What is Ketamine? Why Ketamine Works with Dr. Steve Yun, Kure

Introduction and Guest Presentation

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Steve: We’re not going to promise you the world and under deliver. We’re going to go through a very safe process to provide you with the safest treatment. We’ll be honest with you and upfront and letting you know what ketamine may or may not do. 

There’s plenty of patients who Can benefit properly from ketamine therapy if you do it the right way. So why not do it the right way?

Why not do it the proper way? And give patients a safe medical experience.

Bruce: Welcome To the future of psychiatry podcast where we explore novel technology and new innovations in mental health i´m your host, Dr. Bassi, an addiction physician and biomedical engineer. Today we’re going to be focus on ketamine now I´m here with Dr. Yun.

Dr. Yun. is anesthesiologist and medical director at Kure, spell with K U R E, a Santa Monica based ketamine clinic that helps patients in L. A. and surrounding areas live fuller lives through dedicated ketamine therapy that meets the growing demand for effective solutions to treat mental health conditions. He prides himself on being able to provide the gold standard of ketamine therapy and has successfully treated those suffering with chronic treatment, resistant depression, bipolar disorder, anxiety, PTSD, and even substance use disorders. He’s received his BS with honors from the University of Wisconsin, Madison, and his MD with honors from the University of Southern California. Follow by three years of additional training in anesthesiology at the UCLA Medical Center . He´s been practice in private practice since the year 2000, and for the last 15 plus years, he has served as the director of anesthesiology for Dr. Daniel Kharrazi. A former team position for the L. A. Lakers. Dr. Yun is also a clinical professor at Western University of Health Sciences and a lecturer at Loma Linda School of Dentistry. Welcome to the show, Dr. Yun.

Steve: Great, thank you very much, Bruce. It’s a pleasure to be here.

Bruce: Thank you. Like I mentioned, we’re going to be talking a little bit about ketamine. Ketamine was first synthesized in the 1960s. It has advantageous qualities as an anesthetic because of its rapid systemic absorption. It’s wide safety margin, making an appealing anesthetic agent. And now since the early 2000s, ketamine has been gaining more and more data regarding the rapid management of depressive symptoms. The first approval by the FDA for ketamine derived therapy for mental health came in 2019 for intranasal S ketamine as an augmentation agent for treatment resistant depression. Tell us a little bit about your perspective on ketamine and what is ketamine therapy and how does it work?

Steve: Well, let me preface my discussion by first stating the obvious. I’m not a psychiatrist, nor do I profess to have any expertise in psychiatry, which is why it’s really important and really beneficial that I get to talk to professionals such as yourself who have much more experience in psychiatry. And that underlines my philosophy and our philosophy at Kure that we’re just one small part of the process in treating depression.

We obviously want to work very closely with the patient’s psychiatrist and psychologist and other mental health professionals. But as an anesthesiologist with over 25 years of experience, I am intimately familiar with ketamine as an anesthetic. I literally use it almost every week in my clinical practice.

And so when the medical team at Kure approached me with this idea of opening a clinic in the West Los Angeles area, I thought it fit in very well with my interests and expertise in ketamine as an anesthesiologist. So, as you mentioned in your introduction, ketamine is a well known anesthetic, has been around for decades, and when used correctly at the proper doses, is a very safe anesthetic.

We’ve taken that one step further at the Kure ketamine clinic by offering very safe doses of ketamine, sub therapeutic doses of ketamine in terms of anesthesia potency. But by offering a level of about 0. 5 milligrams per kilogram, which again is very much lower than the typical anesthetic dose of ketamine we can offer patients an alternative therapy and treatment, for severe depression that has not responded to traditional therapies.

When to prescribe ketamine

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Bruce: That’s good to know. So tell me or walk me through a typical patient experience for average patient. It sounds like they’ve already tried a number of antidepressant options before, they have a psychiatrist they’re working with. Perhaps you get a referral from that psychiatrist. And then walk me through the process of, understanding whether or not ketamine is appropriate for that patient.

Steve: Yes. So typically, we will start with a thorough medical screening because as safe as ketamine is, there are some contraindications, particularly severe, uncontrolled high blood pressure, a history of active psychosis or bipolar disorder. So we want to screen our patients very carefully first by doing a thorough medical history and medical screening.

