set you on a path of joy.

IV ketamine treatment isn’t magic, but it can restore you to the best you remember ever being.

That’s why we’re here. Because seeing people like you get better is the whole point.

To the restoration of your best self,

November 18, 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
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
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.

Read the Original Article Here

July 19, 2019
How the Biology of Suicide Illuminates Prevention

When someone commits suicide, you’ll sometimes hear people say, “It makes no sense! She had everything to live for…” Or, “What a selfish thing to do. What about all the people who loved him? What about his kids…his wife..?” But this sort of tragedy isn’t about selfishness. To grasp what happens with your suicidal loved one, we are beginning to understand that there is a biology of suicide, and it can play into whether or not someone takes her life. It also helps to know what can be done. Read one young woman’s story to see what I mean…

…Casey climbed the stairs and disappeared into the darkness of her room without flicking on the light. Somehow the darkness was more comfortable. More familiar. She dropped her keys on the hall tree and her purse and coat on the floor, then flopped onto the sofa.

Settling back, her neck resting on the back cushion, she stared blankly at the ceiling. Another day was behind her.

It was always a feat to survive another day of work. Miserable. Now that she had, her mind wandered to nothingness. The billowing relief that would come if she could just get off this ride…this miserable journey day in and day out… Casey lost herself in reverie thinking about what a relief that would be.

She couldn’t do it anymore. She just couldn’t. And…she wouldn’t.

No one in Casey’s life had any idea what she goes through. She seemed astute, responsible, reliable to those around her. Quiet. Sometimes a little short-tempered… But pretty self-sufficient.

The darkness wrapped itself around her, and she hung her head in exhaustion.

Random thoughts drifted through her mind. The summer she was 3. She had climbed a tree and went too high. As she looked down she felt a little lightheaded and swayed in the branch as the wind blew. She had thought that if she just jumped, she would go to heaven.

“Good grief,” she thought. “I was only 3 then. Was there ever a day in my life I didn’t think about dying? Wish I could die? Figure out how to die…??”

She closed her eyes. “Thirty one years. I guess it will go on as long as I live…” Then, she thought, but why? What’s the purpose of my life beyond dreading, thinking about dying, seeing only futility..?”

“Why put it off any longer..?”

And then, something happened.

She opened the drawer in her nightstand, reached to the back, and pulled out a tin of pills she’d been saving for years. The prescription said TWO pills. And she’d taken one and stashed one. There was another bottle she’d squirreled away in her closet, so she felt around till she found it and tossed it on the sofa.

After a bit she dragged herself into the kitchen, and pulled the Kentucky Honey Whiskey from the cupboard a friend had left at her house 6 months ago. As she reached up for it, she saw the Tylenol and grabbed it.

She knew that too much Tylenol would damage the liver, so slipped that into her pocket. The whiskey bottle was three-quarters full. That will help, she told herself. Then she grabbed a glass and took the bottle to the coffee table.

With all she would need in place…she lay down and drifted off to sleep…

Honking from the street below. HONK HONK HONK!! Wondering about the time, she looked at her watch. 11:49. Just a few minutes before midnight.

Methodically, she poured Kentucky Honey into her glass and chased the first few pills. Then poured another glass, and swallowed 4 or 5 more.

Pain pills and sleeping pills… hmmmmmm… It seems to me I should feel a little different by now. She was glad for the late hour. Unlikely anyone would find her too soon. No one ever knocks or stops by.

She popped more pills into her mouth.

The Kentucky Honey was becoming harder and harder to swallow. Her head was spinning from the glasses of it she’d had so far.

All she could think about was the relief she would feel when this was over…

No one had any idea…she had always held her feelings and frame of mind close to the vest. Impossible to get her to talk, really…

We do so much research about what drives someone to suicide. But what actually happens– biologically?

Why Now? Why Tonight ?

Some people think about suicide every day of their lives and never act on it. What’s behind the moment someone actually takes the step to end his life? And what role does biology — the biology of suicide — play?

Two prominent researchers are known for their insightful hypothesis about this way back in the 1990’s. Their contemporaries swore by the prevailing belief that depression was caused by low levels of the neurotransmitter serotonin. (You remember those days?) These two were burning the midnight oil trying to figure out HOW that was true.

