Dr Maria Dobreva, a private specialist psychiatrist in KwaZulu-Natal, calls on medical schemes to support comprehensively the “Holy Grail of antidepressant treatments”, which is much cheaper than hospitalisation.
My relationship with ketamine started in 2014 at a conference sponsored by Cipla. A young Cape Town psychiatrist presented a few case studies and I was intrigued.
I did some research on ketamine infusions and started treating selected patients at my rooms. I would book an anaesthetist to administer the infusion and monitor vital signs. The process worked reasonably well, although we were unaware of certain critical “do’s and don’ts”.
We weren’t aware that the therapy should be administered in silence and with minimal external stimuli; preferably with noise-cancelling headphones and eye-shields. The importance of background music, not disturbing the patient and keeping totally quiet, was not on our priority list. Avoiding concomitant benzodiazepines (and probably lamotrigine and topiramate) because of potential GABA/glutamate conflict, was one of the nuances of which I was not aware.
The importance of the recovery period, remaining with a responsible adult for four hours after an infusion, and not driving until the following day, were similarly not given due consideration.
I was never completely satisfied with the clinical results. They were mediocre.
During September 2019 Dr Alan Howard, ran a very successful trial from a local medical practice. I became a total believer in the power of ketamine. He adopted the protocols used by the Ketamine Clinics of Los Angeles, which have administered more than 16,000 infusions.
It boggles my mind why more of my fellow psychiatrists are not referring their patients to one of these state-of- the-art outpatient clinics in SA. These have changed the landscape of practicing sound psychiatry in this country.
Administering ketamine infusions for mood disorders correctly and in an appropriate environment is key: NOT in busy surgeries, day-clinics, side rooms or surgical theatres.
Emphasis must be placed on patient safety, appropriately qualified staff, monitoring and emergency capability. Appropriate dosing and titrating to response are critical. In short, all of the ‘rules’ need to be followed to derive maximum therapeutic benefit.
I began to see a major shift in outcomes. My patients felt better and most had reversal in suicidal ideation after one infusion (none of the antidepressants or psychotherapies can claim that).
As for treatment-resistant depression (TRD), ketamine infusions are the way to go. Patients with TRD usually need a series of six infusions administered twice a week for three weeks. Subsequent occasional, maintenance or ‘top-up’ infusions are important to maintain remission in most cases.
Ketamine infusions have application for a number of psychiatric conditions: TRD, PTSD, OCD, bipolar depression, and addiction, to name some. Mild cognitive impairment, migraine, fibromyalgia, and chronic neuropathic pain of various aetiologies are other conditions which may benefit from a series of infusions.
I have found outcomes almost too good to be true.
In a nutshell, it works, and I firmly believe that ketamine is the new potential saviour in the old psychiatric bag.
There is solid science behind ketamine. Neuroplasticity, synaptogenesis, and dendritic sprouting are demonstrable benefits after an infusion series, occurring under the influence of BDNF (brain-derived neurotropic factor).
Ketamine administered for mood disorders has a complex mechanism of action but works primarily as a non-competitive antagonist of NMDA receptors, leading to a surge in the excitatory neurotransmitter, glutamate.
To date, I have successfully treated more than 100 patients from my practice, primarily TRD and suicidality, but several other conditions as well.
In my view, ketamine is the “Holy Grail” of antidepressants.
Remarkably, it has been around for more than 50 years as a dissociative anaesthetic, but its antidepressant potential was not realised until 2006.
I wish, as a clinician, that medical aid schemes would come on board fully and offer their members comprehensive benefits for what is truly a highly effective and affordable treatment modality, far less costly than hospitalisation.
Dr Maria Dobreva
Private specialist psychiatrist in Pietermaritzburg, KwaZulu-Natal.
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