We’ll then also do a thorough psychiatric screening. We really discourage patients who simply want to try ketamine for the first time who have not sought out other traditional therapies first. So we really encourage patients that if they do have depression, consult their psychiatrist, consult their primary care physician first, try some of the proven traditional remedies. And then if those fail, if they’re not producing the desired response, to then talk to their physician about possibly pursuing ketamine therapy.

Bruce: But if ketamine is, a really great option, I can see some people saying, well, why don’t I just try that great option? What is the reason behind them wanting to, or telling them to try other options first?

Steve: As good as ketamine can be, it is not necessarily the best choice as a first option. One obviously is cost and we’re up front with our services. Our services are relatively expensive and unfortunately at this time not typically covered by insurance. Secondly, it does involve placing an IV. Which is a minor but an invasive medical procedure. Requiring then the infusion of ketamine over the period of about 90 minutes. So, because it is a more invasive medical procedure than perhaps just taking a pill or, traditional psychotherapy, I think it’s prudent to advise patients that there may be an easier, cheaper, more historically proven option as a first line treatment for your depression. Rather than jumping all the way to getting an IV infusion of ketamine. Because as good as ketamine is, again, we still don’t have a lot of long term data as to its efficacy. We’re very upfront and honest with our patients about what the evidence shows and what we can promise.

Routes to administer ketamine

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Bruce: We’ll talk about the long term data or the how long it lasts and the effects on mental health. But I want you mentioned route there were you mentioned that Kure uses an IV. And I’m sure other clinicians are wondering, well, I thought the esketamine is intranasal and it sounds like there are some clinics that continue to do the more traditional route with IV and then there are maybe some other clinics that use intranasal administration. What are the advantages and disadvantages? Is there any data there to suggest one might be better than the other? Or does a patient have both options when they come to Kure?

Steve: Yes, so we do offer both options, and there is good evidence for both the intranasal and intravenous route. In fact, the New England Journal of Medicine, just in the last few months, has published two very compelling studies. Looking at the efficacy of intravenous ketamine and then also intranasal ketamine.

The biggest downside of intranasal ketamine is that it is prohibitively expensive at this time. Over 500 dollars wholesale just for one dose. Then you have to add on, of course, our expenses as a clinic, the expense of monitoring the patient, etcetera. So the costs quickly become prohibitive. So at this time, I don’t think it’s a viable economic option for most patients.

With intravenous ketamine, it’s much more affordable, still expensive, but much more affordable when compared to intranasal ketamine. And its efficacy is also, growing in terms of the evidence, as I mentioned, especially with this latest New England Journal of Medicine article.

Scientific evidence of using ketamine for diagnoses other than depression

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Bruce: You mentioned that you do a psychiatric evaluation to assess for any prior history of psychosis or bipolar disorder. I’ve heard from other clinicians that individuals with high anxiety might not necessarily respond well to ketamine. What’s your perspective on that for individuals with high anxiety, which is obviously frequently comorbid with depression.

Steve: Exactly. Again, we try to be upfront with patients as much as possible. So, we have successfully treated patients with high anxiety, PTSD, substance use disorder. But, when you look at the evidence, There’s not a lot of good clinical evidence that supports the efficacy at this time of ketamine therapy.

Most of the evidence is more towards and directed towards severe treatment resistant depression. So we tell patients, we can offer this service, it may help. But we cannot give you a lot of scientific evidence, unfortunately, at this time, because the randomized clinical trials are lacking that this is a proven or historically proven efficacious treatment.

But we do have anecdotal reports and cases of where patients have benefited from ketamine therapy with severe anxiety and these other disorders. We’re totally upfront and honest and say, if you’re looking for scientific randomized clinical , You know, controlled trials. The best evidence comes with ketamine and depression.

Ketamine for substance use disorders?

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Bruce: Since we’re on the topic of uses and use cases, you mentioned , on the website that you’ve used it for substance use disorders. Are there certain substance use disorders in particular that stand out to you that it’s particularly effective for?

