Ketamine Clinics

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Mocaman

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It appears unlike Suboxone for example there are no guidelines or additional training or certification needed to prescribe ketamine infusions in the outpatient setting...does anybody have any experience with managing patients with ketamine and or starting a clinic

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I don't have much experience but I have worked with a researcher in this field and at a private hospital that was doing research in it.

My opinion, ketamine can be a very useful medication but I have serious doubts that many if not most of the ketamine clinics out there are drug dealers with white coats.

Why?
Well first ask yourself why would an anesthesiologist, the one type of physician even want to go into mental health treatment, a field they know so little about with their training?
And to give a medication with no established standard of care, no FDA approval for depression, no professional societal approval, with that medication having a strong abuse potential, all the while charging huge amounts of money for it?

And if even a physician wanted to give it with good intent shouldn't they be giving it only for severe and/or treatment resistant cases of depression? Then why a clinic that is advertising as if they want to give it to anyone even with mild depression and charging huge fees that are above standard treatments for depression?

Again ketamine will have IMHO a place in depression treatment that is more standard and patients can benefit from it now if it's severe enough but to give it out as if it's an SSRI so long as the patient it willing to give money IMHO is bad medicine.

Take for example a specific physician who I will not name who runs a ketamine clinic. His website claims he pioneered a treatment protocol for ketamine. Okay I checked his publications. He has only 1 and it's concerning schizophrenia. He "pioneered" a treatment protocol? Sounds like it's science but if it's not published or at least scrutinized by an outside source this is pretty much home-brewed treatment.

Okay so yes, with any cutting edge treatment one would be practicing outside the norm but ethically such treatments should be limited to cases where the conventional was tried and failed, done under high scrutiny, and not by someone who just read a few journal articles about the topic.

The Green Journal a few months ago published a case of a patient clearly abusing ketamine that was provided by a neurologist. If you read between the lines it seems like this neurologist didn't know WTF he was doing.
http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2015.15081082

Further buprenorphine is showing emerging data that it too can treat depression extremely quickly. Shall I then start giving it first line to every depressed patient I see? Of course not.

Also a place I used to work at did provide ketamine. It was done as part of a research study and IMHO ethically so especially since it did go through and IRB. All of the borderlines (rich borderlines that is) took it and just wanted to take it again and again and again and when told no they'd freak out and then you had an even bigger problem on your hands---a borderline that wants to use a substance of abuse to treat their emotional dysregulation.
 
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I don't have much experience but I have worked with a researcher in this field and at a private hospital that was doing research in it.

My opinion, ketamine can be a very useful medication but I have serious doubts that many if not most of the ketamine clinics out there are drug dealers with white coats.

Why?
Well first ask yourself why would an anesthesiologist, the one type of physician even want to go into mental health treatment, a field they no so little about with their training?
And to give a medication with no established standard of care, no FDA approval for depression, no professional societal approval, with that medication having a strong abuse potential, all the while charging huge amounts of money for it?

And if even a physician wanted to give it with good intent shouldn't they be giving it only for severe and/or treatment resistant cases of depression? Then why a clinic that is advertising as if they want to give it to anyone even with mild depression and charging huge fees that are above standard treatments for depression?

Again ketamine will have IMHO a place in depression treatment that is more standard and patients can benefit from it now if it's severe enough but to give it out as if it's an SSRI so long as the patient it willing to give money IMHO is bad medicine.

Take for example a specific physician who I will not name who runs a ketamine clinic. His website claims he pioneered a treatment protocol for ketamine. Okay I checked his publications. He has only 1 and it's concerning schizophrenia. He "pioneered" a treatment protocol? Sounds like it's science but if it's not published or at least scrutinized by an outside source this is pretty much home-brewed treatment.

Okay so yes, with any cutting edge treatment one would be practicing outside the norm but ethically such treatments should be limited to cases where the conventional was tried and failed, done under high scrutiny, and not by someone who just read a few journal articles about the topic.

The Green Journal a few months ago published a case of a patient clearly abusing ketamine that was provided by a neurologist. If you read between the lines it seems like this neurologist didn't know WTF he was doing.
http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2015.15081082

Further buprenorphine is showing emerging data that it too can treat depression extremely quickly. Shall I then start giving it first line to every depressed patient I see? Of course not.

