Ketamine myths and facts: What PCPs need to know [PODCAST]

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Join Carlene MacMillan, chief medical officer at Osmind, to explore the evolving role of primary care physicians in addressing mental health challenges, particularly in the context of emerging therapies like ketamine. We delve into misconceptions surrounding ketamine use, factors to consider when prescribing it, and its potential benefits when combined with psychotherapy.

Carlene MacMillan is chief medical officer, Osmind, a public benefit corporation dedicated to aiding clinicians and researchers in advancing life-saving mental health treatments. In this role, she concentrates on product development, growth initiatives, and medical affairs. Dr. MacMillan is also a co-founder of Fermata Health, an interventional psychiatry practice located in Brooklyn, NYC. She can be reached on X @CarleneMac.

She discusses the KevinMD article, “Ketamine for mental health conditions: What every primary care physician needs to know.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Carlene MacMillan. She’s a psychiatrist and chief medical officer at Osmind. Today’s KevinMD article is titled “Ketamine for mental health conditions: What every primary care physician needs to know.” Carlene, welcome to the show.

Carlene MacMillan: Thanks. Happy to be here.

Kevin Pho: So we’ll talk about ketamine in your article in a little bit, but first off, briefly share your story and journey.

Carlene MacMillan: Sure. So I’m an adult and child psychiatrist by training, still practicing, but for the past two years or so, I’ve been the chief medical officer at a health tech company called Osmind. We’re an electronic health record and technology platform specializing in breakthrough mental health treatments like ketamine.

Kevin Pho: All right, and tell us about that dual role you have, a physician executive as well as a practicing psychiatrist. So how did you get into that executive role?

Carlene MacMillan: Yeah, so I used to have a very large group practice and found myself essentially partnering with a number of different technology companies just to solve the problems in my day-to-day workflow, and eventually kind of went deeper with some of them. And one of them was Osmind, because I really saw a major gap in electronic health records for my specialty. So I ended up essentially selling my practice, going to work for Osmind full time, and then I still maintain a smaller private practice kind of on the side, where I use Osmind, of course. But I like to be able to essentially do both. I think they inform each other, for sure.

Kevin Pho: All right, so let’s talk about ketamine. Your KevinMD article is titled “Ketamine for mental health conditions: What every primary care physician needs to know.” And before telling us how this article came together, just give us some context and tell us what ketamine is.

Carlene MacMillan: Yeah, sure. So ketamine is an anesthetic. It’s on the World Health Organization list of essential medications. It’s been around for several decades, but for the past, well, over a decade, it’s been used off-label for psychiatric conditions like depression and particularly suicidality. So there’s been increasing interest in using it across settings, from outpatient to hospital settings to even now some home ketamine companies for mental health.

Kevin Pho: All right. And what kind of data supports its use in mental health conditions?

Carlene MacMillan: Yeah, so there’s a lot of real-world evidence supporting the use of IV ketamine, as well as clinical trials. The reason that it’s off-label is because it was originally studied for anesthetic conditions, and now it’s off-patent. So most of the data that we have comes from more real-world evidence studies, so people actually using it in clinical practice.

Kevin Pho: So your article is subtitled what primary care physicians need to know about ketamine. I’m a primary care physician. What do I need to know about ketamine?

Carlene MacMillan: Yeah, so hopefully you’ve heard of it, or patients are asking about it. So we wanted to write this article because indeed, it’s been in the mainstream public press a lot. People are getting ads for it, hearing all about different companies offering it. And I felt it was very important that primary care doctors in particular know what to say when patients are asking. And I think the biggest takeaway, as a psychiatrist, is that these are patients with pretty severe psychiatric conditions. And it’s important that if they’re going to be exploring the ketamine treatment landscape, it be done in collaboration with a mental health professional, which is not always the case.

Kevin Pho: So as you know, we have a lot of options from a primary care standpoint to treat depression and anxiety. So of all the treatments that we have available to us, where does ketamine land in that algorithm?

Carlene MacMillan: Yeah, so that’s a good question. So we used to say that about two-thirds of people with depression would respond to a typical antidepressant, your Prozac, Zoloft, et cetera. But more recent data suggests that actually may be reversed, and that maybe only about a third respond. And so that leaves a significant chunk of patients whose depression is not responding to those oral antidepressants. And so those are patients who have tried a medication or a couple different medications, it’s not doing the trick, and they’re still really impaired. They may be potentially a good candidate for ketamine.

