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Yes, Insurance May Cover Ketamine. Here’s Where To Start


Yes, Insurance May Cover Ketamine. Here's Where To Start

November 18, 2022

Ketamine-based therapies have proven to be a game-changing solution for many individuals struggling with mental health conditions, providing rapid relief after several other options have failed.

 

With any mental health intervention, it’s important for patients to determine whether it’s covered by insurance. This is especially so when it comes to ketamine and its newer cousin, SpravatoOut of pocket, Ketamine treatments can be expensive. For example, a round of six ketamine infusions can cost several thousand dollars at local clinics here in Austin, Texas, and online providers costs are similar with just a few months of treatment quickly adding up to thousands of dollars. Additionally, the effects of ketamine may not be robust or long-lasting when not supplemented with therapy or maintenance infusions. Studies have found the antidepressant effects of a single ketamine infusion last between four to seven days, while repeated infusions can extend this to several weeks.

 

Though through concurrent therapy, a much more sustained effect can be achieved, this is not widely offered – which is something we remedy with our team approach.

 

The truth is information about ketamine and insurance can be very confusing. For example, we looked at clinics in our nearby area of Austin. One clinic claims that ketamine is generally not covered by insurance, and many mention they do not accept insurance. As a result, while insurance can cover ketamine, those interested in receiving treatment will need to take special precautions to ensure they get the financial support they are entitled to through their plan.

 

Our team at Heading has worked hard to ensure we can provide coverage for the majority of our patients. 

How to Assess Whether Your Treatment Will Be Covered

While you won’t know for certain if any treatment will be covered before your insurance company receives a claim, you can gather strong evidence with the following steps.

#1 Ask Your Insurance Company if They Cover Ketamine-Based Treatments

Insurance coverage is determined on a case-by-case basis. Some companies don’t cover it at all. Before pursuing treatment or completing any other steps for assessing the likelihood that your treatment would be covered, call your insurance company and ask them if your policy covers ketamine for mental health conditions under any circumstances.

 

If the treatment is covered in specific scenarios, ask your insurance provider for specifics. For example, most insurance companies that cover ketamine require evidence of previous trials with other antidepressants (more on this below).

#2 Review Your Treatment History

Knowing your insurance company covers ketamine is a step in the right direction, but you’ll also need to know if they’ll cover your particular case.

 

Insurance companies generally want evidence that the treatment is 1) necessary and 2) likely to be effective enough to justify the cost of covering it. Demonstrating this often involves providing medical documentation proving you have tried several other interventions with unsatisfactory results. For example, when deciding whether to provide coverage for Spravato for a case of treatment-resistant depression (TRD), insurance companies most often want to know that you’ve tried two to three oral antidepressants (e.g., Prozac, Zoloft, Lexapro, etc.) and have not experienced a significant improvement.

 

The good news is that providing this information is simple if you know your history.

 

Your treatment history will be part of your evaluation with the prescribing physician at the clinic where you’ll be receiving your ketamine-based therapy. From there, they relay your treatment history and their recommendation to the insurance company, who will make a final determination.

#3 Check if Your Clinic Works with Insurance Companies

Despite the high cost and the need for repeat sessions of ketamine-based treatments, most clinics cannot secure coverage for their patients. Before settling on a treatment center, be sure to check if they work with insurance and ask how often they are able to secure coverage for patients. If you are considering at-home providers, do your research on insurance coverage and reach out to the company regarding finances prior to starting treatment.

#4 Determine Whether You’ll be Receiving Ketamine or Spravato (Esketamine)

If you’re looking around for ketamine-based treatments for your mental health condition, you’ve probably heard about ketamine and Spravato. Ketamine is a dissociative anesthetic whose antidepressant properties were first confirmed in 2000. Esketamine is structurally and therapeutically similar and is the active ingredient in Spravato.

 

Source: NeuroMend

Despite their commonalities, they are often treated very differently by insurance companies. Spravato is far more likely to be covered. The main reason is that Spravato is approved by the U.S. Food and Drug Administration (FDA) to treat TRD and major depressive disorder (MDD) with suicidal ideation.

 

Ketamine is not approved for any psychiatric conditions. This means that when ketamine is prescribed to treat a mental illness, it’s considered an “off-label” use. As Simon Tankel, CEO of Heading Health, notes, while insurance companies often cover off-label prescriptions for oral antidepressants, they are much more reluctant to do so in the case of ketamine because it’s significantly more expensive.

What to Do if Ketamine is Not Covered

Even if your ketamine treatments aren’t covered, you can take steps to make covering the cost of treatment more manageable. 

#1 Check if Your Clinic Offers Payment Plans

Though most clinics can’t secure insurance coverage for ketamine for their patients, many offer zero-interest payment plans that allow them to pay off the treatment in low-cost installments.

#2 Try to Get Reimbursed

Insurance companies that won’t cover the cost upfront might be willing to reimburse you after you have paid out-of-pocket.

 

When submitting a claim for reimbursement, it can be helpful to send your insurance company what is known as a “superbill.” This document contains several important pieces of information, including all of the services you received, along with relevant clinical data regarding your medical history. These superbills act as a “proof of service” and will help your insurance company decide whether they can offer you a partial or full reimbursement.

#3 Consider the Benefits of Psychotherapy and Ketamine Concurrently

Though not insurance specific, per se, it is important to consider how to foster longer-lasting effects and faster healing. Not only does faster healing improve your quality of life, it impacts your financial health too. Studies suggest that when psychotherapy and medication protocols align, it fortifies the benefits of ketamine treatment.

 

While psychotherapy is important regardless of whether insurance is covering your treatment, it’s absolutely essential when you’re paying the full price. Consider providers that can offer both or seek out a therapist or counselor familiar with ketamine treatment to ensure more optimal outcomes for your health and your wallet.

Is Ketamine Covered at Heading?

Yes. At Heading, we are proud to say that we are able to provide insurance coverage for both Spravato and Ketamine for the majority of our patients. Our team has worked closely with a wide array of insurance companies to highlight the advantages of ketamine-based therapies and demonstrate why it’s in their interest to cover them. Click here for a complete list of participating providers.  