Also a place I used to work at did provide ketamine. It was done as part of a research study and IMHO ethically so especially since it did go through and IRB. All of the borderlines (rich borderlines that is) took it and just wanted to take it again and again and again and when told no they'd freak out and then you had an even bigger problem on your hands---a borderline that wants to use a substance of abuse to treat their emotional dysregulation.
Lol buprenorphine for depression lol ridiculous. I mean i agree with you, in terms of the ethics...but why is this being allowed. This is a drug of abuse, bottom line. It just seems a little whacky that any doc can open up
One of these clinics and get at it. No bueno
 
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No, definitely as ridiculous as i think. Getting high is not a substitute for treating depression
If this is your line of thinking, how come ketamine treatment, which would also qualify as "getting high" using your terms, seems any less ridiculous to you?
 
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Just to let everyone know I have treated 1 patient so far with buprenorphine for depression. She only required about 1.5 mg of it. For those of you who know this medication opioid addicts need about 16 mg of it to feel stable and be free from triggers to use (of course it varies per person but think about 16 mg). Trust me someone seeking to abuse buprenorphine will not seek it at 1.5 mg.

But this is a patient that was treatment resistant even to ECT. Seriously. One of the top psychiatrists in the world treated her without much success. (I know cause I work with him in the same office). Another top psychiatrist in the world tried and failed to treat her with pramipexole. Pt had 60 ECTs, tried every single SSRI, every single antidepressant that went to the market in the last 30 years and still no success, and a heck of a lot of combinations.

The patient even made a color coded spreadsheet of what worked and what did not. The stuff that did work literally only took a slight edge off her depression and it is severe and has been for years.

Again this is where out of the ordinary treatments should then be considered-when pretty much nothing else worked, the disorder is moderate to severe and you explained to the patient why you are using this very unconventional treatment. They should not be offered as if it's a first line treatment with some claim that I "pioneered" this treatment when I have no journal article where I'm an author about it.

Oh by the way I have a tendency to be very regular with my bowel movements thanks to the way I eat and what time I drink water during the day. I guess I "pioneered" a new treatment for constipation! Noble Prize people here I am!
 
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.but why is this being allowed. This is a drug of abuse, bottom line
Why? Cause state medical boards are for the most part impotent.

Doctor sexually assaults patient. He likely will not lose his license. Assaults 5 patients? will likely not lose his license. Assaults 50? Ok then he loses his license.

I'm not kidding.
Here's a guy who literally sexually assaulted dozens of patients and the state only went after him after dozens. Yes I know the article mentioned only a few but those were the few who had the courage to take him to court after complaints did nothing.
http://www.psychsearch.net/leo-dsouza/

Farid Fata got away with telling people who didn't have cancer they had it and gave them very expensive treatments for it for years. One of his nurses and colleague doctors even reported him to the state medical board and he still got away with it for literally years.


Here's a Florida Pill Mill. What is the state medical board doing? Pretty much nothing.


Here's a nurse that literally killed dozens of patients. What did the state medical board do? Hardly anything.


Oh and here's someone from the state medical board.
 
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I'd be wary of any patients asking for infusions at 10pm on a Friday night.
 
Ketamine should be given IMHO to severely depressed and/or treatment resistant patients but only after more research is done or in very controlled settings where several conventional treatments were tried and failed. Yes it has abuse potential but so do so many other meds that can be appropriately administered.

Again this is not in defense of ketamine clinics cause it seems they're willing to give it to anyone willing to pay enough money.
 
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If this is your line of thinking, how come ketamine treatment, which would also qualify as "getting high" using your terms, seems any less ridiculous to you?
No i think it absolutely is as ridiculous. But who am i to say, just my opinion.
 
No i think it absolutely is as ridiculous. But who am i to say, just my opinion.

How is that pt now? Any genetic testing done. I agree with u on the buprenorphine, most of the addicts in my area buy the 8mg/2mg off the street and abuse it in 1/4's..speaking of addiction..ABPM took addiction medicine under its wing and now is abms cert. I wonder when the next exam will be offered as nothing is available in 2016.
 
No i think it absolutely is as ridiculous. But who am i to say, just my opinion.