Their names were Charney and Krystal. Dennis Charney is now the Dean of Icahn School of Medicine at Mount Sinai in New York. He was focused on depression. John Krystal was exploring schizophrenia to better understand and treat it.

In both cases, their work at Yale at the time led them to glutamate, the most prolific neurotransmitter in the human body. As an excitatory neurotransmitter, glutamate helps brain cells communicate, so it’s critical in learning, memory development, mood and …. the list goes on.

So they went to work together to learn what they could.

Now, you need to understand that at that time, even though ketamine was a solid and relied-upon anesthesia medicine, its dark reputation as an abused substance in the club scene — and on the street — kept it from getting much attention in research.

Glutamate Paves the Way to Ketamine

Ketamine causes specific behaviors in people who use it on the street, usually within 2 hours after taking it. But the amount they ingest is around 100 times greater than the doses used in anesthesia, or the even smaller dose these researchers gave their subjects.

This is where some people get the wrong idea about ketamine. If they’ve heard about it or seen it on the street, they tend to be terrified of its use therapeutically because of severe side effects they’ve seen.

But when ketamine is used in tiny doses therapeutically, it’s a completely different “animal.”

Even so, Charney and Krystal didn’t want to miss anything that might show up later so, in an abundance of caution, they decided to monitor their research subjects for a full 72 hours after their ketamine infusion. They chose 9 subjects to try the ketamine infusion, but 2 of them dropped out. So they followed 7 depressed subjects for 72 hours. This was a turning point. Keep reading…

Four hours after the ketamine was administered, they checked on the patients. These patients declared they felt better. In fact, they felt a great deal better! Our researchers were shocked beyond belief. Everyone knew that antidepressants take weeks or months to produce an antidepressant effect, and this medicine produced dramatic results within 4 hours.

They didn’t expect anyone to believe them, and kept these results under the radar for years. When they finally did publish their results in 2000, they got …. not much attention.

Low Serotonin Severely Alters the Brain – Which Plays into the Biology of Suicide

But during the same time another research team, John Mann and Victoria Arango, set out to study the brains of suicide victims. Over time, they discovered that certain areas of the brain showed alterations in serotonin. A significant kind of alteration.

In fact, this situation reminded them of the well-known story of Phineas Gage, back in 1848. Gage was a railroad worker, and had been impaled by a 43-inch cylindrical iron tamping bar right through his skull.

Amazingly, he survived the accident, but his personality completely changed. His doctor later wrote that Gage’s “character” was altered by the damage and his “animal propensities” emerged, as he put it. He wrote that Gage was fitful and irreverent. He called him capricious and vacillating, and complained that he used the “grossest profanity.” Now Gage had been a foreman: a responsible, circumspect, hardworking man before the accident. So you see, the change was dramatic.

It wasn’t until more modern times that research revealed the area of the brain destroyed by the iron tamping bar is the area that controls inhibitions, and in Gage’s case, his social inhibitions.

And that’s one of the same areas affected by “low levels of serotonin transporter binding.”

So, with low levels of serotonin, the inhibition disappears. In the cases of these suicidal victims, the researchers think the inhibition that kept them from committing suicide was lifted, and they surged forward and ended their lives.

But again, this may have happened as a number of other social, economic, and interpersonal factors were unravelling. There are so many contributing factors to suicide. And even when we can study and pinpoint biological correlates, we know that low levels of serotonin in the cerebrospinal fluid, and probably low levels of serotonin transporter binding don’t always result in suicide.

Of course they don’t.

Moreover, even if the doctors of these patients had known the exact biological areas and brain processes involved in suicide, and had a way to modulate the activity there, it still might have taken weeks or months to reach a therapeutic effect — and it might not even have worked …as it may have been too late.

Ketamine Takes Its Cue From the Biology of Suicide in YOUR Brain

So this is a HUGE key to why ketamine treatment can be so vital to erasing suicidal thinking. Because it can erase those thoughts in an afternoon, in the psychiatrist’s office. No need to wait weeks or months and risk suicide while you wait for it to take effect.