 

Talk with your doctor to determine whether one of these treatments is right for you, or you can schedule an appointment with one of our psychiatrists or therapists to advise you on potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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Can Ketamine Treat PTSD?


Can Ketamine Treat PTSD?

November 3, 2022
health.hardvard.edu

Post-traumatic stress disorder (PTSD) is a debilitating psychiatric condition caused by exposure to a terrifying or traumatic event. Individuals with PTSD may experience flashbacks, nightmares, severe anxiety, and uncontrollable or intrusive thoughts about the event. About eight percent of the population will experience PTSD over the course of their life. This condition is significantly more common among combat veterans, with nearly a quarter developing it during their lifetimes.

 

The standard treatment involves some form of psychotherapy, oral anti-depressants, or some combination. Many psychotherapies (e.g., exposure therapy, cognitive behavioral therapy, cognitive processing therapy, etc.) require patients to confront aspects of the traumatic event or how they think about it. While these therapies can be effective, they can also be stressful, causing many to stop treatment early.

 

The FDA has approved two medications, sertraline, and paroxetine, for the treatment of PTSD. These medications have several drawbacks. They take four to six weeks to start working. They also come with many side effects that lead many to stop taking them. Even when patients stick with the medications, only around 30 percent achieve remission. While other medicines have been used, the evidence for their efficacy remains questionable. As a result, there is a desperate need for faster, more effective, and more tolerable treatments for PTSD.

Why Test Ketamine for PTSD?

Over the past few years, ketamine has been explored as a potential solution. Researchers have turned to this medication for several reasons. One reason has to do with how ketamine acts in the brain. Ketamine is an N-methyl-D-aspartate receptor (NMDA) receptor antagonist. This means that it increases the amount of glutamate (a chemical messenger in the brain) and brain-derived neurotrophic factor (BDNF), which helps neurons grow and form new connections.

Credit: Yang H. Ku/C&EN

Early animal studies indicate that glutamate and BDNF play important roles in PTSD. One study found low levels of glutamate in mice exhibiting PTSD-like behavior after exposure to stress. Other experiments have found that several brain regions associated with fear and mood regulation had shrunk in mice after similar stress tests, suggesting BDNF might help rebuild these atrophied areas.

 

Ketamine is also well-established as a rapid-acting antidepressant. Since depression is a prominent symptom of PTSD, it should help with this part of the condition.

The Studies

Initial Experiments

With all this in mind, researchers turned theory into practice and began testing ketamine as a treatment for PTSD in human participants. In a 2013 study, an army veteran who was given a single infusion of ketamine experienced rapid and robust relief of his PTSD symptoms that lasted 15 days. 

 

Following this finding, another group of researchers conducted a randomized controlled trial (RCT), meaning they gave one group ketamine and another a placebo. They found that PTSD levels were significantly lower in the ketamine group 24 hours after the infusion, and the effects persisted for around seven days.  

 

Experimenters, hoping to extend the amount of time before symptoms returned, tried giving subjects repeated infusions of ketamine. In one study, patients received six infusions over two weeks. Eighty percent of patients achieved remission for 41 days on average

 

Ketamine With Psychotherapy

While 41 days is a significant amount of time, more sustained relief would be ideal. Instead of using more ketamine treatments, some researchers have explored whether the effect could be extended when combined with psychotherapy. 

 

One of the commonly cited reasons for doing this is that PTSD is associated with deficits in what is known as  “memory reconsolidation,” which occurs when a recalled memory is changed or altered in some way. Normal memories decay or degrade over time. Some theorists believe that for patients with PTSD, their trauma memories remain as clear and vivid as the day they were formed. Many therapies target this process of reconsolidation. 

 

Ketamine is associated with neurogenesis. Recent studies have found that neurogenesis is important in reconsolidation. As a result, researchers have tested whether therapy might extend the effects of ketamine. One study which combined ketamine with prolonged exposure therapy found that after 90 days, the ketamine group had lower PTSD symptoms when compared to the group that received a placebo. 

Prevention Vs. Treatment

Aside from comparing ketamine with and without therapy, researchers have tested its effects on PTSD when administered at different stages in the PTSD process. A recent meta-analysis compiled all the research on combat veterans and found some surprising results. Most notably, they found that when given during the early stages of PTSD (1-3 months after the traumatic event), ketamine exacerbated their symptoms. However, when administered beyond this stage, ketamine was consistently helpful. Exactly why the timeline is so important is unclear. 

Conclusion

Ketamine appears to be a powerful treatment for PTSD. With that said, there are some caveats. When administered on its own, the effects are short-lasting. Repeated infusions can extend the benefits, but only to around 41 days. Psychotherapy may prolong the therapeutic results further, but more research will need to be done to confirm this. Lastly, the treatment may not work for all PTSD patients, especially those who experienced their trauma more recently.

 

 

If you feel you need to see a mental health professional or could use help deciding which service is right for you, please give us a call at 805-204-2502 or fill out an appointment request here. We have a wide variety of providers, including therapists, psychiatrists, nurse practitioners, and nutritional therapists who can see you in as little as one day via teletherapy.  

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Upcoming Events and Content in Honor of Veteran’s Days


Upcoming Events and Content in Honor of Veteran's Day

October 28, 2022

During the week of Veterans Day, Heading Health will be hosting events and publishing articles to honor our military veterans. We will be taking a close look at the mental health issues veterans face, highlighting providers who specialize in treating veterans and gathering insights from their experience, as well as discussing the therapeutic potential of psychedelics as treatments for service-induced mental health conditions.

 

Check out the details of these events and others in the Austin area below.

 

Heading Health Speaker Series: What Now? How Veterans Can Overcome Post-Deployment Hurdles to Happiness

Teressa Carter – LCSW

In the Heading Health Speaker Series events, we highlight perspectives from our team of mental health professionals to learn from their unique backgrounds, experiences, and viewpoints.

Femi Olukaya – LPC

 

In our Veteran’s Day edition, nutritional therapist Sally Twellman will interview Femi Olukaya, a therapist and military veteran, and Teressa Carter, a social worker with experience serving and treating active duty service members. They will explore the difficulties veterans face when integrating back into civilian and family life, the problems this can cause, and what we can do to soften the landing and ease their transitions back home. 