Kevin Pho: So how long should we give an initial trial of antidepressants to work before determining that, “Hey, we need to try something else”?

Carlene MacMillan: Yeah, I mean, it definitely needs to be an adequate dose of the medication. So if you start the lowest dose of Prozac just for a couple of days, you’re not really going to get anywhere, but usually six to eight weeks on a therapeutic dose of one of these medications. And if there’s no response whatsoever, no partial improvement, chances are they’re not going to respond, and it would be time to switch gears.

Kevin Pho: OK, so we take that next step, and we involve the services of a mental health professional, and we’re considering ketamine. Tell us what a typical patient would look like. What would it look like for them if they were to undergo ketamine?

Carlene MacMillan: So patients can get ketamine in different contexts. So while there are direct-to-consumer companies, or they could even go online and answer some questions and meet with somebody, the setting that we really recommend is to meet with a clinician, usually a psychiatrist or psychiatric nurse practitioner, get a thorough evaluation of their mental health and medical history, and then either that mental health clinician would be the one directly overseeing the ketamine, or they may work in conjunction with an anesthesiologist or a CRNA who would be administering the ketamine, particularly if it’s IV. And typically, they would come in for a couple sessions a week for a couple weeks, usually about six to nine treatments over the course of several weeks. So over one or two months, they’re starting to see real improvements.

Kevin Pho: What would patients feel like? What would a typical session be like, going to a ketamine clinic?

Carlene MacMillan: Yeah, so with the ketamine clinics, we know the concept of set and setting is really important. So the mindset people go into: We really emphasize preparation with a clinician so they can set intentions. What do they want to get out of this? What are they wanting to work on? And then the setting, what kind of place or music. Can they select their own music that’s going to be calming for them, lights? I see you have some nice lights in your office, right? So things that make people feel calm and grounded. And then during the session, usually people wear eye masks and kind of go into that head space.

And then it’s not just about that head space, though, right? It’s about the changes that happen in the days to weeks after. We think ketamine is opening up kind of new learning in the brain. So it’s going to be the period of time in the weeks following that you’re going to be kind of more open to new experiences, maybe more open to what you’re working on in therapy, ready to kind of change behavioral patterns. And so we’re not just so much looking at the experience itself. It’s really that kind of aftermath.

Kevin Pho: And what age groups is ketamine typically targeted towards?

Carlene MacMillan: Yeah, so because it is off-label, it is used in a wide range. We don’t see it too much in younger children, but we do see it starting in adolescence. Adolescents who have really severe depression sometimes are being suggested to try it, but probably the majority, I would say, is adults. And then there are some more geriatric patients that will get it as well, but the vast majority are going to be 18 and up.

Kevin Pho: So tell us a typical case study that you would see where ketamine moved the needle for that patient. And it could be a hypothetical situation or one of your own patients, but just give us a scenario and a story where ketamine moved the needle.

Carlene MacMillan: Yeah, so I think for me, it’s patients that basically feel that suicidality is part of their day-to-day life. Like a person that thinks, “I’m always going to be suicidal. There’s no hope for me. This is just how it is. I’ve tried everything, been to the hospital, tried,” you know, somebody tried 27 medications, right? It’s like, is number 28 going to work? Probably not. It’s another pill.

Whereas when they get the ketamine, what I can recall distinctly is one person describing it like a light switch had been flipped, and that suicidality evaporated. It was just gone. And whether or not that lasts forever, the durability isn’t going to last forever, most likely, but what it showed them in that moment was, “This is just a state of mind. This is something going on chemically in my brain, and I just sat down, got this medication, and that feeling that I felt so strongly, that I needed to die, is gone. And that means that other things in my life could bring about that change, and that this is not a fixed state.” So that really has stuck with me, even when people say, “Oh, how long does it last? Am I going to need it again?” It’s like, we want to show you that this is chemistry in your brain that can be changed, because when you’re in that state, you feel like nothing is going to help.

Kevin Pho: And when one undergoes a course, how many weeks is that typically?

Carlene MacMillan: Yeah, so usually you’re talking about two months or so, because you’re getting a couple a week at first, and then down to once a week, and then it varies. And some people will just do that course and be done, and other people will continue on in more of a maintenance fashion, and that really usually depends on the individual person and their needs, as well as logistical and cost factors.

Kevin Pho: And you mentioned maintenance, so people come back long-term periodically for these treatments?

Carlene MacMillan: They do, they do. And so some people, particularly if they live near a clinic that’s offering this, may be able to come quite frequently in kind of an ongoing way. Whereas others may go and then go back home, wherever they are, and then six months later, a year later, maybe they need to come in for a full course again, or maybe just a little bit of a booster.