Steve: The breadth of data here as a specialty is lack. We don’t have a lot of good scientific data on the use of ketamines for substance use disorders. But we’ve had several patients especially with alcoholic use disorder. Who have responded well to ketamine therapy who have reported a decrease in their alcoholic intake and craving.

These are anecdotal reports, obviously not high quality evidence in terms of scientific rigor, but it does offer some promise and some hope for patients who are struggling with these sorts of chronic, often difficult to treat addictions.

How to choose between ketamine and other alternative drugs

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Bruce: Say, I’m a patient I’ve been identified with having treatment resistant depression. I’ve tried a number of different options and now you want to try some off the beaten path, psychedelic is ketamine similar to other psychedelics? How would an individual evaluate whether I want to try psilocybin, MDMA, ayahuasca, ketamine? Can you give any sort of anecdotal evidence about which one is better than another? I know there’s no head to head studies, but just from your experience, what would you advise an individual who’s just looking for now an option in the psychedelic realm?

Steve: Yeah, let me state the obvious, we don’t have very good scientific evidence at all about these other alternative therapies. I think for the patient who has really severe depression that’s refractory to the traditional treatments, I think it’s worth pursuing the idea of alternative therapies after careful consultation with your physician and with your family members.

The strongest piece of advice I would give is be very careful though. That is, we want you, the patient, to explore these alternative therapies in a safe setting. And unfortunately, right now, we sort of have a wild west situation when it comes to these psychedelics, in which doctors are prescribing these medicines.

But not without necessarily the medical safeguards in place. So as an anesthesiologist, as a doctor who has performed safety inspections for various offices and service centers, etc I know it is in my training to never underestimate safety standards or guidelines. So if you are going to pursue an alternative therapy, Do your due diligence as a patient.

Make sure that the doctor and the clinic in which you’re receiving the therapy has all the medical safeguards in place. Make sure that you’re personally monitored by a health care provider. Make sure they have all the necessary emergency equipment. Make sure they have a safe environment in case you have a severe disassociative reaction or even a psychotic reaction to therapy that you’re not in a harm yourself or others.

How patients can assess safety of a ketamine clinic

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Bruce: What should they look for in terms of keeping safe

Steve: Right, so you want to look, obviously just beyond the typical, interior design of an office, right? Especially in the West Los Angeles area, where image is so important many offices will spend all their money on making the interior design, the furniture, the decor, state of the art, beautiful, you know, magazine worthy, but then they won’t spend the money on basic safeguards like simply having an emergency oxygen cylinder to provide supplemental oxygen or an AED, a defibrillator, or even just basic emergency drugs like epinephrine in case there’s an anaphylactic reaction.

Is there a basic vital signs monitor? Do they have a means to monitor your blood pressure and your oxygen saturation? And then finally, and most importantly, is there a qualified health care person who’s going to be there at the clinic monitoring and observing you and helping guide you through the process when you do receive these sorts of alternative therapies

Accompaniment and safety for the patient

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Bruce: So there should be somebody in the room that would be monitoring or in the building, I would say if they’re coming in and out of the room to check in on you. Does that get into the idea of psychotherapy or ketamine assisted psychotherapy? Is that done at Kure or do you have any thoughts about ketamine assisted psychotherapy where there’s a therapist helping an individual through that session and continuously talking to them through that session

Steve: Yeah, absolutely. I think multimodal therapy is the most prudent option. So we are fortunate at Kure that we have wonderful nurse practitioners, psychiatric nurse practitioners. You know, these are advanced nurses with specialized psychiatric training as well as a registered nurse who also has strong interest and expertise in mental health issues.

And then also an in house or in building psychologist that we can also use as a referral. So with our model at Kure, we have the patient in our clinic and we spent a lot of money on a fancy interior design to make a very comfortable, smoothing, soothing environment. But we also spent the money on making sure the medical safeguards are in place, in particular having an experienced psychiatric nurse practitioner with the patient, if not myself.

In addition to a registered nurse and then also having in building psychologists also immediately available to help the patients, talk them through the process because as safe as ketamine therapy is, it can cause some unusual disassociative reactions. And sometimes patients need to be reassured during the treatment that everything is okay.

You’re in a safe environment that these sorts of effects are normal and will quickly dissipate.