It's an interesting point, and yet there are multiple hypotheses about the significance of a dissociative experience. Phenomenologically, patients can consistently differentiate the transient, sometimes uncomfortable but at times euphoric experience they have during a ketamine infusion from a distinct sense of elevated mood which occurs several hours after, is not associated with other dissociative phenomena, and typically endures for 2 weeks. Nothing suggests they are 'high' for the entirety of this recovery period. Currently efforts are being made to understand the importance of an initially dissociative experience in predicting overall likelihood of a ketamine response.

A greater concern is that owing to the time limited nature of ketamines effect people are now receiving repeated dosing, which likely warrants further study regarding safety and dependence.
 
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It's an interesting point, and yet there are multiple hypotheses about the significance of a dissociative experience. Phenomenologically, patients can consistently differentiate the transient, sometimes uncomfortable but at times euphoric experience they have during a ketamine infusion from a distinct sense of elevated mood which occurs several hours after, is not associated with other dissociative phenomena, and typically endures for 2 weeks. Nothing suggests they are 'high' for the entirety of this recovery period. Currently efforts are being made to understand the importance of an initially dissociative experience in predicting overall likelihood of a ketamine response.

A greater concern is that owing to the time limited nature of ketamines effect people are now receiving repeated dosing, which likely warrants further study regarding safety and dependence.

Theres no significance or importance to the dissociative experience of overall likelhood response. That is the response by definition of its MOA, say what you will about the euphoria or high...the literature on sustained elevated mood substantied by some objective data is what we need. I mean, we might as well open ether clinics. At the end of the day, if it saves a life, hey im all for it
 
My first impression of ketamine: I remember being at a party in college... went to the bathroom where some kids were snorting lines of some white powder. I asked "what the hell is that?" "Oh, special-K dude" said some stoned-out surfer looking kid. I looked over my shoulder to see some girl sleeping in the bathtub. "What's with her?" I wondered. "Oh... she's in a K-hole!" said surfer dude. "Yeah, I think I'll stick with the red cups and the keg. Later dudes."

Tough to shake that thought when I hear ketamine.
 
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My first impression of ketamine: I remember being at a party in college... went to the bathroom where some kids were snorting lines of some white powder. I asked "what the hell is that?" "Oh, special-K dude" said some stoned-out surfer looking kid. I looked over my shoulder to see some girl sleeping in the bathtub. "What's with her?" I wondered. "Oh... she's in a K-hole!" said surfer dude. "Yeah, I think I'll stick with the red cups and the keg. Later dudes."

Tough to shake that thought when I hear ketamine.
Lol A k-hole, in the bathtub, yikes. Red cups and keg..right on!
 
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Ketamine infusions have their place. But it's in a hospital setting for now.
 
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I'll tell you why I don't think ketamine as a treatment is ridiculous.
1-The dosage to obtain the antidepressant benefit is not the dosage that gets most people high.
2-If it's administered in a controlled environment where depression was thoroughly investigated and other treatments tried addicts will likely not go through the vetting needed (e.g. several visits, thorough evaluations).
3-In an ER setting with the help of a central pharmacy doctors can make sure the patient isn't ER hopping getting one and then another cause only then the dosage would accumulate to amounts that would get one high,
4-There are neurootropic benefits being found suggesting the antidepressant benefit simply isn't because the patient isn't getting high. It might truly be getting rid of the depression in a beneficial physiological sense.

Again all of these require it be given in a judicious manner and not in the manner where so long as the person has enough money they can get the treatment. That's the problem with doctors giving ketamine now. They give it as if they're drug dealers.

I would've been open to giving it to a very small number of my patients and tried to do so in a controlled manner in a unversity setting and I wanted another doctor to vet my case at that time too. Ultimately we did not because the hospital head pharmacist couldn't figure a way to give it out that was appropriate in his opinion. This was literally a patient where the next option was brain surgery and everything else was tried.

Well lo and behold now some guy in Cincinnati opened his ketamine clinic where he's giving it out. Again how much is the state medical board looking into it? I bet hardly at all.
 
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My issue with Ketamine is that it seem that in academic settings we speak of how careful to be with this medication, but outside these centers its the wild west.
Another issue is that any treatment we have that involves a product that is prized in the criminal world and or gets pulled into the criminal world enterprises (i.e. Suboxone and now Ketamine) will be quickly overshadowed by misuse, pill mills, etc.