 

This event will be recorded and available to stream on YouTube. Stay tuned for more details.

 

Articles

Provider’s Perspective: Why Veterans Struggle to Seek Mental Health Care and What to Do About It

Despite the prevalence of mental health issues among veterans, many struggle to seek out help. In this article, Teressa Carter, will take a deep dive into this problem, offer suggestions for veterans and active military members unsure of whether or how to seek care, and provide advice for clinicians to help them perform patient outreach and build rapport with military clients. 

 

Ketamine for PTSD

Estimates suggest that 10-20 percent of veterans have post-traumatic stress disorder (PTSD), characterized by flashbacks, nightmares, and severe anxiety caused by exposure to a terrifying event. Recent research shows that ketamine may help veterans recover from this debilitating illness. This post will summarize the research, highlight key findings, and explore what this means for future treatments for PTSD.

 

Other Events in the Austin Area

The Rebirth: A Veterans Day Celebration Exploring Psychedelic Medicine

This three-part event will highlight the healing power of psychedelics for veterans. Specifically, it will include:

 

  1. A showing of the documentary film From Shock to Awe, which covers the lives of U.S. military combat veterans and highlights the transformational impact psychedelics have had on their mental health
  2. An expert panel which will discuss the importance of psychedelics and the urgent need to increase accessibility to these alternative treatments.
  3. A chance to hang out, listen to music, and catch up with friends at famed music club, Antonne’s

 

This event will take place on Friday, November 11, from 3:00 PM – 11:00 PM CST.

 

Get your tickets here.

 

 

The Mission Within: Psychedelics & Healing the Wounds of War

Founded by Dr. Martin Polanco, The Mission Within offers psychedelics such as ibogaine, 5-MeO-DMT, and psilocybin to treat veterans with traumatic brain injury (mTBI), PTSD, depression, and addiction as a result of experiences during military service.

 

In this panel, you’ll hear from veterans who participated in The Mission Within and how psychedelics helped them overcome service-related trauma and heal their relationships with loved ones.

 

This event will take place on November 3, from 6:45 PM – 8:30 PM CST.

 

RSVP here.

 

 

 

If you feel you need to see a mental health professional or could use help deciding which service is right for you, please give us a call at 805-204-2502 or fill out an appointment request here. We have a wide variety of providers, including therapists, psychiatrists, nurse practitioners, and nutritional therapists who can see you in as little as one day via teletherapy.  

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Treatment-Resistant Depression


Treatment-Resistant Depression

October 24, 2022

When treating depression, physicians often prescribe a first-line anti-depressant (e.g., Zoloft, Prozac, and Lexapro). While these treatments work for many, a significant portion find that their symptoms remain even after trying several antidepressants. Known as treatment-resistant depression (TRD), this condition affects around 30 percent of adults with major depressive disorder (MDD).

 

Despite its prevalence, many are unaware of treatment-resistant depression, how to determine if they might have it, or what to do about it. 

 

Explore answers to these questions and more below.

When is Depression Treatment Resistant?

Treatment-resistant depression is generally defined as a lack of response to a few adequate trials of antidepressants. However, this leaves several questions open, including:

 

  • What counts as a lack of response?
  • What is an adequate trial?
  • How many antidepressants must a patient have tried?

It’s important to note that there are no universal answers to these questions. Instead of settling them, try answering the following questions:

 

  • Have your treatments failed to make you feel good?
  • Do you still not feel like your old self?
  • Have the side effects been difficult to manage?

Answering yes to any of these questions means you’re not getting the help you need, and it’s time to talk to your physician, who can decide the next best course of action. 

Risk Factors for Treatment-Resistant Depression

Though researchers are still uncovering all traits that can increase the chances of having or developing TRD, we know several factors are associated with the condition. In particular, depression is more likely to be treatment-resistant:

 

  • If it began at an early age
  • The longer one has had depression
  • The more frequent or longer lasting one’s depressive episodes are
  • When there are ongoing stressors
  • If one has other physical or mental health conditions

What to Do About Treatment-Resistant Depression

Treatment-resistant depression is treatable. Below are steps you and your physician can take to alleviate your depressive symptoms that haven’t responded to the first few treatments.

 

  • Confirm your diagnosis: Depression that co-occurs with or is caused by other mental health conditions may require a different treatment protocol. As a result, your physician should confirm your diagnosis if your depression isn’t improving in response to treatment.

 

  • Add on talk therapy: Medications often work best when combined with some form of talk therapy. If you find your depression hasn’t responded adequately to your antidepressants, adding on therapy can give them a boost and help alleviate symptoms.  

 

  • Change your medications: Just because a few medicines haven’t worked doesn’t mean none will. Newer anti-depressants (e.g., Spravato and Auvelity) that act on different neurotransmitters than first-line treatments can provide relief even when the standard solutions haven’t worked.

 

  • Try a non-medication-based intervention: While oral antidepressants are the most common medical treatment for depression, other options exist. For example, transcranial magnetic stimulation (TMS) is a non-invasive procedure where magnetic pulses are used to modulate activity in parts of the brain associated with mood regulation and is FDA approved for treatment-resistant depression.

How We Treat TRD at Heading Health

At Heading, we offer a comprehensive set of solutions to tackle TRD from every angle and provide rapid and sustained relief. We work hard to ensure that cost is not a barrier to accessing the interventions you need. We work with most insurance plans, from United Healthcare to Medicare to Blue Cross Blue Shield, and can provide coverage for all of our services, including ketamine, Spravato, and TMS, for most patients with TRD. Click here for a complete list of participating providers and to schedule a consultation to see whether our solutions are right for you. 

 

 

 

If you need to see a mental health professional or could use help deciding which service is right for you, please call us at 805-204-2502 or fill out an appointment request here. We have a wide variety of providers, including therapists, psychiatrists, nurse practitioners, and nutritional therapists, who can see you in as little as one day via teletherapy.  

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Is Ketamine a Psychedelic? Does it Matter?


Is Ketamine a Psychedelic? Does it Matter?

October 21, 2022

Over the past few years, psychedelics such as LSD and psilocybin mushrooms have garnered much attention as researchers explore their potential use in treating mental health conditions.   