Bruce: You mentioned providing reassurance, having a blood pressure monitor, having epinephrine in case of anaphylactic reaction. Are there any other types of, even small types of remedies for any typical side effects or responses? Zofran maybe? Can you go further in that?

Steve: Absolutely. At Kure we have the full emergency medical kit in our clinic. So that not only includes epinephrine in case there’s a severe allergic reaction, but we also have Zofran, which as you know is an anti emetic. we also have blood pressure agents to help gently reduce the blood pressure if needed.

Because many of our patients do have substance use disorders or a history of substance use disorders, and you never know for sure what a patient may have taken before the visit. We also carry naloxone in case we need to reverse the patient from an opioid overdose and also flumazenil, which is used to reverse benzodiazepine overdose.

In addition to that, we have other medications. for all the other typical emergencies that may occur, including angina or chest pain from heart disease. So we have nitroglycerin, supplemental oxygen, and aspirin. So all the basic things that we take for granted, perhaps in a medical or surgical setting, we try to do the same things at Kure.

Again, never underestimating the importance of safety.

Why go to Kure and not somewhere else?

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Bruce: And when a patient is trying to evaluate which clinic to go to. Is there anything they should consider in regard to the protocol? And can you talk a little bit about the, whether or not the protocol for ketamine has been or become more standardized over time? If you speak to any of your colleagues who do ketamine, is there much variability there between what a patient might expect at one clinic versus another? in terms of how frequent they’re receiving the ketamine over the course of the first week, then the next week, then week after. What should they look out for? I Always wonder if there’s ever any sort of conflict of interest because not for you guys, but for just anyone in general, and I’m sure patients even think of this too, you know, if they’re benefiting by more and more doses, how do I know that they’re not overdoing it for me?

Steve: this is really unfortunate because we literally are in a Wild West unregulated situation. So if I’m a patient, the best advice I can offer to you is if it sounds too good to be true, if the clinic keeps saying yes and yes and yes, then you need to think about saying no. That is, you’ll find a number of clinics that will say yes to anything that the patient requests.

Can I have a supra megadose of ketamine? Can I have four or five ketamine infusions in one week? Can I have ketamine infusion even though I haven’t seen a psychiatrist in 10 years? So, When a clinic is willing to say yes and yes and yes to all your demands or requests, that really should give you pause as a patient.

Now, not to say that our way is the best way, but at Kure, we really try to stick to the scientific protocols that have been promulgated in the literature. So we start with a very traditional dose of 0.5 milligrams per kilogram. But we have had patients, and we have seen other clinics, Offer patients one milligram per kilogram to start even 1.5 milligrams per kilogram to start, we’ve seen clinics tell patients, we’ll mail you a ketamine lozenge that you can take in your home, and then we’ll just monitor, we’ll just monitor you via zoom. And you know, just because you can do something and get away with it doesn’t necessarily mean that it’s safe. And, unfortunately we’re seeing a lot of these sort of practices or protocols that really are pushing the envelope. As a patient, do you really want to be put in that position where you’re using alternative therapy and you’re using it in a way that is not really regulated or the safest environment?

So we really try to discourage that. And we’re not afraid, a Kure of saying no. No, we want to help you. We want to offer therapy, but if it’s not right, if it’s not safe, then we say no.

What about microdosing ketamine?

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Bruce: So the, dosage is just important, and there are clinics that offer micro dosing, and I’ve had patients who say they don’t notice anything to micro dosing. Is there any data there to support micro dosing?

Steve: No, again, we don’t have a lot of very good scientific evidence as regards to microdosing. And the doses, again, are so small that, I’m not surprised that many patients would not report a benefit or any effects from that.

Timeline of treatment of ketamine

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Bruce: In your experience, how long do the antidepressant effects last for ketamine, and is there anything that has been studied to extend that, and do you typically incorporate that agent into your practice, or does it depend on the patient?

Steve: Yes, so why we to tell patients is that the long term efficacy of ketamine is still unproven. We don’t have a lot of good scientific data. However, the best evidence indicates that Ketamine therapy can provide effective relief for several weeks, which sounds trivial, but for a patient with severe treatment resistant depression. Even a window of benefits of several weeks can make a tremendous difference in the quality of their life.