People have been robbing animal hospitals for some time now for Ketamine. Sometime I feel our field is so naieve about realities of why patients come to us asking various controlled substances and how vast the trade of substances we prescribe is. Just waiting to hear people robbing these Ketamine clinics.
http://fox59.com/2015/12/28/burglars-target-animal-hospitals-for-drugs/
https://www.avma.org/News/JAVMANews/Pages/s091501b.aspx
https://www.avma.org/News/JAVMANews/Pages/s091501b.aspx
http://gantdaily.com/2010/12/13/bur...thefts-at-pittsburgh-area-veterinary-clinics/
 
No i think it absolutely is as ridiculous. But who am i to say, just my opinion.
Is this why you opened this thread asking about experiences with ketamine or opening ketamine clinics?
It appears unlike Suboxone for example there are no guidelines or additional training or certification needed to prescribe ketamine infusions in the outpatient setting...does anybody have any experience with managing patients with ketamine and or starting a clinic
Sounds like trolling to me, though a worthwhile topic to discuss.
 
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Is this why you opened this thread asking about experiences with ketamine or opening ketamine clinics?

Who cares, its generating good discussion. As a psychiatrist it's very concerning that i or any colleague of mine could just start one of these clincs up. To open an OTP MAT there's at least certification /applications review officers etc. granted that's addiction but in terms of public health, ominous. Trolling..gimmie a break. 2004 called and..
 
My issue with Ketamine is that it seem that in academic settings we speak of how careful to be with this medication, but outside these centers its the wild west.
Another issue is that any treatment we have that involves a product that is prized in the criminal world and or gets pulled into the criminal world enterprises (i.e. Suboxone and now Ketamine) will be quickly overshadowed by misuse, pill mills, etc.

People have been robbing animal hospitals for some time now for Ketamine. Sometime I feel our field is so naieve about realities of why patients come to us asking various controlled substances and how vast the trade of substances we prescribe is. Just waiting to hear people robbing these Ketamine clinics.
http://fox59.com/2015/12/28/burglars-target-animal-hospitals-for-drugs/
https://www.avma.org/News/JAVMANews/Pages/s091501b.aspx
https://www.avma.org/News/JAVMANews/Pages/s091501b.aspx
http://gantdaily.com/2010/12/13/bur...thefts-at-pittsburgh-area-veterinary-clinics/
Agreed
 
The biggest problem with ketamine IMO, is the anesthesiologists opening these clinics and charging cash are not doing any of the diagnostic work themselves to determine if it is an appropriate patient with treatment resistant depression. Which of course they can't really do, because they're not trained in mental health diagnosis. The clinic websites I've viewed describe getting referrals from psychologists or psychiatrists, who would be the ones recommending the treatment. I don't think this absolves the anesthesiologist of any responsibility/liability. If the doctor giving the medication doesn't agree with the diagnosis, they need to be able to say so and decline the referral, but the anesthesiologist is not able to really do this because they haven't done appropriate history and mental status examination.
 
The people most against using ketamine to treat depression tend to be the ones with the least experience. Check out the doses. Look at the selection criteria for who receive it at reputable places.

Poo-pooing ketamine for depression because you've seen people on Special K and equating the two is about as sensual as telling dentists they are insane for utilizing cocaine, cause hey man that stuff ruins lives.


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The people most against using ketamine to treat depression tend to be the ones with the least experience. Check out the doses. Look at the selection criteria for who receive it at reputable places.

Poo-pooing ketamine for depression because you've seen people on Special K and equating the two is about as sensual as telling dentists they are insane for utilizing cocaine, cause hey man that stuff ruins lives.


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I mean i guess but come on...

Our colleagues http://forums.studentdoctor.net/threads/ketamine-and-depression.345664/
 

In fairness, literally the second person to respond in that thread kind of nailed the fact that it appears that NMDA antagonism is not responsible for ketamine's anti-depressive effect:

http://slatestarcodex.com/2016/06/07/ketamine-research-in-a-new-light/

If/when a drug is developed based on this AMPA agonist mechanism, there probably will not be much of a place left for ketamine for us.
 
