Ketamine can be costly — and isn’t typically covered by insurance. But researchers are working to determine if biomarkers, such as mere blood test, may help to determine if the Rx will reduce your symptoms.
In March 2013, after years of trying — and not responding to — over 20 medications for her anxiety and depression, then-27-year-old freelance writer Becky Ford turned to ketamine. Historically used for anesthesia but popularly known as “Special K” for its abuse as a hallucinogenic club drug, ketamine has been shown to effectively relieve depression when administered intravenously by a doctor.
At the Brain-Mind Institute of New England, Becky received six 40-minute infusions, just days apart, at what would have cost $600 each without her discount. By the second infusion—and after so many failed attempts with other prescriptions—her depression was virtually gone.
“I cannot adequately put it into words,” Becky told HealthCentral. “I was not chronically depressed and anxious anymore, or experiencing suicidal thoughts. It was as if part of me returned and I could breathe for the first time in a very long time.”
From those initial infusions—and with the help of her antidepressants and anti-anxiety medications—Becky stayed in remission for two years.
Tiffany Jenkins’s experience wasn’t so life-transforming. In 2017, the 44-year-old Texas native participated in a National Institutes of Health clinical trial and received a series of ketamine infusions. “I remember feeling better for about five days post-infusion before relapsing into my depressive episode,” she says. “The infusions seemed to lose their efficacy over time. Not to say ketamine is worthless, but as with so many drugs, I do think there is a tolerance build-up.” According to Tiffany, by the third week or so, the effect of the infusion was wearing off by the evening of the day it was administered.
Miracle Drug or Snake Oil?
This widely varying response to ketamine isn’t uncommon: Two-thirds of people typically respond to ketamine, and although a single infusion can improve depression in two to four hours, the effect typically wanes after a week for a single infusion, or after a month for multiple infusions.
To prolong the effects, many patients receive monthly maintenance “boosters” of ketamine (two infusions every three to four weeks), while others will come in to get two to six infusions whenever they feel their depression has returned. A study in the Journal of Clinical Psychopharmacology reported all participants with treatment-resistant depression benefited initially from maintenance ketamine treatments. At the end of the study, four out of 11 participants discontinued due to lack of effect. The cost (more on that below) and the side effects, like dizziness and nausea, deter many from keeping up with it.
Who Should Consider Ketamine?
It’s fast-acting but short-lived. And it’s expensive: $400 to $1,000 per infusion — depending on the provider, location, ketamine dose, and the condition being treated — which typically isn’t covered by insurance. So why pursue it?
The appeal of ketamine is that it can work for people who haven’t responded to other drugs, because it targets different pathways than typical antidepressants. It relieves depression by blocking the actions of the N-methyl-d-aspirate (NMDA) receptors, which are critical in the brain’s ability to form neural connections and to adjust to new situations.
And for those really struggling, it’s quick hope in comparison to the typical solutions: In one study published in Biological Psychiatry, 70 percent of people responded to the drug, some experiencing a reduction in depression symptoms two hours following the first infusion, a vast improvement compared to the eight to 12-week response time of most antidepressants.
Proof Before Pay
While ketamine offers great hope for some, there’s still that 30 percent who might shell out and not respond. In the future, though, a blood or imagining test may change that, one that looks at biomarkers, indicators of a person’s biological type of depression, which can determine if you’ll respond favorably to a drug before you ever actually use it.
Enter the Biomarker Discovery Project, an unprecedented scientific collaboration by the National Network of Depression Centers, a group of 26 leading mood disorders center across the country. This multi-site study — involving the Mayo Clinic, University of Cincinnati, University of Pennsylvania, Johns Hopkins, University of Michigan, and the University of California, San Francisco — is measuring biomarkers of response to ketamine as an option for patients with treatment-resistant depression (TRD).
In the trial—which started in mid-2017 and is estimated to be completed early next year — researchers have enrolled 100 patients with major depression or bipolar disorder and are evaluating symptom responses. Subjects are given three IV infusions of ketamine over a period of about a week, with blood samples taken before and after the infusions, to be stored for later biomarker development. The goal of the project is to determine the predictors of an antidepressant response. If successful, this study will end up saving patients time and money.
The recent FDA approval of the ketamine-derived nasal spray esketamine (Spravato) makes ketamine even more convenient, although a doctor still has to administer the drug, typically twice a week. Each treatment ranges from $590 to $885, depending on the dose, which is comparable to the cost of IV treatments. Esketamine, used for treatment-resistant depression, is likely to be covered by most insurance companies, but with restrictions — for example, for patients who have tried a certain number of antidepressants first, and requiring a prior authorization from a psychiatrist or another physician.
In one study, only 25 percent of patients receiving the eskatamine spray plus an oral antidepressant had a relapse in depressive symptoms during 16 weeks of treatment, compared to 57 percent of patients taking a placebo spray. Like ketamine infusions, the drug can bring relief in hours.
Esketamine is taken in a doctor’s office, under medical supervision, although patients give it to themselves after an initial lesson with a healthcare provider. They are required to sit in the office for two hours until given the okay to leave. Ketamine infusions, on the other hand, happen in a clinic, and finding the right clinic is clutch to getting a good favorable response.
What to look for? According to the April 2019 Berkeley Wellness Papers, experts stress a few factors:
- The clinic should have a qualified psychiatrist or anesthesiologist who administers the treatment. Ketamine is usually administered in addition to a typical antidepressant, so that it is important that you are first in regular psychiatric care.
- Ask whether the clinician will monitor you during treatment. This is important as a safeguard to handle any adverse reactions, which are rare but can include dissociation from the body or hallucinations.
- If you can’t afford the infusions, consider participating in a clinical trial. The U.S. National Library of Medicine provides a large database on ongoing studies at clinicaltrials.gov. And remember, that with the FDA approval of esketamine, insurances should soon start reimbursing for this new option.
Whether via nasal spray or infusion, for people like Becky who have tried more than a dozen medications, ketamine provides unprecedented hope. In the next five years, with studies like the Biomarker Discover Project, the goal is even more relief—including that time- and money-saving knowledge of whether your response will mirror Becky’s or Tiffany’s.