Compassion for Suicidal Loved Ones

People who succeed in, or even attempt, suicide, aren’t thinking about the feelings of others. (There’s some truth to that…but not necessarily what the criticizers think.) Quite honestly, in that condition they can’t. They may have been induced by their disordered brain to think about suicide for a very long time, or maybe just so intensely, whether they wanted to or not. Then, if the biology of suicide kicks in and they have little or nothing to help them hold back, they may act impulsively and without recourse or consideration of consequences.

For those of us who love them, unless we’re tormented by the same suicidal thoughts, we can’t imagine what it’s like to want to die, or to feel compelled to die.

This isn’t selfishness…it’s sickness. It’s also not selfish when a Type 1 diabetic’s blood sugar drops so low he convulses. It’s a consequence of his serious illness.

And it’s for this reason that it’s important to never dismiss or ignore talk of suicide.

Thankfully, IV ketamine treatment can provide the safety stop to put on the brakes and end the suicidal thoughts.

It can give your loved one time to heal and move forward with their lives.

Biology of Suicide at Innovative Psychiatry

At Innovative Psychiatry, we’ve seen so many who fought the torment of suicidal thoughts and inclinations, walk out free of those thoughts after IV ketamine treatment.

Many times they’ve reached the point of emergency late in the day and needed immediate treatment. Then, after ketamine treatment, found immediate relief. The biology of suicide – in those cases — is side-stepped and overcome by the most rapid and effective treatment for suicidal thinking of our time.

We’re also flooded with relief for them as the suicidal thoughts subside, the light comes to their eyes, and they leave relaxed and eager to continue restorative treatment for their depression symptoms.

***If you have suicidal thoughts a few times a week, or 20 times a day: please know that there is hope. Those thoughts can stop. Reach out immediately for support by calling the National Suicide Prevention Lifeline at 800-273-8255. OR text HOME 741741. Someone is available to listen 24 hours every day. ***

And consider IV ketamine treatment. It can help you experience freedom from those tormenting thoughts and find hope and purpose in your life again through relief from depressive and anxious symptoms. Fast.

The first step happens when your life is no longer at risk.

Your life really can be fulfilling, rewarding, and productive as you experience what ketamine treatment can do for you. While it’s not a one-size-fits-all treatment, IV ketamine treatment can restore your motivation and initiative, your creativity and energy, so you can invest in your relationships, your career, and your hobbies with enthusiasm and joy.

July 15, 2019
Antepartum and Postpartum Anxiety: Moms Who Suffer Without Feeling Sad

Treatment can help anxious moms relax and enjoy their babies.

Jill was so excited to be pregnant. She’d waited for 4 years after she and Joe were married to start trying. She was just elated three months later when a home pregnancy test showed those two little lines. She was pregnant! Even the slightest thought of antepartum and postpartum anxiety never crossed her mind.

In spite of waves of nausea off and on the first couple months, by the time she got through her first trimester, she was feeling better. Her excitement to see and hold her precious baby was bubbling up like crazy. How could she wait six more months??

But as she moved through the 4th month, she began to feel… uneasy.

Just this vague sense that something bad could really happen… maybe something about her pregnancy wasn’t going as it should? She worried that something was going wrong with the baby. What if there was something wrong that they couldn’t see? Or a problem with his development? What if he was in that 3%? What if something went really wrong during delivery?How would she take care of him?

Day by day the dread grew worse. She asked her doctor about her concern, and she assured her that everything looked good. Told her that she should enjoy her pregnancy.

That was the problem. She couldn’t. She was worried sick.

Then, when she reached her third trimester, the dreams started with a vengeance. Night after night she’d dream she gave birth … to an alien. Or a forest creature. Or a monstrous murderous demon. She was so ashamed that these were her nightmares that she couldn’t tell anyone. No one.

When something is so terrible, who can you tell? Who can you trust?

The nightmares were so cruel, so vivid, that she’d wake up in the wee hours sweating, heart pounding, and screaming. Her husband would try to comfort her, then she’d go back to sleep. And the nightmare would continue. It was as if she couldn’t escape.

By the time the baby was born, her joy was gone, and in its place loomed a terrible dread. She feared for the baby, and what he would grow to be. Not who…but what. She tried to nurse him in the hospital but would break down and cry and ask the nurses to take him for awhile to give her a break.

Going Home From the Hospital Didn’t Help

It wasn’t supposed to be like this! What was happening to her? Why couldn’t she enjoy her newborn son?