 

Ketamine and its close cousin Spravato (esketamine) are often included in this motley crew of psychedelics due in part to their “mind-altering” effects.  

 

Though many are eager to label ketamine a psychedelic, others are less certain, feeling it would be most appropriate to avoid associating ketamine with psychedelics.  Let’s explore these different viewpoints to get a clearer sense of whether ketamine is genuinely a psychedelic and why the label matters, if it does at all.  

What is a Psychedelic? 

One obvious way of determining whether ketamine is a psychedelic is by comparing its features to those listed in its definition. Unfortunately, there are no agreed-upon criteria for what makes something a psychedelic drug. Experts waver on the importance of three conditions.

#1: Psychedelics Cause Altered States of Consciousness

Though there is much disagreement about what counts as a psychedelic, it’s generally accepted that they must induce specific mind-altering effects. Some argue this is all that is required. In other words, they claim that as long as the substance causes a “psychedelic experience,” then it’s a psychedelic.  

 

But what are psychedelic experiences? While the list is potentially endless, psychedelic experiences are generally thought to impact one’s perception of themselves and the world around them, alter the way they think and reason, and provide insights into how their mind works and the nature of reality. They include experiences like the sense of being at one with the world, distortions of space and time, profound inner peace, ego dissolution, and many more.  

#2: Their Conscious Effects Must Have Therapeutic Benefits

While many agree that psychedelics must cause certain altered states of consciousness, some argue that this isn’t enough. They claim that these changes in thought and perception must have a therapeutic effect on the mind or promote psychological growth. As Dr. Yehuda, director of the Center for Psychedelic Psychotherapy and Trauma Research at Mount Sinai Hospital in New York, notes when discussing ketamine’s status as a psychedelic:

 

The unanswered question in all of this is whether the transpersonal state is what heals you or whether it’s something about the molecule. […] The dissociation or psychoactive effects of ketamine might be incidental. They occur. But that’s not necessarily why the healing is happening.

 

For these experts, if ketamine’s mind-altering effects have nothing to do with its mental health benefits, then it’s not a psychedelic. 

#3: Psychedelics Must Act on Specific Areas in the Brain

In the world of psychedelics, some have been around for longer than others and are more well-studied. For example, mescaline and psilocybin mushrooms have been used since ancient times and were researched heavily in the 1950s and ‘60s. These compounds all appear to affect serotonin (a chemical messenger in the brain) at the “2A” receptor. 

 

Some researchers feel these “classical psychedelics” are the only true ones, and that what really matters when deciding whether to categorize a new agent as a psychedelic is how it works in the brain. As Dr. Yehuda notes:

 

When we talk about chemistry and drug development, we should mostly be defining a psychedelic drug on the basis of the chemistry of the molecule, its pharmacokinetics, and its mechanism of action. 

Does Ketamine Meet These Conditions?

How does ketamine stack up against these criteria? As far as its effects on the brain go, ketamine does not act as the classical psychedelics do. It works on N-methyl-D-aspartate (NMDA) receptors, causing an increase of glutamate and brain-derived neurotrophic factor (BDNF) instead of serotonin.  Under this condition, then, ketamine is not a psychedelic. 

Credit: Yang H. Ku/C&EN

 

However, acting on a specific set of serotonin receptors is not the only way to produce psychedelic experiences. As Dr. Steve Levine, co-founder of Heading Health states:

 

It does appear that subjective psychedelic effects may be induced by a number of stimuli or conditions that also include sensory deprivation, virtual reality, meditation, and suggestibility, among others, and not necessarily mediated through a particular brain receptor.

 

Importantly, many of these psychedelic experiences can be produced by ketamine. It is most commonly associated with dissociative experiences (i.e., the sense that one is separate from their thoughts and body). It can also cause distortions in one’s perception of space and time. Patients have also reported gaining new perspectives and an enhanced ability to make sense of their thoughts. Rarely, ketamine can cause delusions and delirium, otherwise known as psychotomimetic effects. In many ways, then, ketamine seems to have the right sorts of effects on the mind to be considered a psychedelic. 

 

However, it’s worth highlighting that the experiences won’t be identical to “classical psychedelics.” For example, psilocybin appears more likely to cause what’s known as ego dissolution, where one loses their subjective sense of self. Classical psychedelics may also have a greater tendency to induce visual distortions. In general, because they have different effects on the brain, their conscious effects will differ. As Dr. Arif Noorbaksh, Psychiatrist at Heading, states:

 

Ketamine is distinct because it works on a completely different neurotransmitter system (glutamate), exerts an effect in different areas of the brain, and as a result, the perceived effects are different.  They both result in non-ordinary states of consciousness, but the experience a particular person has when exposed to conventional psychedelics versus ketamine will be different.

 

When it comes to the therapeutic effects of the altered states of mind that ketamine puts subjects in, the evidence is mixed. A 2020 review concluded that overall, the evidence does not suggest that ketamine’s dissociative effects are responsible for its antidepressant properties. Others argue that ketamine’s ability to cause a shift in perspective and increase cognitive flexibility and open-mindedness are directly responsible for its therapeutic effects. For example, Celia Morgan, professor of psychopharmacology at the University of Exeter, found in a recent experiment that individuals who underwent ketamine and talk therapy experienced longer-lasting antidepressant effects. Professor Morgan notes that talk therapy “requires that individuals think differently about things and learn new ways of thinking about old problems.” As a result, ketamine’s ability to induce shifts in perspective and open-mindedness may explain why it appears to enhance the effects of therapy alone. 


Where does this leave us? According to some criteria, ketamine seems to be a psychedelic, while on others, it does not. The answer as to whether ketamine is a psychedelic, then, depends on who you ask and which criteria they feel are most essential.

Does it Matter What We Call It?

Some might think this is all just semantics and that there’s no real principle we can use to determine what to call ketamine. 

 

While the dispute may be verbal, how we talk about ketamine matters. As Dr. Noorbaksh notes:

 

I think it matters insofar as the term “psychedelic” comes with preconceived notions for many people, and it also places the emphasis on the acute effects of the agent rather than the potentially longer-term effects these agents can have on neuroplasticity, relation to self and others, and other important contributors to mental health.

