Revitalize Psychiatry: Disrupt – Include – Engage – Innovate !! – The APA 2019 Conference

I just returned from the American Psychiatric Association’s 2019 Conference in San Francisco.

This is the 175th Anniversary of the APA, and look how far we’ve come. The theme this year was: Revitalize Psychiatry – Disrupt – Include – Engage – Innovate. and it certainly provided fodder toward those goals. It was an informative and eye-opening conference with a wide array of talks and poster presentations. Plus, I was privileged to make a presentation, too. More about mine in a bit.

The attendance at this conference exceeded them all, with thousands of attendees from around the world and new research presentation abstracts which spread out over 800 pages!

You may not be aware that the APA is the oldest medical organization in the nation. (We’re proud of that.) The venue was enormous and the camaraderie rich, inclusive, and restorative.

The presentations flowed from every aspect of psychiatry, including geriatric issues as well as issues specifically relevant to children, and adolescents, too. There were talks from ADHD to dementia and addiction to psychosis.

From Saturday through Wednesday the venue was chock-full of courses, convocations, lectures, symposia, talks, and media presentations by the hundreds. There were more than 360 new research presentations every day in the poster sessions which went up every morning and every afternoon.

There’s no way I could ever provide a synopsis here of all the findings presented. But there were a couple I do want to mention.

My own focus was on those presentations specifically related to suicide, depression and other mood disorder treatment, and especially ketamine treatment. I drank up all the information and data I could hold. (That and espresso kept me going.)

Here we’ll talk about two of the presentations focused on ketamine and the one I presented on suicidal thinking.

Ketamine’s Effect on OCD

I was so pleased to see there has been more work focused on ketamine for obsessive-compulsive disorder (OCD). Clinical Psychiatry News featured this article with the title: “Ketamine may help OCD, but much work remains.”

The author, Carolyn Rodriguez, MD, pointed out that the symptoms of OCD are severe, and 1 in 7 people with OCD attempts suicide at some point in their lives. She said that there is a significant and painful delay between the time of diagnosis and the time when the patient experiences benefits from the medicine — 2-3 months or even longer.

She talked about her interest in looking at therapies that worked much faster, and were more thorough. This is so important so that patients could feasibly experience more complete eradication of symptoms.

Since more and more evidence indicates that glutamate seems to contribute to neuron communication as an excitatory chemical messenger, she chose to see what ketamine could do, considering it blocks the glutamate receptor.

The only study using ketamine with OCD was conducted by Dr. Rodriguez and her team in 2013. Not surprisingly, she’s planning a new one now which will compare ketamine with midazolam, to study the effects of ketamine on the circuits associated with OCD. 

She Called for More Studies On Ketamine’s Effects on OCD

She says a larger study is needed to learn more about how long ketamine’s effects on OCD symptoms lasts. It’s also important to see if the effects seen in the 2013 study can be replicated.

This is exciting work, as we need more information about what ketamine does for OCD so we can help more patients.

Dr. Rodriguez commented on the FDA approval of esketamine this past March. She made the point that those OCD patients with “contamination OCD” are likely to be unwilling to use a nasal spray. 

Disrupt – Include – Engage – Innovate …

Ketamine and Opioid Receptors

Another talk, presented by Nolan Williams, MD, from Stanford University, discussed ketamine’s mechanism of action. Since there’s wide recognition that stress is directly related to a buildup of glutamate outside the cells which causes unwanted effects, ketamine blocks the NMDA receptors, blocking glutamate, and reverses these unwanted results.

Dr. Williams made the point that ketamine affects many neurotransmitter systems and has a wide variety of effects, both good and bad, as a result of that.

Researchers know that ketamine’s effect on pain is complex, and an opioid receptor antagonist prevents ketamine from relieving pain. We know that opioids have an antidepressant effect, and Dr. Williams wondered if ketamine’s antidepressant effect depended on the opioid system.

There were 12 subjects in all who completed the study; 7 had dramatic relief of symptoms. Even more interesting, 6 of the 7 achieved remission. 

Now, the design of the study included crossing over between 2 groups of subjects. So, to accomplish this, one half received a placebo an hour earlier, then ketamine. The other half received naltrexone an hour beforehand, then ketamine. As you may know, naltrexone blocks opioid receptors, so if ketamine relies on the opioid system, in part, then naltrexone should prevent ketamine from reducing depression symptoms.

After the ketamine infusion, they allowed the subjects to become depressed again. They became deeply enough depressed to reach the 20% mark on their evaluation tool. Then they were given another infusion of ketamine. If they received placebo with the first infusion, this time they were given naltrexone. If they received naltrexone with the first infusion, this time they were given placebo.

Opioid Receptor Antagonist Blocks Ketamine’s Effects

Those who received naltrexone experienced no benefit from the ketamine infusion, whether they received it prior to the first ketamine infusion or the second one. 

The same is true of suicidal thinking as measured on the tool. Those who received naltrexone experienced no reduction in suicidal thoughts.

