Lori Calabrese, MD

Tag: Omega Fatty Acids for Your Brain

  • Omegas: The Very Real Effect of Fatty Acids on Your Brain

    Omegas: The Very Real Effect of Fatty Acids on Your Brain

    The very real effect of fatty acids like omega-3s help your brain function at its best.

    Eat a diet that supports your positive mood and mental health.

    We’ve talked about the microbiome, or “second brain,” and how we can weaken or strengthen it with what we eat. We’ve talked about eating fresh vegetables of all colors. And how fermented foods like sauerkraut, pickles, kimchee, and kombucha introduce healthful organisms into our intestinal DNA system. We’ve talked about curcumin, and its benefits against depression. Now let’s talk about the very real effect of fatty acids on your brain.

    Did you know that some of the most important, even vital, foods you can ingest are fatty acids? Maybe that sounds a little creepy… But it’s true.

    The World Health Organization estimates that major depression is the greatest single cause of disability worldwide.

    A study by JR Hibbeln showed that around the world, countries that consume the least amount of fatty fish show the highest levels of major depression (MDD) in their population. And countries where fatty fish is the main diet show the lowest incidence of MDD.

    You Have a FAT Brain

    You think I’m kidding..??

    The effect of fatty acids on the brain turned this miserable man to a happy fulfilled one.

    I’m telling you, your brain is 60% fat.  60% !! Shocking fact when you step on the scale. But don’t try to lose that excess weight from your head, because THAT fat is pretty important. 

    Fats reside in the neuronal membranes–the brain cell membranes–and in the myelin sheaths that surround them. And they’re important for delicate synapses. Remember that synapses are the connections between neurons.

    The saturated fatty acids are combined in what’s called a lipid bilayer and that lipid bilayer forms the membrane that surrounds each brain cell. It’s made up of straight chain carbon atoms so the membrane is more firm like butter is firm at room temperature.

    Now–this is where it gets interesting– unsaturated fatty acids are made of bent chain double bond curvy molecule structures. Because of this, there’s more space between molecules so when unsaturated fats are incorporated into the cell membrane, the membrane is more fluid. So, if you compared oil to the firmness of butter, these are more fluid like olive oil, for example. 

    The omega 3 fatty acids are fluid ones.

    Another remarkable characteristic of omega-3 fatty acids is that they’re precursors to eicosanoids like prostaglandin which can reduce inflammation. Super important for psychiatric disorders, which are associated with increased inflammation.

    Eicosanoids go by the nickname ‘local hormones’ because they act on cells close to their site of production. So fatty acids in your brain cause the release of prostaglandin, which reduces inflammation that contributes to depression.

    That’s a mouthful! But it tells a promising story.

    Get the effect of fatty acids by eating more fatty fish.

    The effect of fatty acids on your brain results in wellbeing for you.

    Fatty acids like omega-3s are considered essential fatty acids, and you can only obtain them from your diet.

    So to maintain a healthier, more positive outlook, decrease inflammation that can lead to depression, and actually fight depression symptoms, increase the amount of mackerel, salmon, oysters, sardines, and trout in your diet. Make sense? I hope so, because doing that can make a real, tangible difference for you.

    In addition, seaweed is a nutrient dense food that’s rich in omega-3 fatty acids. Nori seaweed typically presents itself in sushi, and is a tasty snack on its own.  Also spirulina and chlorella are also in the algae family and are a good source of omega-3s that you can add to shakes and smoothies.

    Fatty Acids Are Essential for Your Brain Health

    In a presentation at the annual meeting for the Society of Biological Psychiatry in NYC last year, Dr. Roel Mocking spoke about the critical requirement of fatty acids in psychiatric wellness.

    He demonstrated that Omega 3 fatty acids reduce inflammation, reduce the release of cortisol from the hypothalamus-pituitary-adrenal-cortex-axis, and activate the amygdala. 

    This family love to hike together and enjoy life together.
    The amygdala is one part of the brain that contributes significantly in processing emotion and decision-making. When someone’s amygdala is damaged, or destroyed, they tend to be fearless, and don’t use the necessary caution to make safe decisions since the caution the amygdala would create is absent. 

    So, by multiplying your fatty fish consumption, you provide your amygdala the fuel to be activated to process fear and enhance circumspect decisions. You can also reduce the release of cortisol, the stress hormone that has a negative impact on your health. And you equip your brain to reduce inflammation…all of which improve your mental and emotional functioning.

    The Effect of Fatty Acids on Your Brain

    Dr. Drew Ramsey, a nutritional psychiatrist, and author of 3 books on foods that feed the brain, is an assistant clinical professor at Columbia University. Dr. Ramsey promotes better nutrition for the brain with his patients. He laments that most Americans overfeed themselves in calories but starve themselves of the critical micronutrients the brain needs to thrive.

    He prescribes antidepressants and other medications for his patients, and engages in psychotherapy with them, too. And he teaches that fresh and nutrition-packed foods help make other treatments more effective.

    It’s a shame, according to Dr. Ramsey, that it’s so rare for Americans to eat foods that meet the needs of the “most complex and energy consuming organ in the body” which is the human brain.

    Eat the Rainbow

    This meal can contribute to the effect of fatty acids on your brain.

    He recommends “eating the rainbow,” as in eating all the colors of fruits and vegetables. Fresh foods like oranges, apples, bananas, pineapple, bell peppers, tomatoes, avocados, kale, sweet potatoes, and blueberries. 

    Combine these with fish like mackerel, salmon, trout, sardines. And walnuts, pecans, and almonds.

    These can help prevent harmful inflammation, and feed your brain, your heart, and your digestive system.

    They can reduce symptoms of depression and anxiety, and promote mental clarity. 

    Ketamine Treatment Can Help Give You a Fresh Start

    So, if your diet changes and medications aren’t bringing the relief you hope for, then let’s talk about ketamine treatment. Because this remarkable treatment of at least 6 infusions within 2-3 weeks has been changing lives across the country.  It just may change yours, too.

    At Innovative Psychiatry, we encourage brain supporting foods that improve your outlook and emotional wellbeing. 

    While we don’t center an entire treatment program around food, we do work with patients and guide them in supporting their brain function by avoiding food dyes and preservatives.

    In addition, we show them that by adding healthy foods, micronutrients, and lifestyle changes, they give their brains and emotions an optimal environment for restoration.

    This young woman is upbeat because of the effect of fatty acids in her diet.

    If you suffer from depression, symptoms of anxiety, or other mood disorders, and other treatments have brought no relief, call us.

    We’ll talk with you and determine whether you’re a candidate for ketamine treatment. We’ll guide you to eat foods that improve your well being. And please do follow the links in this article to read more information about your microbiome and your restoration.

    It’s all about getting better. Enjoying your life. Watching symptoms fade and your strengths rise. 

    Call us, and let’s create a plan to help you restore joy and fulfillment in your life.

    Can we stop suicide? Yes, with a series of IV ketamine infusions.
  • Can Genetic Clues Really Predict Bipolar Disorder and Schizophrenia?

    Can Genetic Clues Really Predict Bipolar Disorder and Schizophrenia?

    Can genetic clues really predict bipolar disorder in people like this young woman, who doesn't understand her disorder.

    If you struggle with bipolar disorder, and the symptoms that seem to dominate your life, it may help you to know that many psychiatric disorders don’t really come with a list of predictable symptoms.

    If you have times when you’re short-tempered, highly energetic, sure of yourself, and quick to argue, you may have a mood disorder…or you may have had a frustrating week at work… And so goes the conundrum. You may feel like you’re low on energy most of the time, or find it hard to identify purpose for your life. How do you know if you’ve got something going on? How can you get a clue? It may seem far-fetched, but can genetic clues really predict bipolar disorder and schizophrenia?

    We look for clues all the time–little signs and symptoms that herald bigger problems to come. If you have all that going on… and it seems to run in cycles…  depression interrupted by periods of energy, over-confidence, a strong drive to win arguments… then periods when you can only think about dying…or ending your life yourself… Well, chances are, this may be more than a bad week at work. In fact, you should probably see a good psychiatrist in your area to help sort it out — because you may have a disorder. And if you do, treatment can help.

    So, let’s say maybe you feel intrigued to talk someone you just met into having risky sex with you…or maybe you’ve lost touch with the limits of your credit cards and feel inspired to do lots of shopping or travel and splurging. Maybe spending money gives you exhilarating feelings, but you feel like you’re accomplishing so much– and …you don’t notice this is out of character for you. You think it’s great.

    Oh boy.

    Your Disorder May Display Different Characteristics Than Someone Else’s

    Fighting cranes depict the unexpected conflict from someone with bipolar disorder.

    People with bipolar disorder don’t usually display all the symptoms, but they do display some of them. Whether it’s something like getting frustrated that leads to a major blowup and rage…and display of super human strength… or something like feeling untouchable and indestructible that leads you to do things that are so risky (so incredibly fun!) that the adrenaline just courses through your veins. Rather than feeling fear per se, you feel exhilarated — and want more of that feeling.

    Let’s look at it this way…

    If you contract a virus, something like the common cold, it’s easy to predict your symptoms, isn’t it?  

    Sneezing and a runny nose is how it starts.

    Sound familiar?  

    If it’s a particularly nasty cold, you might even have a fever. Then, the runny nose gives way to a stuffy head, maybe a cough or a scratchy throat, and you just feel awful. So predictable. We can pick up on the first inklings

    But some psychiatric disorders aren’t quite so easy to pick up on. 

    So Many Symptoms – Who Can Tell?

    Sure, there’s depression.  Everyone knows what that is…right? Or maybe not…  If you broke a nail right before a black tie event, that may seem depressing. But we’re not using the word appropriately when we say that. Because major depressive disorder (MDD) is a disorder… i.e., an illness. Grab your file and smooth out that nail. It won’t interfere with your fun at all. But if you have MDD, it’s not likely you’ll be able to have a very good time. Depression just takes the fun out of everything.