 

As a result, it’s important to be mindful of the language we use to describe and categorize ketamine and to avoid clinging to one label or another without regard for how this impacts patients. As Dr. Levine suggests:

 

Ultimately, whether a molecule is “truly” a psychedelic is likely beside the point. […] Let’s not let feeling precious about terminology distract from the real goal, which is improving well-being in a safe and responsible way.  

 

 

 

Talk with your doctor to determine whether this treatment is right for you, or you can schedule an appointment with someone from our team of psychiatrists or therapists to advise you on this or any other potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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Ketamine Vs. Esketamine (Spravato) – What’s the Difference?


Ketamine Vs. Esketamine (Spravato) - What’s the Difference?

October 18, 2022
Source: NeuroMend

In 2019, 19 years after researchers first demonstrated ketamine’s therapeutic effects on depression, the Food and Drug Administration (FDA) approved Janssen Pharmaceuticals’ esketamine nasal spray (Spravato) for treatment-resistant depression. In 2020, it was also approved by the FDA for major depressive disorder (MDD) with co-occurring suicidal ideation. With similar names, ingredients, and research-backed mental health benefits, many are likely to wonder whether there are any important differences between the two and if there are any reasons for preferring one over the other. 

 

Let’s explore how they compare. 

What are They Made Of? 

Ketamine, or more specifically racemic ketamine, is made up of two enantiomers (i.e. pairs of molecules that are mirror images of each other), known as r- and s- ketamine (arketamine and esketamine). Esketamine contains only the S enantiomer.

How Do They Work?

Both ketamine and esketamine are thought to work by blocking N-methyl-D-aspartate (NMDA) receptors, which causes a release of glutamate (a chemical messenger in the brain) and, ultimately, brain-derived neurotrophic factor (BDNF), which helps neurons regrow and form new connections. 

 

Though they share this mechanism of action, esketamine has a four-fold higher affinity for the NMDA receptor, which means it is more potent. 

Which is More Effective?

For some drugs, one enantiomer is more “effective” than the other, which raises the question, are ketamine and esketamine equally beneficial?

In the past few years, several randomized controlled trials have directly compared the antidepressant effects of ketamine and esketamine. However, synthesizing their findings can be difficult as the studies utilize different methods of administration, treatment durations, depression-related outcomes, and more. 

 

Despite these obstacles, a team of researchers set out to comb through the data. They analyzed 36 randomized controlled trials comparing the efficacy of ketamine and esketamine on depression in a 2022 meta-analysis. They found that while the racemic mixture was more effective overall, the evidence suggests this is not the case when the same method of administration is used alongside doses that account for differences in potency. For example, one study found that when administered intravenously and in equally potent doses, both formulations had similar remission rates after 24 hours. 

Do They Feel the Same?

Both ketamine and esketamine are psychoactive substances, meaning they can alter one’s normal state of consciousness, affecting one’s thoughts, feelings, and perceptions. For example, ketamine is known for causing feelings of relaxation, dissociation, alterations in the perception of space and time, and more. A natural question, then, is whether the esketamine experience differs from the ketamine one. 

 

Answering this question exhaustively and definitively is challenging for several reasons. To start, ketamine and esketamine can cause a wide range of experiences, so much research needs to be done to demonstrate how likely each drug is to produce each one. Second, because esketamine is more potent, it’s not always clear that researchers have used equivalent doses. 

 

By and large, the experiences appear to be pretty similar. With that said, a few interesting preliminary findings reveal how they might differ. For example, some studies have found that ketamine is more likely to cause feelings of dissociation (i.e, a feeling of being disconnected or separate from one’s thoughts and body). 

 

Another important result has to do with how pleasurable the experiences are. Some studies indicate that the combination of ar- and esketamine is less likely to produce unpleasant reactions like stress and anxiety. For example, one researcher found that:

 

The (R)-enantiomer was able to balance the (S)-enantiomer’s adverse parts of the altered state of consciousness and promote positive psychedelic experiences so that a more coherent state of consciousness is experienced. 

 

It’s important to note that much future research will need to confirm these results and compare the drugs across all their potential subjective effects. It’s also worth pointing out that the therapeutic significance of ketamine and esketamine’s psychoactive effects is currently unclear, so any differences in how they feel may not impact how well they work.

What is the Treatment Like?

Treatments differ by how the drug is administered, the number of sessions needed, and appointment length. 

Esketamine is only available as a nasal spray called Spravato. For this treatment, patients visit their physician’s office twice a week for the first four weeks, once a week for the next four weeks, and then bi-weekly if needed for maintenance. Each appointment lasts two and a half hours.

 

Ketamine is available in several different forms, each with a slightly different protocol. At Heading, we offer intramuscular ketamine. This treatment takes place over three weeks, with three sessions in the first week, two in the second, and one in the third. Patients may continue to receive additional treatments for maintenance if needed. Each appointment lasts around an hour and a half. 

Does Insurance Cover Them?

Several insurance companies cover Spravato for treatment-resistant depression and MDD with suicidal ideation. While ketamine can be more difficult to find coverage for, our team has worked closely with insurance companies to ensure we can secure coverage for most patients.  Click here for a complete list of participating providers.

 

Talk with your doctor to determine whether one of these treatments is right for you, or you can schedule an appointment with one of our team of psychiatrists or therapists to advise you on potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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Interview with an Expert: Should Ketamine Be Combined with Psychotherapy?


Interview with an Expert: Should Ketamine Be Combined with Psychotherapy?

October 7, 2022

With evidence mounting in support of ketamine’s therapeutic effect on depression and other mental health conditions, clinics and physicians are increasingly prescribing it as a standalone solution. While ketamine has clear benefits on its own, experts are beginning to explore the role psychotherapy plays in enhancing or extending its effects.

 

In a recent edition of The Peter Attia Drive, Professor of Psychopharmacology and leading ketamine scholar Celia Morgan addresses this topic, among several others related to ketamine’s use in treating depression and other mental health conditions. 

 

Her take? Psychotherapy is critical to obtaining a lasting effect from ketamine. Here’s why.

 

Ketamine Increases Neural Plasticity

One of the key reasons Professor Morgan believes ketamine is most effective when combined with psychotherapy is its mechanism of action (i.e., how it changes the brain to produce its therapeutic effects).