Interesting, right? But, keep in mind, this was a very small study, and much, much more work needs to be done looking at these issues. This is too preliminary, and these numbers are too small, to make sweeping generalizations. Certainly, closer to home, at Yale, patients treated with naltrexone have responded to IV ketamine. So much to learn!

Disrupt – Include – Engage – Innovate…

Ketamine Infusions Stop Suicidal Ideation in Outpatients and Avert ER Visits and Hospitalizations

Finally, my own story. I had the opportunity to present my own data.

I’m very interested in how IV ketamine can rapidly reverse suicidal thinking in patients with depression. Passionate about it, actually. Taking a long, hard look at my own experience with more 235 adults and adolescents with treatment resistant depression, I presented data which showed that serial, titrated ketamine infusions stopped suicidal thinking in the majority, and prevented ER visits and psychiatric hospitalization.

We have dozens of case reports, small studies, beautifully written case series, and elegant placebo-controlled trials of ketamine treating depressive episodes — and very fine studies teasing out the effects of ketamine on suicidal thoughts in small numbers of patients.

What’s been missing — for us all — are extensive results from real-world psychiatric treatment with ketamine in large numbers of patients like the ones we see every day–people who are complex, and have more than just one thing going on (like anxiety, OCD, trauma, and histories of substance misuse in addition to their depression or bipolar disorder). People who are medically ill, or in chronic pain. Those who have made numerous trips to the ER for suicidal ideation. So many who have been hospitalized, made suicide attempts, have been failed by ECT, or failed by TMS.

People like you. Or like people you know.

When I think about what ketamine can do best, and who it needs to work for first, it’s the patients I see — people like this: Depressed. Sick and tired of it. Sick and tired of treatment not working. With thoughts it would be a relief to not wake up, or with frank thoughts of suicide.

There were No Suicide Deaths, Suicide Attempts, ER Visits or Hospitalizations in my High Risk Group Treated with IV Ketamine Infusions

This is the first report from a real-world psychiatry office practice in the community using IV ketamine to treat suicidal thinking in hundreds of adult and adolescent patients with treatment resistant depression.

The response from attendees to the data was enthusiastic. But we were even more excited with the breadth of new research presented during that same 2 hour poster session. Information that touched on ketamine, suicidality, and treatment resistant depression. It’s extraordinary to see so much energy and thought put into examining these connections. Here are some examples of the new research posters that surrounded me:

• Effect of Ketamine and Esketamine in Suicidal Ideation: Relationship to Depression
• Patient-Reported Outcomes in Major Depressive Disorder with Suicidal Ideation: A Real-World Data Analysis using Patientslikeme Platform
• Care Setting Type and Readmission/Subsequent ED Visit Risk Among Patients with Major Depressive Disorder and Suicide Ideation or Suicide Attempt
• Do the Impact of Risk Factors or Protective Factors for Suicidality
  Change in Response to Effective Treatment? A Case Study
• Esketamine’s Antisuicidality Effects on Treatment-Resistant Depression: A Role for the Subcutaneous Route
• The Relationship between the Big Five Personality Traits and the Suicide Crisis Syndrome in an Outpatient Population
• Resilience Moderates the Relationship between Suicidal Narrative and Suicidal Behaviors
• Effects of Ketamine and Esketamine on the Levels of Brain-Derived Neurotrophic Factor in Patients with Treatment Resistant Depression
• Development of a Real-World Ketamine Database Registry: Centers of Psychiatric Excellent (COPE)
• Managing Esketamine Treatment Frequency Toward Successful Outcomes: Analysis of Phase 3 Data
• Esketamine’s Antisuicidality Effects on Treatment Resistant Depression: A Role for the Subcutaneous Route

And the beat goes on.

Disrupt – Include – Engage -Innovate !!

So, in fact, we enjoyed a wealth of disruptive information shared through hundreds of studies, new technologies, and new paradigms. We engaged with the information and with each other, included diverse groups who attended and the patients they advocate for and treat. We’re moving forward to innovate in our mindset, our approach, our science, and our treatments.

Because after all, it’s for you that we attend these conferences. No doctor practices in a vacuum, but our best and most healing practices are born from collaboration within the psychiatric and neuroscience community.

Ketamine Treatment at Innovative Psychiatry

So here at home, we focus our energies on you.  Do you have thoughts about suicide that treatment has not been able to stop? Do you suffer from symptoms of depression that recur or persist no matter what you do?

If so, please call us.

Let’s determine if you’re a candidate for IV ketamine treatment.

While it isn’t the right treatment for everyone, (because nothing is) it is remarkably helpful to most. And we’re learning all the time more ways it can help more people.

We live, study, collaborate, work, and share our findings to help you find the rewarding and fulfilling life you’ve longed for. Together, we can Disrupt -Include – Engage – Innovate …and help transform your life. Give yourself the opportunity to feel well and to enjoy the things in life that mean the most to you. We’re here to help.