    Shopping can be fun, but sometimes spending way too much can be a sign of bipolar disorder.

    At the same time if you shopped for the event, spent your entire month’s earnings on an outfit for the affair, and left yourself with pretty much nothing to live on or pay bills with until your next paycheck, it’s pretty clear you used poor judgment. And poor judgment is not a disorder. It’s merely doing something risky that seemed like a good idea at the time …but a tough decision to live with the rest of the month. On the other hand, poor judgment can be a symptom of a disorder.

    Oh. Like when?

    So can explosive outbursts. Fits of rage. Or destruction of property. Again, they can be, but of themselves aren’t necessarily signs of a disorder.  So it begs the question: are there clues that predict whether a disorder is in the making? Are there genetic clues that really predict bipolar disorder and schizophrenia? Well… the answer is sometimes. And maybe.

    (This is where we tear our hair out.)

    You do need a psychiatrist to figure all this out. 

    Thirty years ago, a psychiatrist may or may not have been able to help. But chances were much better than they were 100 years ago, you know?  At that point, psychiatrists stumbled in the dark and devised theories to explain patients’ behavior, with little scientific evidence. There was so little we knew about the brain. Sometimes they helped their patients, but often they couldn’t. 

    In the absence of neuroscience discovery, psychiatrists did what all scientists do: they hypothesized. And they looked for evidence to see if they were right.

    Is it any surprise this branch of medicine was cloaked in stigma? 

    Can Genetic Clues Really Predict Bipolar Disorder and Schizophrenia?

    Now we’re advancing into the 21st century, and we’re still fighting the stigma that began in the dark absence of clear scientific evidence.

    So, let’s talk about where we’ve come in psychiatry.

    Now we can separate the genes on the chromosomes.

    You know what chromosomes are, right? Your DNA. But that tiny microscopic structure – that’s a map of who we are – is made up of genes. Now those are really tiny.
    We know what many of the chromosomes actually do. We also know that a tendency to develop various diseases can be found in specific positions on certain chromosomes.

    By the same token, certain clusters of genes in certain locations on the chromosomes can indicate personality traits that emerge in someone who has not yet developed a disorder. Genetic clues that can perhaps predict the later onset of bipolar disorder and schizophrenia… and the list goes on.

    Nicholas Pediaditakis, M.D.’s article in Psychiatric Times under the title, “The Dog That Did Not Bark,” explains how this might work. Sometimes, certain clusters of genes are missing… like if the “barking” genes are missing, it could result in a dog that doesn’t bark. 

    A child's temperament can be a clue to bipolar disorder or schizophrenia through genetic personality predictors.

    When that happens in people the genes that express themselves as personality traits, can create a “lopsided” personality, as he put it.  So the genes that would express themselves as socially outgoing may be missing or sparse, which can show up in the person as aloofness or an aversion to social situations along with a sense of autonomy. 

    Of course, this is an oversimplification for our purposes in this post, but the point is that this person is “premorbid”(in the sense that he doesn’t have signs of a disorder yet), but his “lopsided” personality can be a signal of schizophrenia or bipolar disorder that may be lurking in the future.

    Dr. Pediaditakis goes on to say that this premorbid asocial trait may result in a group of individuals who may be vulnerable and later turn out to develop schizophrenia or bipolar disorder. It’s sort of like a preview in the developing brain. He says,

    “This synchrony is an emergent property of complexity. This probabilistic shift heralds the expression of the disorders and results in the development of characteristic symptoms for both schizophrenia and bipolar disorder.”

    The Give and Take That Leads to Gifting and Brilliance

    He also says that while both of these disorders tend to include psychosis at some point, there is also some trade off with traits that can be quite favorable.

    For instance, since their personality doesn’t include social traits, it’s as though they’re able to think in terms of unconventional alternatives and distinguish original and revolutionary patterns …whether scientific, mathematical, artistic, or musical. 

    Basically, since they have some freed up space in their head, they can also be remarkably gifted. Sound familiar?  

    Can genetic clues really predict Can genetic clues really predict bipolar disorder? This brooding man wants to know.

    It brings to mind the book and movie, “A Beautiful Mind,” about John Nash, Jr., the gifted mathematician who suffered from schizophrenia. And Vincent Van Gogh, the brilliant but tormented artist. And entertainers like Carrie Fisher, Mel Gibson, and Mariah Carey (to name just a few) who’ve struggled with bipolar disorder along with their creative brilliance.

    There’s a physiological reason, one only identifiable by neuroscience, that these great talents are simultaneously struggling with a severe disorder, while also displaying their creative gifts. The two might actually be linked, if indirectly.

    Neuroscience Leads the Way to Understanding More About These Disorders

    Molecular genetics, functional neuroimaging, and translational neuroscience has made great advancements in the diagnosis and treatment of both bipolar disorder or schizophrenia. Stigma about disorders like these is dying a slow death… we hope, in time, it will disappear altogether. 

    And we hope that time comes soon.

    Modern medical and neuroscience breakthroughs are exploding. And they raise the question: Can genetic clues really predict bipolar disorder and schizophrenia? There’s so much more we’re learning about brain circuitry, the hippocampus, the amygdala, the lateral habenula… and what is called translational neuroscience, where we take basic science research and translate it into clinical applications that help people. Like you, and the people you love.

    In the meantime, if you’ve been diagnosed with bipolar disorder, and if the medicines prescribed for you haven’t helped, you need treatment that works.

    You Deserve to Feel Better

    Ketamine treatment can make a dramatic difference in managing your bipolar disorder by wrangling bipolar depression. Scores of people in your position have been relieved to discover the difference ketamine treatment makes. 

    If your medicines are helping, you’re in a wonderful position. You’re finding you’re able to live your life with less difficulty and build upon the things that matter to you. But if your medicines aren’t working, if you’re tormented, living in chaos, and unable to invest in your job or relationships because of your symptoms, call us.

    Can genetic clues really predict bipolar disorder? Ketamine treatment can can give you great relief, if it does..

    At Innovative Psychiatry, we see people with bipolar disorder get much better all the time. Because lifting them out of depression that just hasn’t wanted to budge is a game-changer. When ketamine relieves depression, there is so much more time and energy left for managing your life. 

    We’re here to see that you get the help you need to enjoy your life, build up what’s broken down, and relish your friends, your family, and your work, as well.

    It can get better for you.  You’ll see.

    Can we stop suicide? Yes, with a series of IV ketamine infusions.
  • Ketamine and Depression Treatment-Time Marches On

    Ketamine and Depression Treatment-Time Marches On

    Ketamine and depression treatment is the subject of this Time magazine special edition.

    Time magazine recently offered a Special Edition on mental health… Did you see it?

    The article about depression treatment – and ketamine specifically – by Mandy Oaklander published in July 2017, was reprinted for this special edition. The title of the special edition is “A New Understanding”…but since the article Oaklander wrote is two years old, I’m concerned this special edition may be misleading.

    Her cover article two years ago touted ketamine as an “anti-antidepressant.” This same term is repeated on this Special Edition cover. But, since Oaklander’s article created some misunderstanding when it was first printed, I’m not sure it’s accurate to refer to the contents of this edition as “a new understanding.”

    In fact, some of her representations of ketamine treatment border on archaic.

    Ketamine and Depression Treatment

    The field of ketamine for depression treatment is a new field in the “psychiatry and neuroscience universe” that’s been growing at break-neck speed. A wide variety of healthcare professionals offer this treatment in a wide variety of places and using a wide variety of methods.

    Ketamine and depression treatment as a whole is developing as a field and is helping people with treatment resistant depression enjoy their lives.

    Still, because we’re on this quest together, you and me, I want to take a few minutes to express my perspective on this reprint of her article.

    What quest?

    Well, that would be our passion to find more ways more people can be relieved of the symptoms that impair their lives.

    We talked about this after this article was published in TIME two years ago. But we’ve learned so much since then. Through neuroscience research as well as in private psychiatry practice and in meeting and collaborating with other healthcare professionals at national and international conferences since then.

    What Have We Learned Since TIME Published That Cover Story?

    Lots. About ways to prolong the effects of ketamine, ways to prolong and maintain remission, more of the actions of ketamine in the brain… We focus on ketamine treatment. So let’s talk again now about how she framed ketamine treatment in a less accurate light than we might wish.

    Because if you suffer, you want to know. You try treatments and medications for months – and years – in vain. You want to know that you’re getting the best possible information you can get your hands on. 
    Is TIME telling truth ketamine?

    Regarding the route of administration

    This article spoke of a lady named Barbara Reiger who’d been depressed since childhood. It said that since no other treatment helped, she goes monthly to a ketamine clinic. And there she has “a needle full of ketamine plunged into her deltoid…” 

    This route of administration for ketamine treatment is only one of many. In the 2 years since the article, there has been much more research about IV ketamine infusions. The intramuscular route is less predictable than an IV for getting the medicine on board. In addition, it’s more difficult to manage the onset of action or the experience once ketamine is sealed into muscle. You can’t slow its absorption or effects, or stop it.

    We later read that Ian Hanley, another person with treatment resistant depression, received ketamine infusions. I assume these are intravenous (or IV).  The term “infusion” speaks of the IV route. (Though surprisingly, I hear there are those who use this term to refer to IM injections.  This isn’t correct, and can be so misleading to patients who don’t know the implications.)

    Is Ketamine and Depression Treatment a “Trip?”

    Another point is the experience itself:  Is it a “trip?” What does the patient experience with ketamine treatment? Oaklander calls these treatment experiences “ketamine trips” as though the concept of a psychedelic trip is the foregone conclusion with ketamine treatment.  While it’s true that there will be a variety of experiences between various patients, and that ketamine is a visionary medicine, ketamine treatment for depression should not be confused with people who use ketamine for a psychedelic trip. 