The first 6 weeks or so she tried. She really tried. She was exhausted, and wondered if she’d ever get enough sleep to feel better. Waking every hour or two around the clock took a toll she didn’t anticipate. Her thoughts about her baby seemed irrational, even to her. She couldn’t imagine why she ever thought she wanted a baby. Now here she was, stuck in a permanent nightmare. She felt cheated.

Then her worries about what she might do to him if she let her guard down overwhelmed her. She mentioned her concerns to her pediatrician during a routine visit, and he explained that this could be postpartum anxiety and gave her a card to see someone he trusted.

Within a few months after her treatment began, she was beginning to see life, her son, and herself in a new light. She could sort of imagine now that it was possible she could have a good and loving relationship with him.

It helped enormously to know all this was a condition her hormonal imbalances and stress created. To fully realize that neither she nor her infant son were to blame. She read all she could find on antepartum and postpartum anxiety.

There wasn’t much.

But where, oh where, did it come from?

We’re all familiar with postpartum depression, but you rarely hear people talk about postpartum anxiety. While the two often join forces, they’re actually individual disorders. Since postpartum depression is often associated with sadness and anxiety, postpartum anxiety is sometimes overlooked.

It’s actually possible to feel overwhelmed, severely stressed, and have thoughts of harming your baby or… of ending your own life… without feeling sad.

When a woman gives birth, several changes go into high gear in her body. Pregnancy hormones drop, lactating hormones kick in, and the sudden changes in her brain give way to mood swings.

Add to that the painful engorgement in her breasts as milk comes in, lack of sleep from her baby’s waking every hour or two to eat, the soreness in her perineum from stitches, (or in her abdomen from a C-section) and cramping of her uterus as it recovers from pregnancy and childbirth, and this new mother is enduring substantial stress.

Stress + Fear = Anxiety

Even though many people are more familiar with postpartum depression, roughly 6% of all pregnant women and about 10% of those who are postpartum develop anxiety that’s severe enough to need treatment.

It’s natural for a new mother to have mild worries or nervousness about whether her baby is eating enough, whether the baby’s stool is like it’s supposed to be…and wonder if she’ll ever feel rested again.

But when mild worries become more intense, concern becomes a constant dread that something bad is going to happen, or intrusive thoughts begin of harming the baby or yourself, it’s time to seek help.

So why do some mothers seem to adapt to the new addition to the family, along with hormone changes, the lack of sleep, and the new routine, while others feel and think things they don’t want to feel or think, struggle to bond with the baby or enjoy her, and wish for a way to escape … either temporarily or permanently…?

There are a number of factors. And none of them are the anxious mother’s fault.

Risk Factors for Antepartum and Postpartum Anxiety

First, mothers who have relatives with anxiety disorders –or have had anxiety disorders themselves in the past — are at higher risk for postpartum anxiety than woman with no family history of anxiety at all. In addition, women with thyroid imbalance are at higher risk, also.

Most of the time when we refer to postpartum anxiety, we’re talking about a generalized anxiety disorder that develops during or after pregnancy. Symptoms like nervousness, constant worry, difficulty sleeping, racing thoughts, tension…

But there are a couple more types of postpartum anxiety that are important to highlight.

Postpartum Panic Disorder

Panic disorder doesn’t mean being panicky, or having anxiety that escalates easily until you feel wound up. It means having frank, out of the blue, and unprovoked panic attacks. You’re not just worried all the time about whether the baby is eating enough, whether you’re capable of being a good mother, or whether the baby will get sick, you begin to get random episodes of sheer panic.

Sometimes multiple times a day.

Shortness of breath, fast heart rate, chest pain, dizziness, and tingling along with feeling confined or like you’re suffocating can make it extremely difficult for you to take care of your baby, yourself, or the rest of the family. These sensations can come and go, but you may need professional help to cope with them and reduce their impact on you and your new family.

Postpartum Obsessive Compulsive Disorder (POCD)

Symptoms of OCD can emerge during or after pregnancy, too. They’re similar to general symptoms of OCD but tend to be focused on the baby. Intrusive thoughts about harm coming to your baby can crowd your mind, and even shock you.

The next thing you know, you find yourself checking things over and over and repeating things over and over to try to avoid a circumstance that would allow your thought to come true.