And on top of that, we really emphasize multimodal therapy. We think of ketamine as a way to help kickstart maybe a stagnant recovery process. But the traditional therapies still have an important role. So for long term efficacy, we don’t necessarily see the patient coming to the chem in clinic for the rest of their life, right?

Getting intravenous ketamine every week, but rather as a kick start to help the recovery and to allow more time for the traditional therapies to kick in, particularly SSRIs, SNRIs, and psychotherapy. But again, unfortunately, we don’t have very good long term evidence as to the outcomes and the long term efficacy of treatment resistant depression after short term ketamine intravenous therapy.

So we still are waiting the results of more studies with regards to those questions.

Bruce: What is the longest that you’ve seen a patient come into the clinic for? Has it been years?

Steve: Well, we’re a relatively new clinic. We started last year in June of 2022. So we have had patients with us since that time. So that’s approximately 14 15 months where we had patients treated more intensively at the beginning of the treatment and then who now come in perhaps once every couple of weeks for a booster infusion if you will, of intravenous ketamine.

Bruce: So you’re kind of growing some data there are for, long term efficacy. I’m sure that could provide a lot of hope for individuals who have tried a number of different options over the years. If they do land on ketamine does work for them, it sounds like it could potentially work for over a year for them

Steve: Yes, anecdotally, that’s what That´s our experience seems to indicate. We are careful to be honest and upfront with patients. And tell them, the gold standard, of course, is randomized controlled trials. And unfortunately, we still don’t have a lot of good data with regards to that.

But anecdotally we are very optimistic and have a lot of very promising results. 

Rapamycin use

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Bruce: Let´s go back to the durability of the effect of ketamine. after an infusion, I know that there’s some evidence for rapamycin to increase the, , effectiveness and durability of the antidepressant effect. What are your thoughts on the data there? And do you incorporate rapamycin dosage into the treatment protocol?

Steve: We personally have not used or incorporated rapamycin into our protocol. We try to leave that up to the discretion of the psychiatrist or the primary care physician. So at this time we try to focus solely just on ketamine therapy. However, I think that the data behind rapamycin is promising and we’re certainly open to the idea and we do suggest it as an adjunct, but that’s something that we would defer to the patient’s psychiatrist or physician

How to reduce the addictive potential of ketamine

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Bruce: So say there is a patient who wants to do it long term. And we do know that ketamine has some abuse potential and you mentioned that sometimes patients ask for a lot of doses or a high dose. How do you decrease the opportunity for abuse and addiction in your patients? What kinds of things would you look out for or hope for?

Steve: Yeah, that’s a great question. So, the key is, that the Kamine infusion is only given in our clinic under direct medical supervision. We don’t allow patients to go home with any sort of ketamine lozenge or intranasal ketamine. We don’t allow patients to come in, without an appointment.

Every appointment, even if it’s a repeat patient, is still screened. We still go through the same process ask the same questions. We also have very good protocols and really just comes down to common sense in screening these patients each time, looking at their vital signs, looking at their overall demeanor looking for signs of drug abuse or substance abuse, all the classic signs that we know, for example, you know, slurred speech inappropriate affect, etcetera.

If any of those signs are present in our screening, and again, Before every appointment, we screen each patient each time, regardless of how long they’ve been with our clinic. We quickly, terminate and say, Hey, perhaps we need to reassess and do a further evaluation and maybe think about having you see your physician or coming back on a different day.

Ketamine for chronic pain

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Bruce: Let’s talk about ketamine for chronic pain relief, and you’re an anesthesiologist, so you probably have a lot of good experience with this. Is there a type of chronic pain, widespread pain condition that ketamine is particularly effective for? Or are there any that it’s particularly ineffective for? And what kind of experience have you had in terms of it helping treat chronic pain conditions?

Steve: Yeah, so every anesthesiologist will tell you that one of the worst, most horrible conditions that we encounter in terms of pain is chronic regional pain syndrome. It’s still a relatively poorly understood disease process, but in these patients for whatever reason, and oftentimes it can be due to even just minor trauma, they will develop refractory chronic sort of neuropathic types of pain that are resistant and not amenable to traditional pain therapies, particularly NSAIDs or opioids.