    Oaklander’s perspective focuses on ketamine as a psychedelic drug. Such characterization draws a narrow crowd of people interested in psychedelic exploration, but can alienate the larger population of patients who have no interest in psychedelic anything. It’s a misunderstanding of ketamine and its properties to limit the characterization of it.

    Who’s in Charge? The Medicine or the Doctor?

    Ketamine for depression has changed the face of psychiatry.

    And it’s the responsibility of the physician administering the medicine to use a route, a rate, and a dose that allows the patient to know the ketamine is actively working. And to prepare and protect the patient from an overwhelming experience. 

    As it takes action in (1) her brain circuits, (2) her BDNF to proliferate synapse connections, (3) her lateral habenula, and (4) those G proteins on lipid rafts in the cell membrane, the patient will experience sensations, feelings, and possibly visuals as a result. (Amazing, isn’t it? These are just a few areas of action we know about ketamine! There may be far more!)

    Because the brain is made up of nerves that connect with each other, and complex systems that perform vital functions of all types, impacting these circuits gives you certain sensations, thoughts, and experiences.

    The sensations feel overwhelming if the dose is too high. And the patient can feel alarm if the rate is too fast or uncontrolled. In fact, the experience might even advance to something you might call a “trip.”

    But … a closely monitored infusion should prevent the overwhelm, while allowing full restorative freedom for the medicine to do its work.

    Ketamine Can Erase Suicidal Thoughts in an Afternoon

    Ketamine treatment lifted depression from this young man.

    Oaklander also pointed out the rapid and dramatic ability of ketamine to stop suicidal thoughts in a few hours, whether it relieves depression or not.

    This is a shining benefit of ketamine — that its ability to erase suicidal thinking is separate from its antidepressant benefits. Lifesaving.

    Now about how ketamine lifts depression.  Oaklander wrote that the “ketamine trips,” as she called them, help people disconnect from their bodies and thoughts. Her idea was that this experience changes the mindset so completely that the depression lifts. 

    However, while we know the experience is important as part of the ketamine and depression treatment, research presented at the American Psychiatric Association Conference in San Francisco a couple weeks ago shows it’s not enough to lift the depression by itself. In addition, if that were true, those who have had these “trips” would all be depression–free … and that’s not true either.

    Even so, the dissociation the patient experiences during the infusion does serve as a sign of what’s actually going on in the brain. This is ketamine at work, restoring synapses, turbo boosting BDNF. This process is not for entertainment but rather it signals the restorative properties at work, just as pain signals something wrong in the body.

    How Ketamine Works… There’s More to Learn

    Oaklander’s statement that “experts aren’t sure exactly how ketamine works…” is still true, but we know far more than we did when she wrote the article two years ago. It seems this one medicine has spawned its own frontier, and we keep learning. Research on ketamine for psychiatric disorders presses on around the world.

    And real-world practices also present data to give the medical community, and our patients more information that ketamine has taught us.

    Learning more about what we already know is paramount. A recent study revealed how ketamine restores brain circuits. We understood that it did… or believed that to be so. But now a two-step process in restoring dendrites and dendritic spines has been revealed through a special laboratory process. This is the tip of the iceberg.

    There is so much more we want to know about this extraordinary treatment.

    Ketamine and Depression Treatment in General: Keep the Research Coming

    And this is where I’d like to see journalists like Mandy Oaklander and her contemporaries use their influence to call for more research. It’s wonderful that pharmaceutical companies continue to search for new possibilities in drugs to target more areas of the brain. The more the better.

    Ketamine and depression treatment helped this mom to enjoy her daughter and build a stronger relationship.

    But, as Oaklander pointed out in that article, the concern and caution about ketamine lies partly in its potential for abuse, but also in its potential for damaging side effects.

    Our concern is that it may be damaging eventually if it’s used too often for too long. 

    For those who receive ketamine infusions every few weeks or every single month with no end in sight, there may be risks. Since ketamine can help such a large population of people with treatment resistant disorders achieve resilience and remission… isn’t it worthy of the research to find out more that it can do? To build our body of knowledge…?

    How many more people can be restored with ketamine infusions if we find out what their physiological and psychological obstacles are? What do we need to learn to remove more of the hindrances to an individual achieving resilience… and even remission?

    It’s true that not everyone responds to ketamine treatment.  We’ve talked about how preliminary research suggests that those with the VAL-VAL allele respond so quickly, and those with MET-MET can respond more slowly, or sometimes not at all.

    But there are also those who respond within the first three infusions, but then their response dissipates. These are responders, and yet not remitters. There are studies that suggest differential responses in certain groups, like the Taiwanese. Let’s find out what we don’t know about why. 

    Ketamine and depression treatment can change an angry man to a happy man like this.

    In some cases, there’s a cerebral folate deficiency that hasn’t been treated, in others it’s Low T, in others it may be deficiencies only found in the cerebral spinal fluid… 

    And if deficiencies that cause depression are there, they need to be teased out and treated, so ketamine can do more to restore those lives.

    But..what other obstacles are there that can be treated so our patient can get the most out of his ketamine infusions…and enjoy resilience… and get the most out of his life?

    We applaud all efforts to find more treatments that will be effective for more patients. But rather than focus on ketamine’s potential danger in the long term, why not invest our resources in finding out how to get more people to remission so they’re NOT exposed for the long term?

    What if that pot of gold at the end of the rainbow is not in fact another medication we also don’t fully understand, but rather a better understanding of the one that works so well already?

    Thank you, Mandy Oaklander of TIME magazine, for spreading the word about this new frontier in treatment two years ago. While your characterization seemed to stray from our perspective through neuroscience, we have appreciated that TIME magazine helped to make this breakthrough treatment a household word. We’re learning so much and the more we learn, the more we see that we NEED to learn.

    Knowledge really is power against psychiatric symptoms.

    Man with peace in his heart is thankful ketamine treatment restored his life.

    Here’s hoping we can all walk together to get effective treatment to more people. Several years ago, studies showed that “60-70% of people with treatment resistant depression respond to ketamine” … but we’re making progress.

    A number of doctors in private practice are learning to get more out of each infusion for better outcomes for our patients. And we’re seeing responses much higher than 60-70%.

    At Innovative Psychiatry, we see extraordinary outcomes in our patients every week. Patients who were too ill to work, who had withdrawn from their relationships, and lost hope in their jobs, their lives, and themselves…go forward to find initiative, resilience, joy, and bushels of hope for a fulfilling and rewarding life after they receive carefully supervised ketamine treatment.  

    If you suffer and endure with symptoms of depression, PTSD, bipolar depression, addiction, social anxiety, and suicidal thoughts... give yourself the opportunity to feel better and live better. Call us and find out what joy feels like. 

    Ketamine KRIYA Conference 2018
  • Study Finds Ketamine Nasal Spray Effective For Treating Depression: What You Should Know

    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]

  • Opinion: The New Ketamine-Based Antidepressant Is a Rip-Off

    Opinion: The New Ketamine-Based Antidepressant Is a Rip-Off

    Johnson & Johnson patented a form of the psychedelic with less research and a ridiculous price tag.

    In a popular and public move, the United States’ Federal Drug Administration recently approved intranasal esketamine, one of the components of the psychedelic ketamine, for treatment-resistant depression. The nasal spray costs nearly $900 per dose—or roughly $7,000 for the first month of treatment, and each treatment takes at least two hours in a clinic. (It has yet to be decided how much of the cost insurance plans will cover.)

    Esketamine can be unwieldy to use and carries a number of significant potential side effects. Shockingly, it was no better than placebo in two of the three short-term Phase-III studies submitted to the FDA for approval.

    But the biggest problem at hand is not the drug itself. It’s the fact that instead of representing a revolution in mental health treatment, as it has been touted to do, esketamine is not a breakthrough at all. It’s just a way for pharmaceutical company Johnson & Johnson to make a significant profit off gullible insurance companies and vulnerable patients.

    Generic Ketamine Works

    Generic ketamine is available for a fraction of the price of esketamine, has been shown to work—and work safely—in small-scale single-dose and multidose trials for treatment-resistant depression, can be administered in a variety of ways, and has already been used off-label for decades to treat thousands of patients with depression and suicidality.

    It’s currently difficult, if not impossible, to provide generic ketamine treatment in public clinics, even to patients who need it, because there haven’t been any large-scale, randomized trials, both with and without psychotherapy. Without these trials, and resources, physicians can’t be reimbursed by insurance companies for ketamine treatment like they will be able to do with esketamine.

    Ordinary ketamine is a racemic medication, meaning it is made up of two molecules that are mirror images of each other. Because ordinary ketamine is generic, Johnson & Johnson simply isolated one of the two molecules in regular ketamine so that it qualified as “new.” The reality is that we don’t know whether esketamine is more or less effective than regular ketamine because there have been no head-to-head trials between the two. Johnson & Johnson only tested esketamine against a placebo, likely because they feared esketamine might actually perform worse than the generic version.

    As many critics have pointed out, this strategy has become the bread and butter of drug development in the United States today. Largely because of the influence of pharma on the FDA itself, our drug approval process rewards copycat variation of already-available drugs instead of truly innovative pharmaceutical design.

    When Psychotherapy Is Missing

    The trials for esketamine also reveal a larger issue in the field: they de-emphasized the importance of psychotherapy while focusing solely on its chemical effects. The most effective treatment strategy for treatment-resistant depression is intensive psychotherapy along with the use of medication, but the FDA esketamine trials didn’t include therapy at all.

    Getting insurance companies to pay for psychotherapy is already difficult, and without it as part of the protocol, they will likely offer no reimbursement for patients interested in receiving a psychotherapy session after their esketamine dose in order to process the experience.

    Our colleagues who offer ketamine-assisted psychotherapy say that this is a vital part of the process. One such session can require upwards of three hours of one-on-one treatment in order to prepare patients for the experience, take care of patients while they are under the influence of ketamine, and then integrate the effects afterwards. Ironically, insurance companies would save more money paying for generic ketamine-assisted psychotherapy rather than esketamine treatment alone, as the former is both cheaper than the latter and can lead to long-term remission of symptoms.