And…you’re probably horrified at the thoughts that pop into your mind. But this is why we call them “intrusive” thoughts. They intrude into your thoughts without you inviting them.

They’re a result of disordered circuitry, and misfiring signals, in your brain as the result of relentless and overwhelming stress, shock, and genetics.

Of all of the antepartum and postpartum anxiety disorders, this may be the most difficult and the most upsetting of all. Even though you probably know in your head you would never follow through on the thoughts, and you also know that the repetitions and cycles of checking don’t really help, you probably feel powerless to stop. But treatment can do what you can’t by yourself.

Because this condition is treatable, and you need to not endure these symptoms alone. Seek help and treatment so you can get your life and your relationship with your child back on track and in a healthier, brighter place.

Postpartum anxiety disorders are not your fault.

You’re not to blame for the intrusive thoughts, the fears, the compulsive reactions. These are a result of your genetics, your circumstances, your stress, and your family history. But treatment is not only available to you, it also can return your world back to its right and rewarding function.

Antepartum and postpartum anxiety disorders come in various forms with a variety of faces. But it’s vital that you not confront this alone. Rather, seek treatment. And please know that this is not your fault. Even so, you may not get better without help outside yourself.

If you’re pregnant and feeling feelings and thinking thoughts that aren’t what you wish you they were, there is help available. If your baby has been born, and those feelings are just starting or are getting worse, call us. We can help you feel better, or refer you to someone who can.

Don’t face postpartum anxiety disorders alone.

You and your baby deserve a loving and happy relationship together.

July 8, 2019
Study Finds Ketamine Nasal Spray Effective For Treating Depression: What You Should Know

A new study finds that a nasal spray formulated from the anesthetic ketamine is a safe, fast-acting and effective treatment for treatment-resistant depression. Researchers presented the findings this week at the annual meeting of the American Psychiatric Association.

Esketamine, the intranasal formulation of ketamine, recently received FDA approval as a depression treatment when used with an oral antidepressant, based in part on findings from this study. The results open the door to a potential new alternative for the estimated 30% of depression patients suffering from treatment-resistant depression.

The study included 197 adults from 39 outpatient centers over a two-year period. All of the participants had either moderate or severe depression and hadn’t responded well to at least two antidepressants in the past. Participants were randomly assigned to one of two groups: The first switched from their current antidepressant treatment to esketamine nasal spray and a new oral antidepressant; the other switched from their current treatment to a placebo nasal spray and a new antidepressant.

The results showed significant improvements in depression symptoms among those in the esketamine group compared to the placebo group four weeks into the study, with signs of improvement starting much earlier.

“The study supports the efficacy and safety of esketamine nasal spray as a rapidly acting antidepressant for patients with treatment-resistant depression,” the study concluded.

“Not only was adjunctive esketamine therapy effective, the improvement was evident within the first 24 hours,” said Michael Thase, M.D., one of the study authors. “The novel mechanism of action of esketamine, coupled with the rapidity of benefit, underpins just how important this development is for patients with difficult-to-treat depression.”

The researchers reported that most of the negative side-effects in the esketamine group, including dissociation, nausea, vertigo, dysgeusia (impaired sense of taste) and dizziness, disappeared within a couple of hours. A small percentage of patients dropped out of the study due to side effects.

Ketamine has been in headlines for more than a decade as the party drug (aka “Special K”) with promise of becoming a next-generation depression treatment. Early studies showed patients with a history of treatment-resistant depression responded well to ketamine almost immediately. Those studies generally used intravenous ketamine at a low enough dose to not deliver anesthetic effects (what ketamine was originally designed to do in humans and animals), but intravenous ketamine for the treatment of depression hasn’t been approved by the FDA. The intranasal formulation (brand name Spravato) received FDA approval in March of this year but is only available through a restricted distribution system with a certified clinic or doctor’s office.

The news isn’t entirely upbeat, however, with some researchers urging caution as the drug moves closer to pharmacy shelves. In commentary accompanying the study in the American Journal of Psychiatry, Alan Schatzberg, M.D., from Stanford University School of Medicine, cautioned that while this study shows potential benefits of using the drug, “there are more questions than answers…and care should be exercised in its application in clinical practice.”

