UCSD Medical Center’s Program
Feifel said that some patients with TRD are receiving ketamine(Drug information on ketamine) or other state-of-the-art treatments at UCSD Medical Center. He told Psychiatric Times that before patients are given ketamine, they must sign a detailed informed consent. “The form points out that the medication is off-label, and not the standard of care for depression; that even if the infusion works and they feel better, the effect will be relatively transitory; and that the treatment is not covered by insurance, so it is likely going to be an out-of-pocket expense.”
When the program first started, anesthesiologists were required to give the ketamine infusions in an acute care setting. The costs were upwards of $2000 per infusion. Last summer, the program moved to an outpatient setting—a highly monitored procedure suite. Because of the low doses of ketamine being delivered (0.5 mg/kg), the UCSD Medical Center’s Pharmacy and Therapeutics Committee, with the support of the anesthesiology department, agreed that anesthesiologists are not needed. Instead the infusion is given by nurses who know what to do in case a patient has a problem, with an attending, usually Feifel, available during the procedure.
“We can now provide the infusion at a lower cost,” Feifel said, adding that the change to a more pleasant, less frenetic outpatient setting also seems to improve outcomes. In a 4-month period, some 20 patients have received ketamine infusions.
The question remains about how the benefits of treatment can be sustained. In a recent study, Murrough and colleagues7 examined the pattern and durability of antidepressant effects of repeated ketamine infusions in a sample of 24 patients with TRD. Participants underwent a washout of antidepressant medication followed by up to 6 intravenous infusions of ketamine (0.5 mg/kg) administered 3 times per week over a 12-day period. Among the responders (70.8%), the median time to relapse after the last ketamine infusion was 18 days.
The median time of 18 days, Feifel said, was disappointing, so he has not adopted the intense infusion series approach, but rather a maintenance strategy. “At this point . . . if a patient responds well to the first infusion and gets at least a week of solid benefit, then I am willing to do repeated treatments as frequently as every 2 weeks,” he said. “We have had a handful of patients undergo repeat treatments.” Those patients, according to Feifel, have experienced “a profoundly improved quality of life and renewed hope.”
“When you start off feeling absolutely miserable and fighting the urge to end your life every single day, it is a momentous change in your world, when you can know that 50% of your days are going to be depression-free.”
Feifel said he hasn’t seen any signs of abuse or dependency from the infusions. “I haven’t had a single patient pushing for another infusion while the antidepressant effect is working,” he said, adding that some patients have asked to push back their scheduled treatment when they have not felt the need for it.
Asked about delivery of ketamine in other forms, Feifel said there are 3 others—oral, intranasal, and intramuscular. “My experience is that the oral and the intranasal don’t seem to have the dramatic effects of the IV infusion,” he said. “IM, on the other hand, seems to be very promising. I’ve been able to convert some patients from IV to IM maintenance, which is a much more practical, cost-effective way of administering it.”