    Alternatives

    Private ketamine clinics currently do exist, but they have to fight the stigma of the drug, and sporadic cases of malpractice. Some private clinics do not properly screen patients prior to initiating treatment and often charge outrageous sums of money—one reason that both patients and medical systems have been hesitant to implement it more widely. Those clinics that are providing ketamine responsibly, however, offer a potentially lifesaving treatment for patients living with depression who have exhausted all other available options.

    Although there are no quick fixes for the broken drug-development and approval process that led us to esketamine, it is possible to take concrete steps to address the most glaring problems. Insurance companies and the FDA ought to require head-to-head study designs of clinical trials to investigate generic and patented medications. Additionally, current research on medication-assisted psychotherapy with other psychedelic substances such as MDMA and psilocybincan serve as a model for future research that explores ketamine-assisted psychotherapy, instead of the drug alone.

    While Johnson & Johnson rakes in the profits from esketamine, patients dealing with depression and trying to navigate our struggling mental health system will bear the cost. Fostering the development of mental health treatments that are novel, effective, and affordable will require a critical examination of the undue corporate interests that drive drug approval in American psychiatry today.

    Dr. Michael D. Alpert is a psychiatrist and clinical faculty at Harvard Medical School. He is also a therapist with the MAPS Clinical Study of MDMA-Assisted Psychotherapy for PTSD.

    Dr. J. Wesley Boyd, MD is a psychiatrist and associate professor at the Center for Bioethics at Harvard Medical School.

    Dr. Marco A. Ramos is a psychiatry resident at Yale University.

    [Read the Original Post]

  • Revitalize Psychiatry: Disrupt – Include – Engage – Innovate !! – The APA 2019 Conference

    Revitalize Psychiatry: Disrupt – Include – Engage – Innovate !! – The APA 2019 Conference

    Disrupt, Include, Engage, Innovate was the theme of the 2019 APA Conference.

    I just returned from the American Psychiatric Association’s 2019 Conference in San Francisco.

    This is the 175th Anniversary of the APA, and look how far we’ve come. The theme this year was: Revitalize Psychiatry – Disrupt – Include – Engage – Innovate. and it certainly provided fodder toward those goals. It was an informative and eye-opening conference with a wide array of talks and poster presentations. Plus, I was privileged to make a presentation, too. More about mine in a bit.

    The attendance at this conference exceeded them all, with thousands of attendees from around the world and new research presentation abstracts which spread out over 800 pages!

    You may not be aware that the APA is the oldest medical organization in the nation. (We’re proud of that.) The venue was enormous and the camaraderie rich, inclusive, and restorative.

    The presentations flowed from every aspect of psychiatry, including geriatric issues as well as issues specifically relevant to children, and adolescents, too. There were talks from ADHD to dementia and addiction to psychosis.

    From Saturday through Wednesday the venue was chock-full of courses, convocations, lectures, symposia, talks, and media presentations by the hundreds. There were more than 360 new research presentations every day in the poster sessions which went up every morning and every afternoon.

    There’s no way I could ever provide a synopsis here of all the findings presented. But there were a couple I do want to mention.

    My own focus was on those presentations specifically related to suicide, depression and other mood disorder treatment, and especially ketamine treatment. I drank up all the information and data I could hold. (That and espresso kept me going.)

    Here we’ll talk about two of the presentations focused on ketamine and the one I presented on suicidal thinking.

    Ketamine’s Effect on OCD

    I was so pleased to see there has been more work focused on ketamine for obsessive-compulsive disorder (OCD). Clinical Psychiatry News featured this article with the title: “Ketamine may help OCD, but much work remains.”

    Young woman suicidal thoughts are gone since her ketamine treatment.

    The author, Carolyn Rodriguez, MD, pointed out that the symptoms of OCD are severe, and 1 in 7 people with OCD attempts suicide at some point in their lives. She said that there is a significant and painful delay between the time of diagnosis and the time when the patient experiences benefits from the medicine — 2-3 months or even longer.

    She talked about her interest in looking at therapies that worked much faster, and were more thorough. This is so important so that patients could feasibly experience more complete eradication of symptoms.

    Since more and more evidence indicates that glutamate seems to contribute to neuron communication as an excitatory chemical messenger, she chose to see what ketamine could do, considering it blocks the glutamate receptor.

    The only study using ketamine with OCD was conducted by Dr. Rodriguez and her team in 2013. Not surprisingly, she’s planning a new one now which will compare ketamine with midazolam, to study the effects of ketamine on the circuits associated with OCD. 

    She Called for More Studies On Ketamine’s Effects on OCD

    She says a larger study is needed to learn more about how long ketamine’s effects on OCD symptoms lasts. It’s also important to see if the effects seen in the 2013 study can be replicated.

    This is exciting work, as we need more information about what ketamine does for OCD so we can help more patients.

    Dr. Rodriguez commented on the FDA approval of esketamine this past March. She made the point that those OCD patients with “contamination OCD” are likely to be unwilling to use a nasal spray. 

    Disrupt – Include – Engage – Innovate …

    Ketamine and Opioid Receptors

    Another talk, presented by Nolan Williams, MD, from Stanford University, discussed ketamine’s mechanism of action. Since there’s wide recognition that stress is directly related to a buildup of glutamate outside the cells which causes unwanted effects, ketamine blocks the NMDA receptors, blocking glutamate, and reverses these unwanted results.

    Dr. Williams made the point that ketamine affects many neurotransmitter systems and has a wide variety of effects, both good and bad, as a result of that.

    Ketamine can eradicate chronic pain like this man on the bus suffers from.
    Researchers know that ketamine’s effect on pain is complex, and an opioid receptor antagonist prevents ketamine from relieving pain. We know that opioids have an antidepressant effect, and Dr. Williams wondered if ketamine’s antidepressant effect depended on the opioid system.

    There were 12 subjects in all who completed the study; 7 had dramatic relief of symptoms. Even more interesting, 6 of the 7 achieved remission. 

    Now, the design of the study included crossing over between 2 groups of subjects. So, to accomplish this, one half received a placebo an hour earlier, then ketamine. The other half received naltrexone an hour beforehand, then ketamine. As you may know, naltrexone blocks opioid receptors, so if ketamine relies on the opioid system, in part, then naltrexone should prevent ketamine from reducing depression symptoms.

    After the ketamine infusion, they allowed the subjects to become depressed again. They became deeply enough depressed to reach the 20% mark on their evaluation tool. Then they were given another infusion of ketamine. If they received placebo with the first infusion, this time they were given naltrexone. If they received naltrexone with the first infusion, this time they were given placebo.

    Opioid Receptor Antagonist Blocks Ketamine’s Effects

    Those who received naltrexone experienced no benefit from the ketamine infusion, whether they received it prior to the first ketamine infusion or the second one. 

    The same is true of suicidal thinking as measured on the tool. Those who received naltrexone experienced no reduction in suicidal thoughts.

    Interesting, right? But, keep in mind, this was a very small study, and much, much more work needs to be done looking at these issues. This is too preliminary, and these numbers are too small, to make sweeping generalizations. Certainly, closer to home, at Yale, patients treated with naltrexone have responded to IV ketamine. So much to learn!

    Disrupt – Include – Engage – Innovate…

    Ketamine Infusions Stop Suicidal Ideation in Outpatients and Avert ER Visits and Hospitalizations

    Finally, my own story. I had the opportunity to present my own data.

    I’m very interested in how IV ketamine can rapidly reverse suicidal thinking in patients with depression. Passionate about it, actually. Taking a long, hard look at my own experience with more 235 adults and adolescents with treatment resistant depression, I presented data which showed that serial, titrated ketamine infusions stopped suicidal thinking in the majority, and prevented ER visits and psychiatric hospitalization.

    We have dozens of case reports, small studies, beautifully written case series, and elegant placebo-controlled trials of ketamine treating depressive episodes — and very fine studies teasing out the effects of ketamine on suicidal thoughts in small numbers of patients.

    APA 2019 poster presentation: Disrupt. Include. Engage. Innovate.

    What’s been missing — for us all — are extensive results from real-world psychiatric treatment with ketamine in large numbers of patients like the ones we see every day–people who are complex, and have more than just one thing going on (like anxiety, OCD, trauma, and histories of substance misuse in addition to their depression or bipolar disorder). People who are medically ill, or in chronic pain. Those who have made numerous trips to the ER for suicidal ideation. So many who have been hospitalized, made suicide attempts, have been failed by ECT, or failed by TMS.

    People like you. Or like people you know.

    When I think about what ketamine can do best, and who it needs to work for first, it’s the patients I see — people like this: Depressed. Sick and tired of it. Sick and tired of treatment not working. With thoughts it would be a relief to not wake up, or with frank thoughts of suicide.

    There were No Suicide Deaths, Suicide Attempts, ER Visits or Hospitalizations in my High Risk Group Treated with IV Ketamine Infusions

    This is the first report from a real-world psychiatry office practice in the community using IV ketamine to treat suicidal thinking in hundreds of adult and adolescent patients with treatment resistant depression.