Kevin Pho: And what kind of side effects do patients typically experience?

Carlene MacMillan: Yeah, so I mean, it is a dissociative anesthetic, so people are going to experience some degree of dissociation and feeling like the world around them isn’t real. It does also cause a transient increase in blood pressure, so that’s all very normal. With abuse of ketamine in a high-dose manner, so not what we’re talking about in use in clinics, it can cause bladder injury and cystitis. So that would be like bleeding with urination and things, but that should not be with typical use.

Kevin Pho: And is ketamine typically covered by most insurance?

Carlene MacMillan: So sadly, it is not. For the IV ketamine, IM ketamine, it is not covered by the vast majority of insurance in the United States, because it is off-label for depression and pain. There is, however, since 2019, a version called esketamine, which is an intranasal ketamine. The brand name is Spravato, and that one actually is covered by insurance, because it specifically is designed for depression and acute suicidality. So that’s been just a game-changer for people that couldn’t afford ketamine otherwise. They can now get their insurance to cover it, that one form.

Kevin Pho: What would a typical cost be for a course of ketamine?

Carlene MacMillan: For a course of ketamine, yeah, so it varies based on parts of the country, but usually each session for IV ketamine would be like a couple hundred dollars. So you’re talking several thousand dollars for a full course. So for some people who are really suffering and have tried everything, that makes sense, but for others, it’s just not feasible, and so that’s when esketamine, or Spravato, comes into the picture. And then it would just be whatever their copays and deductibles are.

Kevin Pho: And you mentioned multiple times that it is off-label. Are there any ongoing studies or hope that it will become approved in the near future?

Carlene MacMillan: It’s a good question. I mean, so I think what Johnson & Johnson did with S-ketamine was they changed the molecule slightly to get the patent and do the studies and go through the whole approval. It really is almost cost-prohibitive to do that for a generic medication. So there are some more philanthropic organizations looking into starting full trials. We’ve been really encouraging the FDA to consider real-world evidence rather than these fancy placebo-controlled trials, because unfortunately, there’s just not been the impetus to spend tens of millions of dollars to run them for the generic medications. So we hope so, but I’m cautiously optimistic. And there are forward-thinking insurance companies. Blue Cross of Massachusetts, for example, is covering it now, which is wonderful.

Kevin Pho: And you mentioned that this is for depression and suicidality. Any other behavioral health conditions that people use ketamine off-label for?

Carlene MacMillan: Yeah, so for Spravato, it’s pretty strictly just that depression label and suicidality. For off-label ketamine, people are using it for other things. They’re using it for chronic pain, some evidence for OCD, use in trauma. So there can be even substance use. So there’s a lot of people that are using it in off-label ways under the supervision of psychiatry.

Kevin Pho: And if I were to look for a psychiatrist who was comfortable in prescribing ketamine, how common is it to find one? Would most psychiatrists be comfortable prescribing it?

Carlene MacMillan: So most psychiatrists, no. I think in most of our training, it’s gotten a little better, but most don’t get direct training in this. So you want to look for someone who specializes either in ketamine or ketamine-assisted therapy, or a specialty called interventional psychiatry. So interventional psychiatrists are going to be more likely to be offering things like ketamine.

Kevin Pho: And where can we find psychiatrists who would be comfortable prescribing ketamine? What are some resources online?

Carlene MacMillan: Yeah, so ASKP3 is the big organization for ketamine clinicians. So that’s a good place to start. And there’s also a great directory called healingmaps.org, and they list all different types of ketamine clinicians, as well as folks offering Spravato and other innovative treatments like TMS.

Kevin Pho: We’re talking to Carlene MacMillan. She’s a psychiatrist, and she’s the chief medical officer of Osmind. We’re talking about the KevinMD article “Ketamine for mental health conditions: What every primary care physician needs to know.” Carlene, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Carlene MacMillan: Yeah, so I think a big take-home message is really literally around taking ketamine home. So ketamine is a powerful agent of change, and so I think it’s really important that rather than having patients just going off and signing up for some website that’s going to mail it to them, if someone’s interested in this, you really work with them to work with a clinician that can give some very clear oversight of it in the outpatient setting, so people aren’t on their own with it.

Kevin Pho: Carlene, thank you so much for sharing your time and insight, and thanks again for coming on the show.

Carlene MacMillan: All right, well, thanks for having me.

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