 

When ketamine enters the brain, it attaches to N-methyl-D-aspartate (NMDA) receptors, causing a release of glutamate (a chemical messenger in the brain) and brain-derived neurotrophic factor (BDNF). The result is that neurons (tiny cells in the brain that send and receive information from each other) have an increased ability to grow, reorganize, and rewire themselves in response to new experiences, a phenomenon known as neural plasticity.

 

Among other things, neural plasticity enables us to learn and acquire new habits, including our cognitive and emotional tendencies. Professor Morgan argues that because many psychological therapies target these mental habits, they may be more effective when used after ketamine treatments. She states:

 

We know that what we’re asking people to do in psychological therapy is to think differently about things and learn new ways of thinking about old problems. [Neural plasticity] seems to me like an intuitively appealing mechanism.

 

Professor Morgan goes on to suggest that not only might therapy be beneficial but that its precise timing after a ketamine treatment may be especially critical, stating:

 

I think the idea you know for me as a psychologist is that you could time your psychological therapy when your brain is most plastic. […] We know from animal studies this might be starting four hours following the ketamine days peaking about 24 hours.

 

Ultimately, more research needs to be done to determine when ketamine causes the greatest increase in neural plasticity in humans. Professor Morgan notes that:

 

We want to be doing some work at the moment to sort of chart the time course of that in humans by looking at EEGs […] and trying to target the window of this synaptic plasticity

 

Experimental Participants Receiving Therapy Maintain Therapeutic Benefits for Longer

Ketamine’s impact on neural plasticity suggests that ketamine should enhance the effects of psychotherapy in theory, but how does this pan out in practice?

 

In a recent study on the effectiveness of ketamine in the treatment of alcohol use disorder, Professor Morgan compared the effects of ketamine used on its own and when combined with psychotherapy. They found the greatest reductions in drinking and abstinence in the group that received ketamine alongside psychological therapy. 

 

What’s particularly shocking is that 86 percent of the ketamine therapy subjects remained abstinent for six months after three ketamine infusions. Given the small number of treatments, the six-month benefit patients experienced further suggests therapy had a positive impact. As professor Morgan highlights, studies show the antidepressant effects of a single IV ketamine infusion typically last from three days to a week, though repeated administrations can extend this effect.

 

Conclusion

While more research is needed to confirm and clarify therapy’s role in enhancing and extending the effects of ketamine on depression and other mental health conditions, these early results suggest the two therapeutic solutions work synergistically to deliver an optimal outcome.

 

Talk with your doctor to determine whether this treatment is right for you or schedule an appointment with one of our psychiatrists or therapists to advise you on this or any other potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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What Does Spravato Feel Like? A Patient’s Perspective 


What's Does Spravato Feel Like? A Patient's Perspective

October 3, 2022

This post was written by a member of our content team who is currently receiving treatment using Spravato in Michigan. In the interest of transparency, he is not a patient of Heading. However, his treatment program and the experiences detailed in this post are very similar to those of patients at Heading.

 

I have suffered from anxiety and depression for most of my life. Treatment began at age 12 when I was diagnosed with generalized anxiety and obsessive-compulsive disorder (OCD). While the initial treatments helped to some degree, many symptoms remained, and the side effects of the drugs I took became intolerable. 

 

Over the next 17 years, I switched from one oral antidepressant to the next, desperately trying to find something that addressed my symptoms without causing side effects that were worse than what I was trying to treat. Eventually, my psychiatrist recommended a drug called Spravato (esketamine nasal spray), a rapid-acting drug used for treatment-resistant depression. He told me that Spravato works differently than traditional antidepressants by increasing levels of glutamate and brain-derived neurotrophic factor (BDNF). These two changes have been associated with improvements in depression and anxiety. Knowing this, I felt hopeful that I might get the benefits I was looking for without the drawbacks I was trying to avoid.

 

Though I was excited about trying out the new intervention, I grew increasingly anxious as I awaited my first treatment session. Both esketamine (the active ingredient in Spravato) and its more famous cousin, ketamine, are psychoactive, meaning they can alter one’s normal state of consciousness, affecting one’s thoughts, feelings, and perceptions. 

 

Before trying Spravato, I had very little experience with psychoactive drugs and none with anything that might be considered a psychedelic. As a result, I had no idea what to expect. To make matters worse, I felt that I wouldn’t react well to the experiences that Spravato might bring about because I suffered from severe anxiety. I went into my appointment blind to what I was about to experience. Though my fears were unwarranted, I would have benefited greatly from a clear and honest description of what was to come.  

 

My Experience with Spravato

Below I describe to the best of my ability what I typically feel during a Spravato treatment session. Though some of these experiences may generalize, it’s important to remember that everyone’s brain is unique and may react differently to Spravato.

 

Dissociation

One of the more talked about effects of Spravato is its ability to cause dissociation. Though it is described differently by different people, the effect is generally characterized as a temporary feeling of disconnection from one’s thoughts and feelings.

 

I like to describe my personal experiences with dissociation as akin to the sensation one gets when looking at their avatar through a virtual reality headset. Everything is in the location it’s supposed to be and moves when it should, but you don’t identify with your avatar. Its movements don’t feel like your movements. Its body doesn’t feel like your body.

 

The feeling of separation from my thoughts is harder to describe. The best I can say is that it feels like I am “viewing” my thoughts rather than “thinking” them. They simply pass by, unauthored by me.

 

Feeling of Relaxation

Despite having unusual sensations like the feeling of dissociation, I often experience a wave of relaxation as my concerns and worries drift away. My thoughts quiet down, and former troubles begin to feel like they don’t matter as much.

 

Feelings of Stress and Anxiety

Though Spravato can be pleasurable, it can also be unpleasant and stressful. I believe this is at least partially the result of the following two factors.

 

First, while under the effects of Spravato, my mind tends to focus on unpleasant thoughts at the core of many of my worries (more on this below). Though these thoughts are easier to entertain at the time, they can still be challenging to confront.

 

Second, aside from its psychological or psychoactive effects, Spravato causes physical sensations that tend to be more unpleasant. For example, I often get dizzy and feel like I am slowly spinning in my chair. As a result, I feel nauseous. When these sensations become too intense, the overall experience can become quite stressful. Fortunately, my doctor prescribed an antiemetic (i.e., an anti-nausea drug), so these sensations have become less frequent and more tolerable.