In fairness, literally the second person to respond in that thread kind of nailed the fact that it appears that NMDA antagonism is not responsible for ketamine's anti-depressive effect:

http://slatestarcodex.com/2016/06/07/ketamine-research-in-a-new-light/

If/when a drug is developed based on this AMPA agonist mechanism, there probably will not be much of a place left for ketamine for us.

It's still equally reductionist to get overly excited about AMPA agonism. There is data for nitrous oxide from our department, also an NMDA-R antagonist as well as an AMPA-R antagonist.

http://www.jneurosci.org/content/18/23/9716.full.pdf
http://www.biologicalpsychiatryjournal.com/article/S0006-3223(14)00910-X/abstract

Much of the groundbreaking research on the glutamatergic and GABA-ergic systems (specifically NMDA hypofunction) was done at Wash U (John Olney, Chuck Zorumski- our Chair, Dennis Choi- fmr chair of Neuro, etc), and we have ongoing clinical trials with Ketamine, yet we don't run a clinic because of the obvious issues (can't keep people on it forever- how else will they function?, question of safety with long term use, dosing is still an issue, intolerable side effects, etc). Also, there is not a good, active placebo. I think most places use midazolam, but now there is a lot of evidence on GABA ergic drugs altering neurosteroid production with effects on mood, etc http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3591791/
 
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It's still equally reductionist to get overly excited about AMPA agonism. There is data for nitrous oxide from our department, also an NMDA-R antagonist as well as an AMPA-R antagonist.

http://www.jneurosci.org/content/18/23/9716.full.pdf
http://www.biologicalpsychiatryjournal.com/article/S0006-3223(14)00910-X/abstract

Much of the groundbreaking research on the glutamatergic and GABA-ergic systems (specifically NMDA hypofunction) was done at Wash U (John Olney, Chuck Zorumski- our Chair, Dennis Choi- fmr chair of Neuro, etc), and we have ongoing clinical trials with Ketamine, yet we don't run a clinic because of the obvious issues (can't keep people on it forever- how else will they function?, question of safety with long term use, dosing is still an issue, intolerable side effects, etc). Also, there is not a good, active placebo. I think most places use midazolam, but now there is a lot of evidence on GABA ergic drugs altering neurosteroid production with effects on mood, etc http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3591791/

Much obliged. I wonder if at the end of the day we end up with drugs that are exceptionally effective but are inappropriate for long term use for all of the reasons you mention.

If that was genuinely the case, might justify short-term inpatient stays in a way that is more convincing than current rationales, no?
 
The people most against using ketamine to treat depression tend to be the ones with the least experience. Check out the doses. Look at the selection criteria for who receive it at reputable places.

Poo-pooing ketamine for depression because you've seen people on Special K and equating the two is about as sensual as telling dentists they are insane for utilizing cocaine, cause hey man that stuff ruins lives.


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This is not true at all. See my post above about our department (which btw invented the term "excitotoxicity" and made seminal contributions to the idea of NMDA hypofunction). It's perfectly reasonably to have a healthy amount of skepticism with the available data and limitations that haven't yet been worked out to not want to go there just yet. On the contrary, a significant number of clinics outside academia are run by people who have no clue what they are doing, psychiatrists or otherwise.
Interestingly, the best and most well respected private practice psychiatrist in our town (who used to be on faculty in our department and still has an adjunct appointment) felt comfortable enough with the data to try it on some of his most difficult cases, and he said that for his practice it was largely unsuccessful.
 
It's perfectly reasonably to have a healthy amount of skepticism with the available data and limitations that haven't yet been worked out to not want to go there just yet. On the contrary, a significant number of clinics outside academia are run by people who have no clue what they are doing, psychiatrists or otherwise.
We are talking different things.

Rejecting ketamine because it's largely early and experimental? Fine. I'm talking about the folks arguing against it because of its misuse as Special K and all that other reactive stuff.


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I don't have much experience but I have worked with a researcher in this field and at a private hospital that was doing research in it.

My opinion, ketamine can be a very useful medication but I have serious doubts that many if not most of the ketamine clinics out there are drug dealers with white coats.

