Thinking about setting up a Ketamine Clinic

This is a letter in draft I'd like to send out to Family Doctors in my area to get a conversation started about Ketamine for depression in Auckland:

Dear Colleague,

Ketamine is a dissociative anaesthetic drug often used in the anaesthesia of children or adults undergoing outpatient procedures due to is tolerability and safety compared to a number of alternatives. It has been proven that lower doses of Ketamine can produce rapid relief from depressive symptoms, and that with repeated administration, sustained remission may be achieved over a period of months. Ketamine shows promise in the treatment of treatment resistant depression, that is, depressive illnesses which are difficult to treat despite multiple courses of therapy. Response rates and side effect burdens of ketamine are favourable, compared to treatment with other alternatives for people with TRD, which include neurostimulation and electroconvulsive therapy, as well as combinations of medications. Some people do not respond to any other measures, but may still respond positively to treatment with ketamine.

As the research has focussed on persons with treatment resistant depression, and more recently anxiety disorders, Ketamine will only be offered to those patients who have an established treatment resistant condition. I am willing to use ketamine for suitable patients who are referred by their own psychiatrist, or to take over the patient's care myself whilst they are undergoing a course of Ketamine treatment. Some patients may remit after a course of treatments, which may take up to three months, and be administered up to twice per week. Other patients may need relatively prolonged maintenance treatment, with varying time between treatments but not usually more than a month.

With regard to consent to treatment, informed consent should be undertaken with a psychiatrist, with a record kept of the fact that this is off-label, but not experimental use of the drug, with written information about effects, side effects and alternatives.

The best setting for treatment with Ketamine is a General Practice setting. The requirements are simple - a small room, a lazyboy, access to nursing staff if necessary, basic monitoring equipment, and a doctor on site. Doses used for the treatment of depression are minimal, administered subcutaneously, and may or may not produce psychoactive effects. Adverse experiences are usually of an existential nature, occur within the patient, and do not produce marked outward agitation. In the rare instances where this has occurred, it has been necessary to use small doses of IM midazolam, and this necessity is another reason why treatment in a GP setting is preferable. Patients should stay for 2 hours post injection, and should not drive themselves home. Thus, the number of patients who can be treated at one time is fairly limited, and the cost in a private setting may be relatively high, initially borne by patients themselves, with a view to treating some DHB patients at their request in future.

Another major reason for undertaking treatment in a GP setting is the normalisation of mental health in general. Many of the patients may prefer to attend an outpatient clinic than a hospital, and some may have disappointing or negative experiences with hospitals, but most people are comfortable with attending a GP's office.

I see this as the beginning of a conversation, I'm very happy to discuss with GP colleagues any questions that arise, and to provide and facilitate training for nursing staff involved. Please give me feedback and suggestions on how me might get started on providing what is a very important service missing from the Auckland mental health landscape.

Please visit http://www.ketamineadvocacynetwork.org/research-gateway/ for more original research material about the use of ketamine in psychiatry.

Many thanks,
Dr Caleb Armstrong
Practice 92"