    The response from attendees to the data was enthusiastic. But we were even more excited with the breadth of new research presented during that same 2 hour poster session. Information that touched on ketamine, suicidality, and treatment resistant depression. It’s extraordinary to see so much energy and thought put into examining these connections. Here are some examples of the new research posters that surrounded me:

    This hand reaches desperately to survive to show how someone suicidal feels.
    • Effect of Ketamine and Esketamine in Suicidal Ideation: Relationship to Depression
    • Patient-Reported Outcomes in Major Depressive Disorder with Suicidal Ideation: A Real-World Data Analysis using Patientslikeme Platform
    • Care Setting Type and Readmission/Subsequent ED Visit Risk Among Patients with Major Depressive Disorder and Suicide Ideation or Suicide Attempt
    • Do the Impact of Risk Factors or Protective Factors for Suicidality
      Change in Response to Effective Treatment? A Case Study
    • Esketamine’s Antisuicidality Effects on Treatment-Resistant Depression: A Role for the Subcutaneous Route
    • The Relationship between the Big Five Personality Traits and the Suicide Crisis Syndrome in an Outpatient Population
    • Resilience Moderates the Relationship between Suicidal Narrative and Suicidal Behaviors
    • Effects of Ketamine and Esketamine on the Levels of Brain-Derived Neurotrophic Factor in Patients with Treatment Resistant Depression
    • Development of a Real-World Ketamine Database Registry: Centers of Psychiatric Excellent (COPE)
    • Managing Esketamine Treatment Frequency Toward Successful Outcomes: Analysis of Phase 3 Data
    • Esketamine’s Antisuicidality Effects on Treatment Resistant Depression: A Role for the Subcutaneous Route

    And the beat goes on.

    Disrupt – Include – Engage -Innovate !!

    So, in fact, we enjoyed a wealth of disruptive information shared through hundreds of studies, new technologies, and new paradigms. We engaged with the information and with each other, included diverse groups who attended and the patients they advocate for and treat. We’re moving forward to innovate in our mindset, our approach, our science, and our treatments.

    Because after all, it’s for you that we attend these conferences. No doctor practices in a vacuum, but our best and most healing practices are born from collaboration within the psychiatric and neuroscience community.

    Ketamine Treatment at Innovative Psychiatry

    So here at home, we focus our energies on you.  Do you have thoughts about suicide that treatment has not been able to stop? Do you suffer from symptoms of depression that recur or persist no matter what you do?

    If so, please call us.

    Young woman is happy with depression lifted by ketamine treatment.

    Let’s determine if you’re a candidate for IV ketamine treatment.

    While it isn’t the right treatment for everyone, (because nothing is) it is remarkably helpful to most. And we’re learning all the time more ways it can help more people.

    We live, study, collaborate, work, and share our findings to help you find the rewarding and fulfilling life you’ve longed for. Together, we can Disrupt -Include – Engage – Innovate …and help transform your life. Give yourself the opportunity to feel well and to enjoy the things in life that mean the most to you. We’re here to help.

    Ketamine KRIYA Conference 2018
  • The Oddities, Charm, and Suffering of Bipolar Disorder

    The Oddities, Charm, and Suffering of Bipolar Disorder

    Suffering of bipolar disorder can include indiscretions in dating and dancing.

    “Though I am often in the depth of misery, there is still calmness, pure harmony, and music inside me.”  —Vincent Van Gogh

    May is Mental Health Awareness Month, and I’ve been thinking about how to disrupt the stigma of “mental illness.” It’s a term I don’t like – but it’s still used throughout the world, unfortunately. To me, “mental illness” is an archaic and stigma-ridden phrase. Because it can isolate people who experience these illnesses in their own dark corner of misery, and surrounds their condition with mystery and skepticism. Yet cardiovascular, pulmonary, or liver disease are all discussed in the light of day and with credibility. There should be no difference. So, let’s talk about the ins and outs of one “brain” illness: the oddities, charm, and suffering of bipolar disorder.

    My patients encounter stigma every day. Family members and friends who are furious with them, and just worn out by it all. Critical. Disgusted. Steeped in stigma.

    And many of my patients are steeped in shame. It’s for them — and their families — that I’m writing today… and for you.

    So let’s talk about what a person can be like who endures the suffering of bipolar disorder. Because the symptoms of a disorder like this one can seem to be intertwined with the person’s personality … for better or for worse. 

    In fact, neuroscience researchers have discovered a genetic connection that influences the personality development of a person with bipolar disorder. We’ll be talking more about the scientific side of bipolar disorder in a future post.

    Emma was diagnosed with bipolar I when she was 15.  She’d stolen her parents’ credit card, and had charged $4700 in a weekend taking friends to nice restaurants, shopping for clothes, and attending concerts. She felt like a million bucks…and tried to spend a million, too.

    Her parents got alarmed, and she got admitted to a mental health crisis unit where she could be evaluated for 72 hours. It was here that she received her diagnosis of bipolar I disorder. The doctors there started medications to help stabilize her mood, and discharged her within a week.

    Shock and awe. Not enough time to see how the medications really worked, or to wade through her questions and fears about this new diagnosis. This wasn’t how it was supposed to go.

    She left confused, a bit shell-shocked, and with no small amount of anxiety as to what life would be like now. The shame she felt gripped her. How could she face anyone? She believed she’d never be able to show her face again anywhere… and the new pills she was taking made her feel weird.

    Bipolar disorder patients seek risky behavior, like this rave party.

    Emma’s next few years were tumultuous, as the medicines didn’t help her stabilize, but even seemed to make her more unstable. Add to that the hormonal changes of adolescence and their affect on symptoms, and the instability…better said, the roller coaster… of her emotions was almost impossible to endure.

    Everywhere she looked, she saw disapproval. Despite regular and frequent visits with her psychiatrist, she felt miserable and her symptoms seemed to get worse and worse.

    Emma and her parents participated in therapy, to become educated about this illness. They also learned how to support structure in her life, as well as methods of helping her decompress when the need arose. 

    Oddities, Charm, Suffering of Bipolar Disorder… So Many Facets

    But her ability to participate with them in counseling got sporadic as her symptoms worsened. During depression she couldn’t get out of bed, and anxiety made leaving the house seem insurmountable.

    But there were also transient periods when she felt a bit more like herself. Her sense of humor had always been spectacular, and often kept her family in stitches. Those light-hearted fun times reminded them of the history they shared, and endeared her to them all the more.

    But…her bedroom floor. Trashed! It was the place clothes and food wrappers went to die. And personal hygiene? …Let’s just say that was a work in progress. She didn’t bother to shower unless she was badgered. But she was feeling better, and creating magnificent, enchanting poetry, so no one wanted to argue with her about hygiene. They had all learned to choose their battles.

    Still, there were also the times when she came home drunk or high.  She told her parents she was sorry, but they feared for her…and wondered what to do.

    She craved the calm, a break from the suffering of bipolar disorder.

    The irony was that when her friends were high, they acted crazy. However, at the same time, when she was high it made her mind feel clear and grounded. She didn’t crave the substance, she craved the clarity. But her parents knew the dangers of addiction.

    She was an odd bird, and she knew it. She figured she’d always feel like the odd one out.

    But, for real, she had to give her parents credit. She could see they were really trying to understand. But it wasn’t a walk in the park.

    At times she felt anxious and angry, and couldn’t tell why. But her parents would react in ways that seemed to her more like an attack. So she responded in kind.

    So Complicated!!

     Through therapy they learned that “pulling rank” and trying to force her to comply only served to escalate her reactions and agitate her when she was manic. They learned to listen patiently when she verbally shot words like bullets in a long tirade. They learned this was a symptom.

    And they learned it was important to treat her with respect, in spite of her outbursts. After all, she wasn’t a spoiled child, she was ill. And… they learned that during times of peace, her talents, empathy, and growing wisdom had a richness they’d never seen in anyone before.

    They had to admit this was new territory, and they couldn’t fall back on their old parenting patterns without making matters worse.

    She was still their Emma, but there were times they didn’t recognize her. The counselor helped them see that all of these behaviors together were part of “their daughter with bipolar disorder.” Good times, bad times, times she amazed, and times she broke hearts.
    Happy young woman having fun in better times.

    Though Emma came home from the crisis center filled with shame, through counseling and the love and acceptance of her parents, along with time, she found she was slowly healing. She and her parents learned together that the mood swings – which were sometimes violent – were not a sign of her contempt for them, but rather a shift in her brain cell function that was involuntary.

    So her parents learned to show her they were standing with her when she found herself in mixed states, exploding with manic energy, rage, and heartbreak.

    Emma had made a friend at the crisis center, and was saddened for her and the awful scenes she described with her parents. Her friend felt so alone and hopeless because her parents viewed her behaviors as threats to their authority, rather than symptoms, and tried to shame her into compliance. Before long, her friend ran away from home.

    Emma knew she was really lucky to have parents who tried so hard to support her and stand with her in this illness.

    At times, she felt upbeat, pleasant, and enjoyed time with her parents, as well as a friend. In those same times, Emma often waxed poetic, writing pages of melodious rhyme, describing her magical wonder of the world as she saw it. Her words carried wisdom far beyond her years, and her creativity resulted in thoughtful and meaningful gifts for those she cared about.

    But as the wonder bubbled up…the bubbles came faster and faster until she felt as though she was all bubbles, like helium…and she was floating, exhilarated, and able to do anything.

    The Suffering of Bipolar Disorder Can Appear To Be Something Else

    People with bipolar disorder seek risky behaviors like climbing this water tower to paint graffiti on it.

    She’d climb a water tower and paint graffiti at the top, or she’d have sex with three different guys in the same night, or shoplift something from Macy’s.  Why?  Because she could do anything. (or at least she thought she could.)

    Was she rebellious? Not intentionally. But she was manic at those times, and her perceptions were distorted, as well as her judgment. And impulsive. Oh my…intensely impulsive. Could that be fixed by her parents’ discipline? Ummm…not likely. Impulsivity and distorted perceptions are symptoms of bipolar disorder.

    Unfortunately, there were times the police brought her home, or the store security officer called her parents, or… once…she found out she was pregnant.

    Sadly, she miscarried 6 weeks later. It was all so terribly painful. The grief so suffocating. She really wanted that baby. It didn’t matter that she struggled to care for just herself…she wanted that baby more than she wanted air.

    The grief continues to this day. On bad days, the pain of it rises up fresh and in waves. It’s almost more than she can bear. And the pain never lessens, or heals, but is always fresh and suffocating…because of the disorder in her brain. And the pain she feels when the waves return often push her into another mixed state episode.

    But eventually, with sleep, healthy meals, and medication, she begins to recover each time.