And these patients and these conditions are incredibly difficult to treat and incredibly debilitating for the patients. We don’t have very good scientific evidence. As to the use of Ketamine for chronic pain, regional syndromes, however, at Kure, we do have some anecdotal reports of patients who have responded favorably, have had a decrease in their pain symptoms after receiving intravenous Ketamine.

has it been a miracle 100 percent cured? No, absolutely not this is such a difficult disease. It’s really unrealistic to expect that any one drug or any one type of therapy would suddenly, miraculously cure such a complex process. It can offer these patients a small window of relief.

Which may seem trivial, but again, just like severe treatment resistant depression, these patients are so miserable and involved in such a frustrating process that even giving them a small window where they can get some relief of their symptoms provides huge practical benefit for them in terms of their daily living.

Bruce: What about for an individual who has fibromyalgia plus depression or chronic fatigue syndrome plus depression, you think that candidate would benefit from the ketamine treating any type of symptoms associated with the fibromyalgia or chronic fatigue?

Steve: we don’t have very good scientific evidence with regards to those conditions. And I would not promise a patient that they would get relief. Anecdotally, we have seen some patients who have responded well with those very complex, difficult clinical conditions. I would advise patients if you have these types of very frustrating, very difficult disease processes. Consult with your physician. Try the traditional therapies. If those are ineffective, then perhaps consider ketamine as an adjunct, as an alternative to help you. But, we want to be very careful and not over promising the benefits of ketamine especially with the lack of scientific data.

Effects of ketamine on sleep

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Bruce: How has the Treatment process of a patient being on ketamine affected their sleep schedule or sleep architecture. Do you find patients tell you that they are sleeping less well or having deeper sleep, better sleep? tell us a little bit about how ketamine can affect sleep.

Steve: Sure, we know more and more and suddenly you field of psychiatry are very familiar with the growing importance and awareness of how sleep affects our mental health. It’s amazing how much time we spend sleeping and yet how little we still understand about the whole process. But certainly we know that sleep plays a huge role in mental health and recovery.

So in the patients that we have seen who have responded chemotherapy, yes, absolutely. We have seen improved responses with regards to their sleep. duration and quality. And whether is that directly due to the ketamine or is that due to the ketamine relieving their symptoms of depression? I mean, that’s difficult to parse out.

But anecdotally, we have seen very good positive reports in patients in terms of their sleep quality.

The future of the company

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Bruce: It’s good to hear for an individual who has those struggles, comorbid, coexisting. Let’s talk a little bit about the business strategy at Kure and business challenges that lie ahead. what are typical ideas, the topics talked about at your company’s board meetings in terms of improving or strategizing for improving the mission that Kure has and any sort of business protocols to address any challenges that lie ahead.

Steve: Yeah, that’s a very good question. In some ways, our business model and philosophy is counterproductive, in that if we were a traditional business, we would simply kick in every patient who calls or walks into the door. And unfortunately, we have seen that happen every day at other clinics not just in the Los Angeles area, but across the nation where these clinics motivated purely by profit are simply accepting any patient that walks through the door.

So we’ve taken a counterintuitive business model where we say, you know, just because you call us just because you’re interested doesn’t necessarily mean we will accept you as a patient. We’re going to do a careful medical and psychiatric screening, and then if we think it’s appropriate, we’ll follow all the proper medical safeguards to give you the safest treatment.

And so that’s how we’ve tried to differentiate ourselves from the competition. Because as you know, there is a proliferation of these ketamine clinics, most of which, the vast majority of which, are unregulated, who are doing all sorts of practices that are pushing the safety envelope. So we take sort of a counterintuitive process in that we tell patients, we’re not going to be like every other clinic.

We’re not going to promise you the world and under deliver. We’re going to go through a very safe process to provide you with the safest treatment. We’ll be honest with you and upfront and letting you know what ketamine may or may not do. So with that philosophy so far. You know, as counterintuitive as it may be has proven to be very successful.

There’s no shortage of patients, right? We know that severe depression is an epidemic and so No, there’s no need even from a business standpoint. Just simply accept any patient that walks to the door. There’s plenty of patients who Can benefit properly from ketamine therapy if you do it the right way. So why not do it the right way?