 

Increased Empathy

The state that Spravato puts me in makes it easier for me to put myself in other peoples’ shoes. Often, I will spend time thinking about past arguments or disagreements. While doing so, I have an easier time understanding where the other person was coming from and why their reactions and feelings were appropriate. More generally, I tend to have a stronger concern for the well-being of others.  

 

Enhanced Ability to Confront Unpleasant Thoughts

Through my Spravato experiences, I have realized that at the heart of many of my daily fears are more general worries that I have trouble recognizing or confronting. While under the effects of Spravato, my attention is almost unavoidably directed toward these fundamental concerns

 

Here’s a personal example to shed light on how this works. Among the many things I worry about, work is often at the top of the list. I worry while working on assignments, submitting them, waiting for feedback, etc. Though I had spent so much energy feeling anxious about this, I never looked at the underlying concern or belief that connected all these more specific worries. During one Spravato treatment, I realized that I had deep concerns about my intellectual abilities and that I viewed each work assignment as a potential instance where my real lack of capability would be revealed.

 

Though the fear remains, knowing it exists and is responsible for so many other specific worries has made it easier to deal with.

  

Visual Distortions

Around 10 minutes into each treatment, I start to notice some visual effects. First, my vision becomes fuzzy, and I have trouble refocusing each time I move my eyes. Over the next few minutes, this effect increases in intensity until everything looks as though it is shaking for a few seconds after I shift from looking at one spot to another.

 

Aside from becoming fuzzier and shakier, my vision tends to change in a different way. Specifically, objects appear to be slowly expanding and contracting as if they are breathing. Often, I’ll try to match my breath to the rate at which the things are “breathing.” It’s pretty relaxing.

 

When I close my eyes, I notice a further visual effect. As I keep them shut, I see faint geometric patterns. This is especially noticeable when my eyes are almost but not completely closed, which happens to me somewhat frequently when dozing off under Spravato. My guess is that my brain is doing its best to interpret the unusual visual stimuli it is getting, and the result is that I have some minor closed-eye visuals.

 

Post-Treatment Effects

Though many of the effects subside by the end of the two-hour treatment, some remain for several hours. I tend to feel tired, off-balance, and a bit groggy. These effects slowly dissipate as the day goes on but do not linger into the next day.

 

Concluding Thoughts

From enhanced empathy to feelings of dissociation, Spravato experiences can feel intense or overwhelming when you don’t know what to expect. After I learned first-hand what the experience feels like, my Spravato sessions became much more relaxing and pleasant. Hopefully, my descriptions will help other anxious patients get there more quickly.

 

Stay tuned for part two of this blog, where I describe the long-term effects of Spravato on my depression and anxiety.

 

If you feel you need to see a mental health professional or could use help deciding which service is right for you, please give us a call at 805-204-2502 or fill out an appointment request here. We have a wide variety of providers, including therapists, psychiatrists, nurse practitioners, and nutritional therapists who can see you in as little as one day via teletherapy.  

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Study Finds Ketamine Provides Rapid Relief from Severe Suicidal Ideation​


Study Finds Ketamine Provides Rapid Relief from Severe Suicidal Ideation

September 20, 2022

Each year, around 800,000 people die from suicide, and nearly 20 times that number attempt it. 

 

Though the causes of suicide and suicide attempts are varied, it is often preceded by suicidal ideation (i.e., contemplations, wishes, and preoccupations with death and suicide). As a result, researchers have increasingly been searching for compounds that treat these thoughts and feelings. 

 

Ketamine has stood out as a promising candidate, with several studies indicating that it is highly effective against suicidal ideation. While these results are encouraging, they generally have not focused on patients experiencing more severe suicidal ideation (SI) or in the middle of a suicidal crisis. Additionally, as far as outcomes go, many studies have measured the number of “treatment responders” (i.e., individuals who experience at least a 50 percent reduction in symptom severity) as opposed to the amount who experience remission (i.e., a complete absence of suicidal ideas).  

 

To fill in these gaps, a team of researchers led by Dr. Mocrane Abbar conducted a double-blind placebo study to assess the effects of ketamine on cases of severe SI. Due to its double-blind placebo-controlled structure, half of the subjects were given an inactive ingredient not known to improve SI. Additionally, neither the subjects nor the experimenters knew whether ketamine or the placebo was given. 

Key Findings

Below are some of the key findings from this study.

 

 

The Majority of Patients Achieved Full Remission

Sixty-three percent of the severely depressed subjects achieved complete remission of their suicidal ideation after just three days and two ketamine infusions.

 

It Worked Rapidly

SI is an urgent condition warranting an immediate and swift response. As such, it’s vital that ketamine not only works for many patients but also exerts its effects quickly and robustly.

 

As the graph above shows, many patients achieved remission almost immediately. Specifically, 43.8 percent of participants suffering from severe suicidal ideation achieved remission of their symptoms only two hours after their first infusion.

 

 

The Effect was Persistent

Immediate and robust relief of SI is a significant result on its own. However, this finding may have a limited impact if SI promptly returns. Fortunately, the researchers found that the effect lasted six weeks for nearly 70 percent of the patients.

While far from permanent, the six-week reprieve many patients experienced is promising for several reasons. For one thing, given that suicidal ideation is strongly associated with suicide attempts, these subjects may be far less likely to attempt suicide within those six weeks. Second, repeated infusions may lengthen this period of relief even further. Additionally, patients who have yet to create a holistic system of support to supplement their pharmacological treatments with other forms of therapy may find they have more energy to do this while the ketamine is lifting the heavy mental burden of severe SI.

 

 

The Effect was Strongest for Those Suffering from Bipolar Disorder

The research team found that ketamine’s therapeutic effect on SI generally depended on the mental condition the patient was suffering from.  More specifically, they found that ketamine infusions had the strongest impact on SI in patients who have bipolar disorder.