    Then, just about the time she feels a little stable, here come the bubbles again. And she forgets to go home by curfew because of the adventure she’s on. Then the crash… and eventually, the recovery.

    The Suffering of Bipolar Disorder Untreated Leads to Worsening Symptoms

    Sad woman with suicidal thoughts because of suffering of bipolar disorder.

    Years later…?  Emma was 22, and the periods of depression became too frightening. The pressure within her gave way to visions of her death. The pain, then the end. The determination to end the pain rose higher and stronger. The risk of an impulsive act that would remove her hope permanently led her parents to deeply research the options that might be available to help her. 

    They learned about IV ketamine treatment and how it can end suicidal thinking in a few hours. They discussed it with her psychiatrist and made arrangements to see a psychiatrist who offered this treatment and would consult with Emma’s doctor to coordinate her care. 

    All three of them made the trip together, planning to stay for a couple weeks and make it a sort of vacation. They hoped the break and new scenery would do her good. And they believed that saving their daughter was the best investment they could make.

    They’d read of people who had experienced help from bipolar depression with IV ketamine treatment, but their greatest concern was to help her continue to live. 

    They’d also read that people with bipolar disorder have an average life span of 25 years less than those who don’t have this illness. They could see the risk and felt they had to take measures to protect her.

    After the couple of infusions, she didn’t appear to be so deeply and dangerously depressed. Her mom mentioned the suicidal thoughts, asking if there was any change.

    Emma blinked. Oh yeah. As a matter of fact, she realized she hadn’t had any thoughts like that in 2 days. With all that was going on…she forgot that was why she was here. Her parents exchanged a hopeful glance.

    With another infusion, her mom noticed she was picking up after herself. And she got in the shower and shampooed her hair…then blew it dry!  Now this was a moment both parents noticed…but tried to not make an issue of it.

    By the end of the series of treatments,  Emma’s mom saw a light in her eyes that had been gone for months. And Emma suggested a shopping trip and lunch, which never happened when she was depressed.

    Once they arrived back home, Emma was upbeat, and disappeared into her room to organize it and clean. This was no small chore, mind you. She asked her dad to carry out the 3 huge trash bags of trash she picked up from the floor. He jumped at the chance.

    This young woman is happy since ketamine lifted her depression.
    Emma, herself, was surprised about her own motivation and initiative. And she found she enjoyed the sun filtering through the trees…the ducks paddling around the pond at the park, and the aroma of someone’s barbecue cooking outside.

    There was no question about it. She was feeling better. In fact, she felt better every week. She slept better at night, and had more energy for living during the day. A few weeks later, she realized she had a song playing in her head. So she hummed along. Her mom flashed a grin at her. It was so good to see her feeling so much better.

    Emma has had some rough days and weekends since her IV ketamine treatment. Times when she felt exhilarated and knew she might make a bad decision. But she’d learned to call her doctor, report the subtle symptoms, go in and do what she needed to do to avoid sliding into hypomania.

    Overall, her life improved dramatically after ketamine. Every month she sent a note to her ketamine doctor to let her know how she was doing. She missed fewer appointments with her local psychiatrist and her therapist. And somehow she seemed better able to manage herself now.

    While Emma still has challenges, her life is happier and easier to manage. She’s more productive and was able to go to college and actually do the work. What traditional medications couldn’t do for her, IV ketamine treatment could.

    At Innovative Psychiatry, we see patients who suffer from bipolar disorder often. Patients who experience significant improvement through IV ketamine treatment. If the suffering of bipolar disorder, especially bipolar depression, begins to return at some point, we’ll quickly arrange an appointment so you can receive a new infusion to refresh your well being. 

    If you suffer from bipolar disorder or another mood disorder, and you’ve not been helped by the medicines your doctor prescribes up till now, please call us.  We will schedule a consult to determine if you’re a candidate for IV ketamine treatment. And if you are, you can begin your treatments right away.

    Be the best version of yourself with ketamine treatment for the suffering of bipolar disorder.

    We’ll help you connect with the version of the best you that has become hidden, and help you feel and function better, so you can enjoy a rewarding and fulfilling life.

    We’re here to disrupt stigma.

    And innovate— not just with fresh new effective treatments like ketamine, but innovate with understanding. 

    We don’t just infuse ketamine—we infuse compassion, and we infuse hope.  We live for that.

    With respect and appreciation for the beauty of your best self,

    Lori Calabrese, MD offers innovative psychiatric treatment like IV Ketamine
    This image has an empty alt attribute; its file name is Angled-dark-blue-Lori-Calabrese-MD.png

    Lori Calabrese, MD

  • When You’re Touched by the Tragedy of Suicide

    When You’re Touched by the Tragedy of Suicide

    We celebrated Mother’s Day yesterday. What was it like for you?

    We truly hope you enjoyed a day of love and hugs as you celebrated with your children. But if you’re a mom who has lost a child, and especially if you’ve lost a child by suicide, this is a day that reminds you of that loss. And we wish you comfort…and hope… as you reflect. We offer these thoughts for solace, along with our warmest wishes.

    The death of someone you love is a terrible event. You’re left with a hole cut through your heart that never closes. Even if you expected the death, and you know that person lived a fulfilling life, you can’t predict how their absence will affect you, or how long it will be before you feel anything close to yourself again.

    After the sudden and unexpected loss of a loved one by the tragedy of suicide, the traumatic experience generates utterly unbearable loss, horror, confusion, shock, and stigma. A tragedy of this magnitude initiates a search for answers that survivors experience that will likely continue the rest of their lives.

    We go through our lives and we don’t remember everyone we’ve known, but we never forget a friend who took his own life. The shock and confusion of the death brands our memories. The questions we asked that couldn’t be answered and the reactions of others around us suffering the same trauma can linger forever.

    Multiply the fallout by a thousand if this person was your child, your spouse, or your parent.

    The BIGGEST Question

    It’s natural for everyone in the inner circle — and the outer one as well — to wonder if something happened that instigated the suicide. Was there a huge disappointment? A terrible argument? Was there something he couldn’t face?

    But underneath all those queries the BIG question lurks: WHY?  “She had everything to live for…” “He’d finally finished school…” “ She was so beautiful and had such a beautiful family…”

    Of course, these questions have no answers. Unless she left a note, or a phone message — and then it might not say why. It might be just a last minute thought for the recipient.

    And here’s an important truth. When someone commits suicide there may not be a clear reason. It could have been an impulsive, spur-of-the-moment act, when something overwhelming makes it seem impossible to go on. 

    Their craving for relief, for release, may have overwhelmed logic and reason.

    The tragedy of suicide can be suffocating, or can fuel your mission.
    Or… if your loved one suffered from from an underlying mood disorder, she may have been having compelling thoughts about death and suicide, about despair and futility, and images of the relief suicide would bring, as well as images that helped her plan this “release.”

    Her reasoning was not your reasoning. Hers may have come from circuitry in her brain that was malfunctioning. So your best intentions in helping her to see “all she has to live for” might have fallen on deaf ears. She may have been incapable of grasping your words.

    When you don’t suffer with suicidal thoughts, it’s hard to imagine what that person’s thinking processes are like. It’s hard to picture how their thoughts can be suffused with distortions that defy logic, and overwhelm consideration.

    You Probably Focus the Most on Your Lost Loved One, But Something Traumatic Is Also Happening To You

    The news of such a tragedy strikes us without warning. We have no time to prepare, to shore up for the devastation that’s sure to follow, like a Category-5 hurricane slamming into a coastal town.

    We instinctively want to tell someone, and we do… whether it’s our spouse, our parent, our best friend…even our child. And when we talk about it, we’re surprised that though there’s a small sense of comfort, the horror of the loss inflated by their absence and the permanence of it, are often far too suffocating to be eased by the sharing of a burden.

    And…it probably seems surreal. Some part of you expects her to walk through the door any minute. You find yourself secretly asking, “Do we really know it was her? Could there be a mistake?”  And you sift through the facts at hand, mentally trace her steps in your mind, to find any inconsistency that would reveal it isn’t really true.

    But eventually, you realize this loved one really is gone. And little by little, perhaps, you begin to notice you’re able to accept it in tiny bites at a time.

    Be Assured: KNOW You’re Not Alone When You Collide With the Tragedy of Suicide

    Like any traumatic event, the pain of this can be isolating. You can feel like no one knows what you’re the going through, and that no one notices your pain, or understands it.

    The tragedy of suicide leaves you heartbroken, so you need time to heal.

    At the same time, you may find you experience “triggers” — locations, tokens, sights, sounds that remind you of your loved one’s suicide. Or it may remind you of where you were when you heard about it.

    And the tragedy of suicide comes crashing down upon you again.

    Bottom line, this has been one of the most traumatic events of your life. Reminders of it can create their own version of PTSD. Trembling, suddenly bursting into tears, lashing out in anger, or hiding in a dark corner, can all happen with you when these reminders trigger the memories.

    Those moments may also cause you embarrassment. It can even make it hard to leave the house. You can feel so vulnerable to these reactions occurring out of nowhere. And you may fear it happening without warning. Just another fallout of this terrible loss.

    When you’re touched by the tragedy of suicide it can seem that you’re often swept away with waves of grief and disbelief.

    Grief is Hard on Your Relationship

    You and your partner or spouse may both be experiencing these symptoms of grief. The energy you each expend to navigate this terrible time reduces the energy you have for each other. What’s more, it’s natural to withdraw to some degree as you sort out these emotions, thoughts, fears, confusion, anger… loss, sadness, maybe even guilt… and the combination of it all can cause a certain distance between you.

    This is a time when you need each other the most. But, circumstances may make it terribly difficult to lean, share, or support.

    Again, be assured you’re not alone. Thousands upon thousands of others are experiencing the same things you are at this same moment. And there is support, kindness, and empathy nearby if you’ll allow yourself to seek it out.