Why?
Well first ask yourself why would an anesthesiologist, the one type of physician even want to go into mental health treatment, a field they know so little about with their training?
And to give a medication with no established standard of care, no FDA approval for depression, no professional societal approval, with that medication having a strong abuse potential, all the while charging huge amounts of money for it?

And if even a physician wanted to give it with good intent shouldn't they be giving it only for severe and/or treatment resistant cases of depression? Then why a clinic that is advertising as if they want to give it to anyone even with mild depression and charging huge fees that are above standard treatments for depression?

Again ketamine will have IMHO a place in depression treatment that is more standard and patients can benefit from it now if it's severe enough but to give it out as if it's an SSRI so long as the patient it willing to give money IMHO is bad medicine.

Take for example a specific physician who I will not name who runs a ketamine clinic. His website claims he pioneered a treatment protocol for ketamine. Okay I checked his publications. He has only 1 and it's concerning schizophrenia. He "pioneered" a treatment protocol? Sounds like it's science but if it's not published or at least scrutinized by an outside source this is pretty much home-brewed treatment.

Okay so yes, with any cutting edge treatment one would be practicing outside the norm but ethically such treatments should be limited to cases where the conventional was tried and failed, done under high scrutiny, and not by someone who just read a few journal articles about the topic.

The Green Journal a few months ago published a case of a patient clearly abusing ketamine that was provided by a neurologist. If you read between the lines it seems like this neurologist didn't know WTF he was doing.
http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2015.15081082

Further buprenorphine is showing emerging data that it too can treat depression extremely quickly. Shall I then start giving it first line to every depressed patient I see? Of course not.

Also a place I used to work at did provide ketamine. It was done as part of a research study and IMHO ethically so especially since it did go through and IRB. All of the borderlines (rich borderlines that is) took it and just wanted to take it again and again and again and when told no they'd freak out and then you had an even bigger problem on your hands---a borderline that wants to use a substance of abuse to treat their emotional dysregulation.

I'll tell you why I don't think ketamine as a treatment is ridiculous.
1-The dosage to obtain the antidepressant benefit is not the dosage that gets most people high.
2-If it's administered in a controlled environment where depression was thoroughly investigated and other treatments tried addicts will likely not go through the vetting needed (e.g. several visits, thorough evaluations).
3-In an ER setting with the help of a central pharmacy doctors can make sure the patient isn't ER hopping getting one and then another cause only then the dosage would accumulate to amounts that would get one high,
4-There are neurootropic benefits being found suggesting the antidepressant benefit simply isn't because the patient isn't getting high. It might truly be getting rid of the depression in a beneficial physiological sense.

Again all of these require it be given in a judicious manner and not in the manner where so long as the person has enough money they can get the treatment. That's the problem with doctors giving ketamine now. They give it as if they're drug dealers.

I would've been open to giving it to a very small number of my patients and tried to do so in a controlled manner in a unversity setting and I wanted another doctor to vet my case at that time too. Ultimately we did not because the hospital head pharmacist couldn't figure a way to give it out that was appropriate in his opinion. This was literally a patient where the next option was brain surgery and everything else was tried.

Well lo and behold now some guy in Cincinnati opened his ketamine clinic where he's giving it out. Again how much is the state medical board looking into it? I bet hardly at all.

Great and thoughtful posts.
 
I would argue since other studies rely upon studies created for supporting evidence through referencing, this then taints all studies which quotes this study. I don't know how deep the rabbit hole is, but it does shine a light upon research methodology and results.
 
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I would argue since other studies rely upon studies created for supporting evidence through referencing, this then taints all studies which quotes this study. I don't know how deep the rabbit hole is, but it does shine a light upon research methodology and results.

Agreed that it is obviously a bad thing, but I am reluctant to embrace guilt by association as a means for evaluating scientific literature.

Good reason to be skeptical about this particular group's work, though.
 
That retraction was initiated by the department. Also, that paper described a particularly fast infusion - something that is not really done in most trials. The retraction doesn't take away the legitimacy of the many subsequent trials. Not having a good active placebo, on the other hand, is a more relevant issue.
 
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I asked my friendly locak ketamine clinic if I could visit for a day to see what they do, and they said it would cost me $10,000.
That didn't make me feel very confident about their state-of-the-art treatment protocol.
 
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