Why not do it the proper way? And give patients a safe medical experience. And so that has been our philosophy. And so with that, we are now looking to expand to other parts of Southern California. And even also across the nation. But we’re going to start off small, focus on quality, and do things the right way.

Bruce: Kure only focused on ketamine therapy, or is there any interest in adding any other types of psychedelics to the treatment options for patients at Kure?

Steve: Yeah, we’re open to the idea of adding other psychedelics, but again, our philosophy is to focus on what we know, focus on what the evidence shows is the most efficacious treatment. So for now, we’re focusing purely on ketamine, but certainly as more evidence comes in, we will be open to the idea of other alternative therapies.

I think the key for us is saying no to all the other, attractive as they may be other options and focusing on what we do best, which is providing safe ketamine in a medical setting.

Ketamine vs ECT

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Bruce: In 2022, a JAMA article came out that said ECT may be superior to ketamine for improving depression severity in the acute phase, but treatment options should be individualized and patient centered. If you’re familiar with that research study, can you comment on that and what your thoughts are?

Steve: Oh, sure. So ECT, as brutal as it sounds, is a historically effective and accepted treatment modality. So that is certainly an option that patients should consider. However, from a practical standpoint, ECT is not the most attractive option for patients, right? And as an anesthesiologist, I’ve participated in hundreds of ECTs.

It requires not only an IV, but actual general anesthesia, where the patient is put into a medically induced coma. For a very brief period of time, but nevertheless it is general anesthesia and then shocked with the ECT electrodes in a hospital or surgery center setting. So as effective as it may be it’s really not the most practical option for many patients as opposed to coming into a clinic , having an IV and getting the ketamine therapy.

so certainly we would encourage patients to look at ECT as an option. but again, the New England Journal of Medicine study, , indicates that , intravenous ketamine may be or is as effective as ECT. From a clinical standpoint. And then just from a practical standpoint, I think intravenous ketamine is a much more practical option for most patients versus ECT.

Bruce: And ketamine probably doesn’t have the amnestic effects that are long lasting, similar to a ECT or a like ECT. I’m sure that’s an attractive component for a lot of patients to not have memory issues down the road.

Steve: Yeah, absolutely.

Government policies

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Bruce: What do you think of patient education as a challenge for Kure and for other ketamine , clinicians and in general, you mentioned the Wild West a couple of times and the fact that we don’t have enough data and there’s a thirst for information about these new ideas that are exciting for people and give people hope. And so I think people just end up trying it for themselves without being well informed about what the other options are, what the outcome is going to be or what the safety protocols should be. Are there any governing bodies that are trying to push out any sort of standardization protocols or requirements or accreditation process for psychedelic treatment centers?

Steve: So that’s a great question. And I think it may be more an issue here in Southern California, especially in the Los Angeles area where fads , seem to be more common, and more of an issue. And so we’ve had a number of patients who call us who say, I’m interested in getting ketamine because my neighbor got it or my friend from the soccer team got it.

And , I don’t really have any issues with depression, but I do have some anxiety issues. I do have some issues with attention. And so I’d be interested in trying it. And so, again, those are the patients that we actually discourage from trying ketamine. You know, as safe as it is, we really want to discourage people who are just interested in doing it as a fad or just to see how it feels.

We really want to reserve ketamine, for people in which there is a medical indication. That being said, unfortunately, we don’t have Many regulations in place with regards to ketamine therapy. I know that the American Psychiatric Association has issued some broad sort of generic guidelines as to ketamine therapy.

and those are helpful, but again, they’re so broad that they really don’t get into the nuts and bolts of the regulatory day to day clinical issues with ketamine therapy. So, that’s an area that’s still. Severely lacking, and I would just urge my colleagues that it’s better for us to self regulate ourselves for us to follow the safety protocols ourselves, rather than trying to push the envelope before some government bureaucracy steps in and makes the process That’s onerous and, unviable.

So yeah, we need to do a better job of self policing ourselves, within this field.

How to innovate in mental health?