    Take Healing Step by Step After You’re Touched by the Tragedy of Suicide

    LIke this girl, you must take care of yourself after a loved one commits suicide. Spend time in a peaceful setting, and let your heart heal.

    First, take care of yourself. There’s a wonderful book by Michael Myers, M.D. and Carla Fine, called Touched by Suicide — Hope and Healing After Loss. As you navigate your way through the days, weeks, months, and years, this book may be a great help in the process.

    Next, take care of your relationship. As soon as you’re able, listen to each other. Your emotions are probably ragged. But, trusting the most important relationship in your life can help you land on more secure footing as you get through your days. When you’re able to open your heart to your spouse, listen to your spouse’s heart, too. You can begin to knit together a greater intimacy than you’ve had before… from the fiber of this tragedy.

    Third, take care of your family and allow them to take care of you. This is the place where you can be nurtured, even while you nurture them. This is your safe place, and you need each other, and will continue to.

    And when you’re ready, look for others who who need the support only you can give, and give it freely. When you have the opportunity to generously give support out of the well of your own walk with the tragedy of suicide and the recovering process, you may find you can triumph in that tragedy. Your most terrible wound can become your strength.

    Intense Stress Can Lead to Depression, So Keep a Watchful Eye

    Sorrow comes in waves when you're touched by the tragedy of suicide.
    And do keep in mind, that the loss of a loved one is an extreme stressor. The fact that the loss you mourn was caused by suicide only makes it greater. 

    If you’ve been reading with us for at least a little while, you know that stress can cause depression. Watch your loved ones as the weeks and months go by, for signs of depression… and encourage them to watch you, too.

    Grief is normal, and sadness is part of grief. There’s no time table for determining an “appropriate length of time” to grieve the loss of your loved one by the tragedy of suicide. But if you find yourself stuck in a spot, and not moving forward, at some point you may want to consider treatment.

    If sadness gives way to despair and despondency, seek help.

    Our hearts are with you, and hope for your joy and resilience to return soon. Remember, while the hole left by your loved one will not really close, over time you’ll learn to live around it, to grieve when it’s time, and to rejoice in life when it’s not.

    And if you already suffer from a mood or anxiety disorder that’s not getting better, and have been plunged into grief and loss, it may be important for you to seek treatment now. Call us and let us help you restore the resilience that can help you navigate the sadness, and in your own time, recover and move forward.

    To the rejuvenation of your best self, 

    Lori Calabrese, MD offers innovative psychiatric treatment like IV Ketamine
    This image has an empty alt attribute; its file name is Angled-dark-blue-Lori-Calabrese-MD.png

    Lori Calabrese, M.D.

  • Relieving Treatment-Resistant Depression By Treating Metabolic Deficiencies

    Relieving Treatment-Resistant Depression By Treating Metabolic Deficiencies

    Originally published in Brain & Behavior Magazine, July 2017

    An important discovery has been made at the University of Pittsburgh. It raises the prospect that there may be an entirely new way of relieving major depression in people who repeatedly have failed to respond to existing treatments—people at elevated risk for suicide whose lives are often unrelentingly dark and full of anguish.

    There are 15 million Americans suffering from major depression, and 15 percent of these (that is, 2,250,000 people in the U.S. alone) do not respond to treatment.

    Last August, 2012 Young Investigator Grantee Lisa A. Pan, M.D., in collaboration with a team that includes 2001 Distinguished Investigator and 2006 Ruane Prizewinner David A. Brent, M.D., at the University of Pittsburgh, reported in the American Journal of Psychiatry that they had successfully tested—so far on a small scale—an approach to treating patients with longstanding, treatment-resistant depression.

    The team’s new approach is based on the theory that in at least some people, resistance to treatment in depression is caused by abnormalities in metabolism—abnormalities that can be corrected. “Metabolism” refers to the myriad processes inside our bodies in which chemical reactions generate all of the compounds that we rely upon to function as living beings.

    That covers a lot of ground. Drs. Pan, Brent and colleagues had something more specific in mind. A portion of our metabolism is involved in the manufacturing of the message-carrying chemicals called neurotransmitters that have long been implicated in many brain disorders, including depression.

    “Not enough serotonin in the brain.” That vitally important observation, made three decades ago in people with depression who were at elevated risk of suicide, helped spur the development of Prozac and other drugs of the same class, called SSRIs (selective serotonin reuptake inhibitors), for depression and other disorders, (notably anxiety, which often occurs along with depression). Prozac (fluoxetine) came on the market in 1987. It and other SSRI drugs have been prescribed tens of millions of times since then, for depressed people in the U.S. and around the world.

    SSRIs prevent serotonin from being soaked up by cells that make and release it. This allows it to remain longer in the tiny gaps between nerve cells, called synapses, and presumably enhances the ability of adjacent cells to communicate. This, in turn, is thought to reduce symptoms of depression, for reasons that even today are not clear. 

    SSRI drugs address the problem of what scientists call serotonin “re-uptake.” But what about the chain of chemical processes through which serotonin is created within cells? This involves metabolic processes. As Dr. Pan has pointed out, strategies that address “reuptake may not be effective if there is an inability to make serotonin.”

    She became acutely interested in the possible role of metabolism in depression after attempting over a period of years to help a young man with treatment-resistant major depression. Dr. Pan had been caring for adolescents and young adults at risk for suicide since 2002. In the lab, some of her research involved using brain imaging to look for markers of such risk.

    At the STAR Center (Services for Teens At Risk) at the University of Pittsburgh Medical Center’s Western Psychiatric Institute, Dr. Pan tried to solve the mystery of the young man’s persistent deep depression, which involved suicidal thinking and several suicide attempts and resisted all forms of treatment they tried.

    In 2011, in what she later called a “case of necessity,” Dr. Pan brought others in to consult. Facing the alternative of committing this young person to a psychiatric institution for longterm care, she engaged Jerry Vockley, M.D., Ph.D., chair of genetics at Pittsburgh, who had helped to train her years earlier. Another consultant was David Finegold, M.D., a professor of human genetics.

    The team conducted tests that ordinarily would not be given to people with depression. Among them was a detailed analysis of the cerebrospinal fluid, or CSF. It is a colorless fluid that circulates around the spinal cord and throughout the brain, and bears evidence of the many metabolites—the chemical reactants—engaged in the synthesis of the many proteins, including hormones and neurotransmitters,
    that help the cells in the brain function.

    Analysis of his CSF revealed the 19-year old had abnormally low levels of “intermediates”—chemical precursors—of tetrahydrobiopterin, or BH4. It has many roles, among them in the synthesis of neurotransmitters including dopamine, norepinephrine and serotonin. The doctors knew of a replacement for BH4 called sapropterin. After a few weeks of receiving it, the young man’s depression began to melt away. Rather than a psychiatric hospital, he went to college, graduating at age 24.

    His dramatic result encouraged Dr. Pan and colleagues to examine the CSF of five more adolescent patients in the same clinic, all suffering from treatment-resistant major depression. Three of the five had low CSF levels of 5-MTHF. This is a chemical breakdown product of folic acid, an essential metabolite throughout the body, including in the brain.

    During pregnancy, mothers must have sufficient dietary intake of folic acid to assure proper development of the fetus’s brain. Deficiency can result in neural tube defects and brain damage to the newborn. Folic acid supplementation, ideally begun before conception and continued through the perinatal period, especially in women with poor diets, is accepted practice worldwide.

    That is only one of many functions of folic acid, however. Deficiency of 5-MTHF in the brain—a condition called cerebral folate deficiency (CFD)—was seen in three of the five additional adolescents studied by Dr. Pan and colleagues. This, too, could be addressed, via treatment with folinic acid over a period of weeks. The patients improved.

    This provided the rationale for the more rigorous “case-control” study funded by Dr. Pan’s 2012 Young Investigator Grant and reported in the American Journal of Psychiatry in August 2016. Dr. Pan and colleagues recruited 33 young people with treatment-resistant depression and 16 healthy comparison subjects. The results were impressive and full of hope. First, none of the healthy participants had metabolite deficiencies in their CSF. In contrast, 21 of the 33 refractory depressed patients (63 percent) were found to have abnormal metabolite levels in the CSF, with 12 of the 21 (36 percent of the total group) suffering specifically from cerebral folate deficiency. Ten of these 12 made it through the treatment and a follow-up period. All 10 had reductions in depression symptoms, and four had remissions. A number of those treated also had significant reductions in suicidal thinking.

    “We’re looking at the end product of multiple complicated metabolic pathways and [in patients we studied] we’re finding something missing, and we’re working backwards to replace it,” Dr. Pan told the Pittsburgh Post-Gazette.

    In reporting their results, the team stressed that blood tests alone would not have identified the metabolic deficiencies that showed up in the CSF. It is not easy to obtain CSF—a lumbar (lower back) puncture with a needle is required, a procedure that is uncomfortable and involves more than nominal risk. Yet it was crucial to obtain the fluid, for in cerebral folate deficiency, folate levels in the blood are normal. The lack of folate is in the brain, where the chemical is involved in neurotransmitter synthesis. They hope to devise a blood test that will identify what the CSF tests reveal.

    In addition to its known role in brain development, folate in one of its several forms (L-methylfolate) has previously been used as adjunctive treatment to improve depression symptoms. L-methylfolate is involved in neurotransmitter metabolism. But, say Dr. Pan and her colleagues “this is different from our findings” in cerebrospinal fluid. In fact, L-methylfolate addresses a different part of the metabolic pathway involving folic acid, and may not help the patients with cerebral folate deficiency, the researchers say.

    At the same time, while folinic acid treatment “seems appealing,” they add, it may take several years to show its full effect due to the very slow turnover of neurons in the brain. They want to know more about the precise role of metabolite abnormalities in depression as well as in treatment resistance. They move forward on two fronts: expanding the size of their study to include more treatment-resistant patients, and trying to learn more about them by sequencing their full genomes. To date, only small portions of patient genomes have been sequenced. With the entire genomes in view, it is expected that new knowledge will be gleaned that can help to resolve the age-old mystery about depression’s root causes.

    by Peter Tarr, Ph.D.

