You will be told to take a low dose of clonidine (0.1mg) by mouth on the morning and evening of the day before your ketamine treatment. Clonidine is approved by the FDA for treatment of high blood pressure, Attention Deficit Disorder, neuropathic pain, seizure disorder, mood disorder and migraine headache. However, clonidine has also been shown to reduce the chance of developing hallucinations or other uncomfortable feelings when a person is given ketamine and you will be given clonidine for this purpose. You will also be given clonidine 0.1mg on the morning of your ketamine treatment and on the evening following your ketamine treatment. Depending on your medical history and your required medications, clonidine might not be given.
It will be important that you not drink any liquids or eat any food before receiving your treatments. Specific information regarding restrictions on fluids and food will be given in advance of your treatments. Your treating psychiatrist will give you instructions on what to do about any morning medications you normally take. You will receive instructions about your arrival time and must bring a responsible adult with you for transportation back home after the treatment. You will not be able to drive yourself since you might experience some drowsiness and dizziness for a few hours after each treatment. Once you are checked in by a staff member, you will meet with the psychiatrist who will discuss your current symptoms and administer the PHQ-9, MADRS, CGI and CSSRS. You will then meet with the anesthesiologist prior to treatment. An intravenous (IV) line will be started for administering ketamine. During ketamine treatment for depression, you will be given intravenous (IV) ketamine once-a-week for 6 weeks (this is called the acute treatment period). Your treating psychiatrist might also recommend periodic additional ketamine treatments, called maintenance treatments, at various intervals (for example, once every two to four weeks).
The decision about maintenance treatments will depend on several things, including your response to ketamine during the acute treatment period, your past history of antidepressant medication response, or symptoms that suggest you are high risk for depressive symptoms worsening, During each treatment, a sub-anesthetic dose of ketamine will be given slowly over a 40 minute period by an anesthesiologist trained and experienced in the administration of ketamine. The amount of ketamine given will depend on your weight. The amount given is calculated by multiplying your weight in kilograms (Kg) time 0.5milligrams (mg) per kilogram. For example, a 155 lb (70.5 Kg) will be given a total of 35.25 mg. The dose of ketamine given for treating depression is much lower than that required when it is used as an anesthetic, where 3-7 mg/Kg might be required instead of the 0.5mg/Kg that you will receive. The psychiatrist and/or anesthesiologist might decide that changes in the ketamine dose, duration of infusions and frequency of treatments are indicated during the course of treatments. During the treatment, your heart rate, breathing, blood pressure, oxygen content in your bloodstream, and electrocardiogram (ECG) are monitored, and you are observed for any evidence of confusion, agitation, or hallucinations.
After the completion of the ketamine infusion, you will be monitored by staff during a recovery period that will usually last 20-30 mins., but could last as long as 90 mins. Ketamine is known to cause side-effects such as confusion and hallucinations. While these are temporary, they can be quite uncomfortable. Medication might be required to control more severe symptoms. These medications will be chosen by the psychiatrist and/or anesthesiologist and, depending on the nature of the symptoms might include antipsychotics (e.g., Haldol, Zyprexa or Geodon), benzodiazepines (e.g., Versed or Ativan), or clonidine (which is used as a medication to control high blood pressure, but may also control side-effects such as hallucinations). If serious or life-threatening medical events occur, then you will be transported to the nearest hospital emergency department.
At the end of the recovery period you will be asked questions by the psychiatrist and the PHQ-9, MADRS, CGI and CSSRS tests will be given. You (and the person transporting you home and staying with until the morning following each treatment) will be given a 24-hr phone number and instructions regarding contacting the treating psychiatrist or, if he is not available, the on-call PAKC psychiatrist, with any concerns. You will be advised to not drive a vehicle for at least 24 hrs or until any lightheadedness clears up.
You will be contacted by phone by the treating psychiatrist 2-4 days after treatment to check on your status. You will receive a reminder phone call on the last office day before your next treatment.