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Bruce: Let’s zoom out a little bit and talk about innovation and mental health in general. Do you have any recommendations for anybody who’s interested in developing new technology or innovations in the field of mental health?

Steve: I think my best advice is to keep an open mind. That is, it’s very difficult for us to know what we truly know. So much of what you and I have been taught in medical school, for example, is simply dogma, right? Stuff that we’ve been taught is just been passed down historically without really looking at the scientific evidence behind the practice or behind the thinking.

So, in this type of field where there’s still so much that is unknown. I would encourage my colleagues to keep an open mind, to look at these alternative possibilities and to really look for high quality evidence, and if it’s lacking, let’s look and help design high quality studies to answer the questions that we need to be answered.

but rather than simply saying, ketamine is a sham or psychedelics are a sham. Those things never work. And I think we would surprise ourselves by how many things in medicine that we think are true really are based no more upon the musings of one physician who in the 17th century decided, let’s call normal saline, normal saline, even though it’s not really normal saline.

So, be careful what you think, you know, keep an open mind, but at the same time, let’s be rigorous and look for the scientific evidence.

Bruce: Great points. Do you have any ideas of any novel treatments out there that are particularly exciting that you’re keeping a watchful eye on that you think are gonna be big in the future?

Steve: Yeah, so one interesting development that has come from the military, which has used ketamine for decades as a analgesic in the battlefield because it doesn’t cause typical respiratory depression like opioids. So you can see why ketamine would be attractive. For military uses, but it involves an intramuscular injection.

And so one thing that military has just developed is an infuser ketamine device in which, the device is simply placed on the soldier’s abdomen and similar to like a continuous insulin infusion pumps, it then infuses, in a safe way, in a slower way, doses of ketamine through the skin

Bruce: Which muscle does it go into the abdomen?

Steve: what they typically place it on the abdomen.

So the rectus abdominis , but really it’s going through the subcutaneous tissue and fat first and then through the muscle. So it’s a really novel idea, but you can see why the military would be interested in that because you’re in the battlefield situation. You have all these patients or soldiers who are injured who are in pain and so then the medic can simply slap one of these devices on the abdomen of the soldier and then move on to the next patient without having to worry about the overdose or respiratory depression in the previous soldier. So rather than getting intravenous therapy for depression in the future, we may be able to offer a continuous infusion device that simply attaches to the skin. So that would be really exciting

Bruce: Is it a patch or does it have a needle in it?

Steve: It has it’s a patch that has micro needles in it. Yeah.

Final thoughts

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Bruce: Well, Dr. Yun, this was an awesome conversation. I thought really interesting one and quite informative as well for both a clinician and a patient who is wanting to find an option maybe for treatment resistant depression especially. And I think your approach and your philosophy has been one of being very much evidence based and, Focused on patient safety, which I really appreciate, and I think a lot of other patients and clinicians, too, would appreciate this very prudent approach that you take with your patients. It was a fun conversation talking about the history a little bit and how it’s, used and the route, the dosage, and the setting that people should look out for. So, I’ll give you the last word for our audience to wrap up about ketamine therapy.

Steve: Yes, so I would just emphasize our message that when it comes to severe depression, which is, as we all know, an extremely debilitating disease, multimodal therapy with close consultation with the patient’s psychiatrist, psychologist and mental health team and family members, I think is still the most important treatment.

Ketamine may be a useful adjunct to help provide temporary relief, but it should be just one part of an entire treatment process. And with that, it’s vitally important that patients do a little bit of homework, do their due diligence, and make sure that the clinic or the provider that they’re choosing is providing the ketamine in a way that is safe, and that follows the best scientific evidence.

Bruce: Well, Dr. Yun, and thank you so much for coming on the future of psychiatry.

That’s it for this episode. I’d appreciate it if you please like and share this podcast with your colleagues. It’d be especially helpful for us. If you’d like, please leave us a rating on your favorite podcatcher. If you’re a clinician, I developed a course on how to start a private practice. And for patients, I’ve also developed a course on acceptance and commitment therapy and cognitive behavioral based therapy lessons for treating and helping anxiety.

You can find all these on our website as well. as well as the show notes and resources for each episode. Thank you so much, and I’ll see you in the next episode.