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The new way to treat depression, anxiety and chronic neuropathic pain
Newsletter No 11 (31st March 2022)
Ketamine infusion or ECT for resistant depression - the debate heats up
The American Psychiatric Association (APA) now endorses both electroconvulsive therapy (ECT) and ketamine for the treatment of resistant depression. There is no doubt that ECT can be an effective treatment for some, yet even after 80-years, quite how it works remains unclear. Ketamine infusion is demonstrably as effective, but with a pro-cognitive benefit in stark contrast with the common cognitive decline and memory loss associated with ECT. Which is the better choice? There is a move afoot to call for immediate suspension of ECT - perhaps unfairly. An international petition has been launched calling for more regulation of ECT. Read about the move to suspend ECT in Medscape after publication of an article in Ethical Human Psychology and Psychiatry.
A randomized open label trial (KetECT) published recently in The International Journal of Neuropsychopharmacology compared the efficacy of ketamine infusion with ECT for unipolar depression. The study outcome favours ECT yet points out that ketamine is more effective in younger patients (under 50 y/o) while ECT is seemingly more effective in older patients. Adverse effects after ketamine infusion are however far less significant and durable than those associated with ECT, the study concedes. Another study in the Journal of Psychiatric Research concludes:
"... Due to its pro-cognitive effects and faster antidepressant effect, serial ketamine administration might be a more favorable short-term treatment option than ECT."
Further studies have shown the antidepressant effect of ketamine administered in conjunction with ECT to be similar to that achieved with sub-anaesthetic doses of ketamine alone.
A paper published 2-months ago in the Journal of BioElectroMagnetics, found that in a sample of over one-million patients with psychiatric diagnoses in the US (1997-2017), those who had received more than 10-ECT treatments were more than twice as likely to develop ALS (amyotrophic lateral sclerosis), and those over 65-years-old more than 3-times as likely.
Inducing a seizure by administering an electrical current to the brain remains anathema to many patients. Those patients unwilling to undergo ECT could and should be offered the 'ketamine alternative' and Medical Aid Schemes should fully endorse this very effective and more affordable outpatient alternative. KCSA remains committed to pursuing 'buy-in' from funders for the benefit of their members.
Ketamine and Phantom Limb Pain - NMDA receptors play a central role in this debilitating condition
A significant benefit of ketamine when used to treat phantom limb pain is the ability to reduce opioid intake and avoid Opioid Induced Hyperalgaesia (OIH).
Around 80% of amputees develop this unique neuropathic pain syndrome.
'Cross-wiring' in the somatosensory cortex following amputation is the likely cause of phantom limb pain. This can be addressed by blocking upregulation of neuropathic pain signaling at the spinal chord level by ketamine.
Read about a 12-year-old amputee who had no recurrence of phantom pain after six ketamine infusions.
KCSA offers outpatient ketamine infusions at the following locations:
BEDFORDVIEW (GP)
CONSTANTIA (WC)
UMHLANGA (KZN)
HILTON (KZN)
COVID-19 patients can suffer from overwhelming hyper-inflammatory syndrome. Ketamine is found to downregulate levels of certain inflammatory cytokines like IL-6 and IL-1ß. Read more in the International Journal of Anesthesia and Critical Care and Journal of Medical Virology.
Further evidence of ketamine's anti-inflammatory properties is discussed in the Journal of Psychopharmacology.
There is a well established association between inflammation and kynurenic pathway abnormalities in depression and patients who have committed suicide.
Ketamine, long-COVID and Chronic Fatigue Syndrome (CFS)
Could outpatient ketamine infusion provide a breakthrough treatment for fatigue in those suffering with long-COVID? It appears quite likely that it may.
Jama Psychiatry suggests that new knowledge about the mechanism of COVID-19 brain damage could direct interventions towards NMDAR-antagonists like ketamine.
Read about an RCT in the Journal of Affective Disorders that specifically studied the effect of ketamine on fatigue. Ketamine infusion significantly lowered fatigue scores from 40-minutes after an infusion to day-14 compared with placebo.
Dr Tasneem Amod discusses whether patients should stop any other medications before ketamine infusion...
Dr Amod is a diplomate anaesthetist and member of The Society of Sedation Practitioners of South Africa (SOSPOSA), who practices at KCSA's Bedfordview Clinic in Gauteng. She is passionate about supporting her patients through their ketamine 'journey' and path to recovery.
In the second of our series of short videos ('KCSA's Fact Finders') discussing ketamine-related topics, Dr Amod explains that, in consultation with a patient's treating psychiatrist, KCSA doctors will sometimes suggest that patients reduce or stop certain medication before ketamine infusion due to a potential reduction in efficacy of the infusion.
Dr Ralph Gilbert takes over as Medical Director of KCSA Hilton
Dr Ralph Gilbert has practiced at KCSA's flagship outpatient clinic in Hilton in the KZN-midlands for the past 2-years. To date, the clinic has administered over 1500-ketamine infusions. He has taken over as Medical Director of the clinic effective 1st March 2022. All at KCSA wish him every success.
We also welcome Asanda Nkosi as the new Hilton KCSA Clinic administrator.
As the first point of contact at the clinic, Asanda is committed to providing excellent service to all of our patients, and the continued smooth running of the Hilton branch.
How did KCSA start in South Africa?
Ketamine Clinics of South Africa (KCSA) was founded by Dr Alan Howard, a Consultant in Emergency Medicine who returned home permanently to his native South Africa from Ireland in 2019.
To read more about Dr Howard and KCSA's flagship clinic in the Natal Midlands in two informative articles published in South African Psychiatry click on the link below.