  • Treating Mood Disorders: Is the Key Hidden in the CSF?

    Treating Mood Disorders: Is the Key Hidden in the CSF?

    No Wonder Treatment Resistance Has Been Such a Mystery! Clue: Look in the Cerebral Spinal Fluid!

    A man in his forties, Greg had never experienced life without depression. Treating mood disorders didn’t seem to be his psychiatrist’s forte. (Oh boy…) At least not in his case. Every accomplishment, every failure, struggled for expression beneath the darkness of that clinging lead blanket.

    People had always admired his quiet humility and unrelenting integrity.

    But they had no idea of the courage he required to face every single day. As a child, just to face each day of school…As a young man, to walk from his apartment to his car, and from his car into the building — to start another work day.

    Complex Disorders Make Things Worse

    Social anxiety filled him with self-doubt, self-consciousness, and dread. Agoraphobia made it incredibly difficult to walk out the door to face another day. To walk into a salon to get a haircut. Or to shop for groceries. 

    Family gatherings were impossible. He’d show up late, linger as long as he could bear, then quietly slip out to seek refuge in the safety of his car, and drive home to the quiet security of his apartment where his cat purred when she saw him.

    His family became accustomed to his disappearances. “Has anyone seen Greg?”

    “No..?” 

    “Well, I guess he went home…”  :::sighhhh:::

    His days filled with thoughts of ending his life, his nights with planning a suicide that would work.

    No one grasped the shame he felt that he couldn’t function like others he saw.

    Of course, he’d sought treatment. Prescriptions of Zoloft, Wellbutrin, and Lexapro tried his patience. Oh and then Effexor, Abilify… He hated taking the pills, but had had the highest hopes for relief that never came…

    Psychotherapy never seemed to make any difference. He’d seen a lot of therapists.

    In fact, it was worse than that. It was maddening… nothing that came up was new to him. It was boring and frustrating. And the effort required to go… to push through the dread and phobias to get there… just became too big a price to pay and he stopped going.

    He’d heard it said that there’s a difference between a good therapist and a great one. He hadn’t found a great one, apparently. Treating mood disorders came to seem like a cruel game to him.

    Decades of Complex Treatment Resistant Disorders

    In his twenties, he had beat all odds by starting and developing a consulting company. When he was in his thirties, with a long list of brilliant consultants on his payroll, and rivers of money streaming in, an episode of severe depression and crippling phobias threatened to bring his company to its knees. His mind shut down and he withdrew. It had been 15 years since he felt desperate enough to seek a psychiatrist’s care.

    So he tried once again.

    Once again, he took the latest antidepressant medicine…Cymbalta…for five miserable months. He tried to give it every chance. But his suicidal thoughts only increased. Depression, anxiety, and desperation made it nearly impossible to work, much less carry the load of generating new clients, advising his team, and keeping the payroll covered. 

    Then recently, he learned about IV ketamine for depression. He scoffed at the idea. As far as he was concerned, this was yet just another shiny new penny. Obviously, people clamored to get in on it. Articles that dismissed the validity of ketamine for depression drew him in. It was easier to find ammunition to protect himself from any more risk of disappointment …until something happened.

    His cousin had been severely depressed all her life, too. He’d heard that depression runs in families. But it happened that she went for IV ketamine treatment. It was a rocky process for her. Because of major stressors in her life, she had ups and downs. But eventually, she seemed to be better than he’d ever seen her.

    He was reluctant to ask questions. He didn’t want to be swept into the “ketamine frenzy.” He knew disappointment was a huge risk. But this was someone he knew well and trusted. And he wanted to know if he could get better.

    Ketamine Slashes Depression in More People When the Causes of Failure Are Explored

    She told him she didn’t experience it quite like others she’d heard about.

    Others who simply received six infusions and by the third were feeling great, caused her to have unrealistic expectations. She wanted a wow. But she had to just take it a step at a time.

    She didn’t improve until the 4th infusion, then felt better and better…almost great…until a terribly stressful bout in the hospital seemed to end the benefits she’d experienced with ketamine. The depression came back. So she’d go for another infusion… a “booster” she called it. And again she’d improve dramatically…

    Until another severe stressor, and she’d lose it again. This pattern had continued for a few infusions. She felt like she was on a see-saw.

    But finally, she began to improve every week. Still, she had a cloak of fatigue that colored her joy in shades of gray.

    She explored various supplements that might help, and found a “smart coffee” product that gave her the extra little spring and energy she needed, and just the right touch of mood enhancement, so she could enjoy her day. It bumped her just enough past the remarkable effects of ketamine, that she finally felt truly better. Soon after that, she realized she had achieved remission. She was bubbly. Her eyes sparkled. She sang spontaneously and laughed infectiously all the time.

    She could cope with difficulties like she hadn’t been able to before. Daily tasks became routine instead of insurmountable. Her hope for the future and what she could accomplish began to rise.

    Greg had watched her transformation. He knew how wonderful she felt now. Quietly, he secretly longed for the same.

    He scheduled a series of ketamine infusions with a local psychiatrist. After 6 infusions, he’d experienced a lifting of the depression and suicidal thoughts, but in less than a week those depressive symptoms — and the suicidal thoughts — began to creep back in.

    Then, he received another, with good then fleeting results, then another.

    His fear that he was so treatment resistant…and had been for so long…that he was beyond help…well, it engulfed him. It settled into his mind like stone and wouldn’t budge.

    He knew it. He decided he just couldn’t be helped.

    When Treating Mood Disorders Sometimes We Have to Fight and Not Let Go

    Then one day he read an article about neurometabolic abnormalities and how they can have such profound impact on the brain that depression can dominate mood.

    He remembered reading somewhere that treatment resistance in some cases can be overcome. One way is by treating underlying conditions like low testosterone, thyroid, and folate deficiencies. He’d dismissed it at the time, but now he asked his doctor to order these lab tests.

    The article he read focused on a study in the American Journal of Psychiatry.

    The study was initiated because of a particular young man who suffered with treatment refractory (same as treatment-resistant) depression for most of his life, as well as unrelenting suicidal thoughts and several suicide attempts.

    It was remarkable to Greg that the young man’s experience and symptoms were so parallel to his own.

    The authors of the study knew that treating mood disorders could be challenging, so they took their exploration of this man’s serum levels a step further. They performed a lumbar puncture to collect cerebral spinal fluid.

    They discovered his CSF (cerebral spinal fluid) levels were much lower than his serum levels. So even though it seemed that his serum levels of key hormones, nutrients, and metabolites were “normal” there were severe deficiencies in his brain.

    In particular, he had a severe deficiency of CSF tetrahydrobiopterin, a critical component you need to manufacture neurotransmitters like serotonin, dopamine, and norepinephrine in your body. After they treated him with sapropterin, a compound with a molecular structure very similar to tetrahydrobiopterin, their subject experienced a dramatic and long-lasting remission of his depression symptoms.

    Wow!

    Study Shows Surprising Results for Treatment Resistant Patients

    Because of this discovery, they conducted a study of 33 adolescents and young adults with treatment resistant depression who hadn’t responded to at least 3 trials of antidepressant medication, and 16 healthy control subjects for comparison. They created profiles of each of them using urine levels, serum levels, and CSF levels of a wide variety of metabolic compounds.

    They found that CSF metabolite levels were abnormal in 21 of those 33 subjects. The most common abnormality occurred in 12 of the 21 participants. In these, the serum levels were normal but the CSF level of 5-methyltetrahydrofolate (5-MTHF) was low.

    There was one patient in that group who had a low CSF level of 5-methyltetrahydrofolate (5-MTHF) as well as low CSF tetrahydrobiopterin.

    These patients were treated with folinic acid and the one who also had low CSF tetrahydrobiopterin was also treated with sapropterin. All of these patients showed improvement in depression symptoms as a result of treating these CSF deficiencies. 

    It’s important to note that the healthy control subjects had no CSF deficiencies.

    The conclusion the authors reached was that checking the CSF levels of metabolites produced a surprisingly large group of people who had normal serum levels but severe deficiencies in their CSF metabolites.

    So — they expect that examination of CSF metabolites can identify unexpectedly high percentages of treatment resistant patients who have treatable metabolic conditions. And treatment of those deficiencies just may resolve their depression symptoms.

    Until recent years, it wasn’t clear that treating mood disorders could be such a complex process, but that so many who have not been helped can be.

    Greg (whose name has been changed to protect his privacy) is currently undergoing treatment for his metabolic deficiency. We’ll talk about the results when he has completed treatment. Meanwhile, we applaud him for taking the emotional risk and making the effort to find solutions for his illness.

    Greg’s story is important to help us understand why we need to dig deeper and sometimes include specialists on our treatment team to find remission and resilience for our treatment resistant patients in every case that we can.

    The more we learn about all the factors that enter in to balanced wellbeing, the more avenues we can explore.

    In the past, psychiatry depended largely on observing a patient for signs of their illness, and listening to them describe how they felt. But as we advance further into the 21st century, we’re stockpiling more and more tools to help in the diagnosis and treatment of our patients.

    At Innovative Psychiatry, in treating mood disorders we encourage our patients to include specialists to explore their possible deficiencies and treat them. We work with the entire health team because often, it requires a team effort.

    After all, the goal of your recovery is our top priority.

    If anything about Greg’s story or this study sounds familiar to you, and if you’ve not found joy or resilience with other treatments, call us. We’re committed to provide the support you need to feel again, to enjoy life and relationships again. To live again.

    IV ketamine treatment combined with treatment of serum and CSF level deficiencies can restore your hope, your initiative, your motivation, and your creativity.

    Don’t sell yourself short. Let us help.

    To the bounding renewal of your very best self, 

    Lori Calabrese, MD offers innovative psychiatric treatment like IV Ketamine
    Lori Calabrese, M.D.
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