 

Among individuals suffering from depression, the effect was more moderate, with 42 percent of subjects experiencing a remission of their SI.  To shed light on the result, the researchers note that “one study of treatment-resistant depression suggests that repeated doses of ketamine might be necessary for some patients to achieve remission of severe suicidal ideas.” In other words, it may be that this group would have experienced a more significant improvement in their SI symptoms had they undergone more ketamine infusions.  Future studies will need to verify whether this is true.

 

 

It Alleviated “Mental Pain”

In addition to compiling more robust, reliable evidence that ketamine is a good treatment for severe SI, the research team collected data that may shed light on why it is so effective. In particular, they measured patients’ levels of “mental pain” and looked for correlations with remission levels.

 

They found that patients’ self-reported mental or psychological pain was strongly correlated with the severity of their SI and that the ketamine infusions had the most substantial positive effect on their SI when they alleviated psychological pain. This suggests that ketamine’s impact on SI is, at least partly, the result of its ability to relieve psychological pain.

Conclusion

Research continues to verify ketamine’s therapeutic effect on SI. This study provides some of the strongest evidence to date, suggesting that ketamine can provide rapid relief in cases of suicidal crises. It also sheds light on why ketamine has this effect and indicates that the degree to which it is helpful may depend on the individual’s particular mental health condition. 

 

If you are experiencing symptoms of SI, please contact the Suicide Crisis and Prevention Lifeline at 988

 

If you feel you need to see a mental health professional or could use help deciding which service is right for you, please give us a call at 805-204-2502 or fill out an appointment request here. We have a wide variety of providers, including therapists, psychiatrists, nurse practitioners, and nutritional therapists who can see you in as little as one day via teletherapy.  

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Ketamine and Alcohol Use Disorder​


Ketamine and Alcohol Use Disorder

September 13, 2022

Alcohol Use Disorder (AUD), a condition characterized by a problematic pattern of alcohol consumption despite physical, mental, and social consequences, is among one of the most common and costly psychiatric conditions. According to National Center for Drug Abuse Statistics, the condition affects around 10 percent of Americans aged 12 and older and is responsible for three million deaths every year.

 

Because AUD remains a difficult condition to treat, researchers are actively seeking novel therapeutic solutions. Due largely to its well-documented effects on depression, many experts are investigating whether ketamine may prove helpful against AUD. As Professors Celia Morgan and Amy McAndrew note:

 

Depressive symptoms are common in individuals entering treatment for AUD, and the likelihood of alcohol relapse is elevated in patients with such symptoms.

 

Ketamine may support alcohol abstinence by temporarily alleviating depressive symptoms during the high-risk relapse period in the weeks after detoxification.

 

Early experiments have produced promising results, with several studies finding ketamine improved abstinence and lowered relapse rates. For example, one study found that 66 percent of patients with AUD who received ketamine infusions alongside psychotherapy were abstinent one year later compared to 24 percent of patients who did not receive ketamine.

 

Recent Study Suggests Therapy Makes Ketamine a More Effective Treatment For AUD

While some experts feel that ketamine can be highly impactful when delivered on its own in the absence of any therapy, others feel patients must be supervised and receive guidance from experts during and after treatment for it to be consistently effective. As Rosaline Watts, a leading scholar in the field of psychedelic research, explains when discussing one of her recent experiments, “the drug was a catalyst to the therapeutic process, not the therapeutic process itself.”

 

With the importance of therapy in mind, a team of researchers led by Morgan and McAndrew set out to directly assess the role of therapy in ketamine-based treatments with a focus on mindfulness. In their study, they reason that:

 

The subjective experiences that accompany ketamine infusions may provide a new perspective that may be helpful in psychological therapy. Ketamine induces a dose-dependent sense of dissociation and disembodiment that has been described as facilitating an “observer state” similar to that described in mindfulness, which may be helpful for allowing patients to consider thoughts and emotions from a more removed perspective.

 

 

Methods

The researchers conducted a double-blind-placebo controlled study to assess the importance of therapy in ketamine-assisted treatments for AUD. This means special precautions were taken so that neither the subjects nor the experimenters knew what treatment they received, which helps ensure the results are more objective, reliable, and free from bias.

 

Because the researchers wanted to examine the effects of both ketamine and therapy on AUD, they needed two placebos (i.e., “inactive” treatments), resulting in four possible treatment combinations.

 

  1. Ketamine infusions with psychological therapy/mindfulness-based relapse prevention
  2. Saline (drug placebo) infusions with psychological therapy/mindfulness-based relapse prevention
  3. Ketamine infusions with alcohol education (“therapy placebo” where subjects were taught general facts about addiction and alcohol use disorder)
  4. Saline infusions with alcohol education

 

Findings – Efficacy and Safety

After three treatment sessions the researchers noticed several important outcomes. They found the number of days abstinent at three and six months after treatment was higher in the groups that received ketamine either with or without therapy, corroborating findings from earlier experiments.

                                                                                               Photo Credit to Professors Morgan and McAndrew

 

The team found some promising results when it comes to whether mindfulness makes ketamine a more effective tool against AUD. In particular, they found that relative to the subjects that received saline with alcohol education (i.e., both placebos), the group that received ketamine alongside mindfulness-based relapse prevention showed the largest percentage increase in the number of days they remained abstinent. However, the latter finding was not statistically significant, meaning future studies will need to verify that the combination of ketamine infusions with mindfulness-based relapse prevention is more effective than ketamine alone.

 

Because ketamine has the potential for abuse when used in recreational settings, Morgan and McAndrew sought to assess whether this might make it a less viable option for individuals with AUD. To do so, they tracked whether subjects used ketamine during the follow-up portion of the experiment after the supervised ketamine infusions had been administered.

 

They found that around six percent of the subjects reported using ketamine on one occasion during this period. Importantly, these individuals stated they had used ketamine recreationally before the experiment. Future studies will be needed to further determine whether AUD puts one at a greater risk of using ketamine outside supervised settings.

 

Conclusion

Though the research is in its early stages, evidence suggests that ketamine, whether used alone or in conjunction with therapy, may help individuals recovering from AUD maintain sobriety.

 

As researchers continue to explore and identify new psychiatric uses for ketamine, it is becoming increasingly clear that psychological therapy is required to unlock the full benefits of this treatment. Patients and practitioners alike should bear this in mind as they consider ketamine as a therapeutic alternative.

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