Hope in Treatment-Refractory Depression

Bret Stetka, MD; David Feifel, MD, PhD


January 10, 2013

Editorial Collaboration

Medscape &

In This Article

How to Use It

Medscape: How does your group administer ketamine?

Dr. Feifel: When we started offering ketamine, it was administered in an intensive monitoring environment -- the post-anesthesia care unit (PACU) at UCSD Medical Center -- and it was administered intravenously by anesthesiologists. The problems with that were 2-fold.Because of the involvement of the anesthesiologist and the intensive setting, the cost of an infusion was very high, and given that patients could require more than one infusion to continue to extract benefit, the treatment was cost prohibitive for many eligible patients. The second problem was the PACU was not a highly conducive setting for this treatment. So, we worked with our anesthesiology colleagues and the UCSD Medical Center and our Pharmacy and Therapeutics committee to develop a protocol that was specific for using low-dose ketamine to treat depression that did not require anesthesiologists to administer it. That has allowed us to move the ketamine infusions to an outpatient infusion center and lower the cost. It is still done in a hospital setting but a much more conducive environment for this type of treatment.

Medscape: Can you walk us through the typical patient experience? And how does dosing work?

Dr. Feifel: Well, keep in mind that our approach is evolving as we learn more about the drug and how best to use it to help patients. Typically, we start with the well-established infusion regimen of 0.5 mg/kg infused intravenously over 40 minutes. The efficacy rate we have been seeing from this single infusion is approximately 70%-80%.

Medscape: Is the response immediate?

Dr. Feifel: Almost all of the patients we have treated describe a dissociative experience that comes on fairly early during the infusion. Everyone experiencing this has generally retained an overarching sense of reality; that is to say, they recognized their dissociative experience for what it was: a drug-induced perceptual distortion. Most patients find it to be a bizarre but enjoyable experience. When we turn off the infusion, those dissociative sensations dissipate very quickly, typically within 30 minutes. However, the interruption of their oppressive depressive symptoms that occurred during the infusion typically persists.