Ketamine, Depression Protocol and Contraindications

In this podcast, Psych Congress Steering Committee Member Rakesh Jain, MD, MPH, clinical professor, department of psychiatry, Texas Tech University School of Medicine, Austin, answers the question: "Is there a ketamine for depression protocol?" during a live Q&A session at the recent Sana Symposium. Dr Jain also discusses contraindications regarding ketamine during the depression protocol as well as dosing and administration best practices.



"Is there a ketamine for depression protocol?" The answer is, depends. If you follow the NIMH protocol, which by the way, if you're just starting out, do that. That reminds me, if you're just starting out with ketamine, don't be overly aggressive with ketamine doses. Don't, not yet. 0.5 milligram per kilogram dose may seem to some of us homeopathic, especially when we use high doses.

But can I assure you as rapidly as I can? 0.5 milligram per kilogram for some of you who hasn't had a lot of ketamine experience is a lot of medication. So, the protocol really so far, it's not a well-developed protocol. It's a research protocol. I'll give you both the research protocol and clinical protocol.

It's typically starting at 0.5 milligram per kilogram. That's an IV dose. For IM, you don't, perhaps if you're starting out, want to go too far beyond it. Maybe 0.6, 0.7, but not more than that, and twice a week, sometimes 3 times a week. The NMH protocols were typically two weeks long. What you do want to do, once the patient is better, is to start spreading out the intervals.

There's a couple of reasons for it. Number 1 is obviously convenience and cost. The other one is, you want to reduce the risk of tolerance developing. Tolerance can develop to ketamine that's used in too high a dose or too frequently. In terms of maintenance, there's now a wide variety of how people are doing it. Again, if you're relatively new, don't go to the fringes.

Stay in the middle. The stay in the middle appears to be between the IM dosing, assuming you're willing to dispense sublingual ketamine, which, by the way, most clinicians are not. If you are, you may want to limit it to 1, perhaps, at the most, 2 doses per week, no more than that. Please control it because the risk of diversion does exist.

What are the medical contraindications to ketamine? Given any route, there are a few. Number one would be uncontrolled hypertension. That would not be appropriate. Ketamine absolutely increases the heart rate, increases the blood pressure.

At least, with Spravato, the guidelines are pretty good. We should follow that even with regular ketamine, so to speak. If the BP at baseline is 140/90 or lower, it's OK to proceed. If it's higher than that, it would not be appropriate because there can be challenges, and we obviously want to minimize it.

The other contraindication, if you are starting out, if you're not in an expert setting with tons of people available and years of experience, I do think a patient with psychosis, a patient with concurrent panic attacks that are uncontrolled would not be a good idea.

It's also a good idea to be aware that at least two medications can diminish the effectiveness of ketamine, that being Lamictal and the other one being benzodiazepines. Maybe we can talk about it offline, but benzodiazepines, in particular, you want to hold it if you possibly can.

There's other contraindications, such as the patient has a history of aneurism or unstable cardiac or cardiovascular health. Generally speaking, there are not a lot of contraindications in psychiatry other than psychosis and the presence of florid, uncontrolled anxiety.