Schatzberg pointed out that clinicians don’t have adequate information about how often the medication should be prescribed, how long patients should use it, or what the correct course of action should be if patients eventually stop responding to it.

He also highlighted the potential for abuse, echoing concerns raised by many health professionals all along the drug’s road to approval. Using the history of opioids as an example, he added, “We have witnessed four decades of supposedly new and safer opioids that have turned out often to be, if anything, even more abusable and lethal.”

“Still, the agent [esketamine] could be helpful to many patients with refractory depression,” Schatzberg said, ending on the positive, “and efforts to develop rapidly acting agents for severely depressed patients need to be applauded.”

The study was published online in the American Journal of Psychiatry.

You can find David DiSalvo on Twitter, Facebook, Google Plus, and at his website, daviddisalvo.org.

[Read the Original Article Here]

May 29, 2019

Category: Esketamine

Esketamine Nasal Spray from Lori Calabrese, MD | The Ketamine Blog

Racemic Ketamine and Its Twin Molecules

Creating a NEW Medicine with an Old Molecule

A Ketamine-Derived Medicine Covered by Insurance?

Will Spravato replace IV ketamine treatment? Probably not.

We’ve talked before about how your diet affects your microbiome, and how your microbiome affects your mood.

Inflammation

Sugar and Sugar Substitutes Increase Risk of Depression

Sugar Interferes with Production of BDNF

Your Eating Affects Your Depression: Sugar Consumption Stimulates a Chemical Domino Effect

Ideally? No More Sugar Than 25 Grams/Day.

But Rome wasn’t built in a day. Baby steps. Every week, you could reduce your daily sugar intake by 1 teaspoon. Little by little. But try to be consistent. You may be flabbergasted six months from now by the difference you’ve made in the way you feel.

Nutrient Deficiencies Can Lead to Depression, Too

The Bees

Omega-3 Fatty Acids

Magnesium

Vitamin D

A double-blind randomized trial published in Y 2008 stated in conclusion that supplementing with high doses of vitamin D seems to “ameliorate symptoms indicating a causal relationship.”

A Thought…

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…

Unbelievable, right?

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.”

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

It’s not a good idea.

People depended on experts to fix their problems.

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

Not likely. Not likely at all.

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

Controlled Substances Require a Physician’s Supervision for YOUR Safety

So let’s talk now about esketamine.

What IF You COULD Buy Esketamine Online?

Would that be a DIY Solution or a DIY Tragedy?

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

There are no shortcuts to reaching that goal.

DIY Brain Surgery

Brain Treatment is for the Experts

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

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

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.

Suffering Together

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.

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.

Quiet Distractions Provide Solace

Shame Torments

Learning to Support Each Other In the Family

“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.

A big part of that pain is helplessness.

The NON-Squeaky Wheel Needs Attention, Too

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

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.

With Psychiatric Disorders, Symptoms Can Look Like Bad Behavior

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.

Family: Suffering Together with Psychiatric Disorders

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.

Breathe.

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.

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.

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

Life Is Challenging on Some Level for Us All

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.

But then, that’s life, isn’t it?

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.

…Casey climbed the stairs and disappeared into the darkness of her room without flicking on the light. Somehow the darkness was more comfortable. More familiar. She dropped her keys on the hall tree and her purse and coat on the floor, then flopped onto the sofa.

“Why put it off any longer..?”

Why Now? Why Tonight ?

Glutamate Paves the Way to Ketamine

This is where some people get the wrong idea about ketamine. If they’ve heard about it or seen it on the street, they tend to be terrified of its use therapeutically because of severe side effects they’ve seen.

Low Serotonin Severely Alters the Brain – Which Plays into the Biology of Suicide

Ketamine Takes Its Cue From the Biology of Suicide in YOUR Brain

Compassion for Suicidal Loved Ones

And it’s for this reason that it’s important to never dismiss or ignore talk of suicide.

Biology of Suicide at Innovative Psychiatry

The first step happens when your life is no longer at risk.

Treatment can help anxious moms relax and enjoy their babies.

In spite of waves of nausea off and on the first couple months, by the time she got through her first trimester, she was feeling better. Her excitement to see and hold her precious baby was bubbling up like crazy. How could she wait six more months??

But as she moved through the 4th month, she began to feel… uneasy.