IV Ketamine for treatment of Depression and Bi-polar disorder

1. IV Ketamine for treatment of Depression and Bi-polar disorder • A. Scott Aylwin, PhD Senior Director, Addiction & Mental Health

2. A patient in need • A very ill female patient (Ms. P) at the Grey Nuns Community Hospital • Had been treated with every typical intervention but without success • Psychotherapy • rTMS • ++medications • ++ECT • Clinician from Ottawa presented a Grand Rounds on IV Ketamine at the GNCH

3. A Doctor wanting to help • Dr. Jan Banasch at the GNCH • Reached out to other clinicians across the country to get Ms. P IVK treatment – no success • Sought protocols from other sites on IVK • Went to UBC to investigate further • Set up an IVK working group at the GNCH • Ms. P was the first patient in the Edmonton Zone to receive IVK

4. Teams wanting to respond • Advancements in Psychiatry happen slowly • Great interest by both COV Sites to effectively and safely deliver this intervention • Working group at the GNCH was replicated at the MCH • Multi-disciplinary from the very start • The teams were passionate and persuasive. • Support for using IV Ketamine came from several parts of the organization

5. Teams leading the way • With a great deal of caution and rigor, the ‘Covenant Protocol’ evolved for both acute and ongoing treatment and monitoring • MCH group lobbied AHS to include IVK on formulary for treatment resistant depression • The literature for IV Ketamine is encouraging but limited. Some resistance to embrace this tx • Clinical response was very encouraging and patients were responding well • There is currently a great deal of interest, optimism, and research into IVK for Depression and Bi-Polar Disorder internationally

7. Taking the protocol further and leading the field • The MCH group has led the way in putting research context around the IVK protocol and treatment • This work has now spurred a Zone wide IVK Committee where the COV group is helping spread this at other sites • Have been actively collaborating with academics and clinicians at other sites nationally and internationally • Have begun to publish and present their findings • Generating significant outside interest

8. Adding to the literature… • Lee V., Archer S., ChrenekC., & Swainson J. (2019). A response to: Repeated intranasal ketamine for treatment resistant depression: The way to go? Results from a pilot randomised controlled trial. Journal of Psychopharmacology.Vol. 33(2): 258–259 • Archer S., ChrenekC. & Swainson J. (2018). Maintenance Ketamine Therapy for Treatment Resistant Depression. J ClinPsychopharm, 38(4): 380-384. • Thomas RK., Baker G., Lind, J. & Dursun, S. (2018).Rapid effectiveness of intravenous ketamine for ultraresistant depression in a clinical setting and evidence for baseline anhedonia and bipolarity as clinical predictors of effectiveness. J Psychopharmacol, 32(10).

9. The best type of innovation • Starts with patient need • Caring professionals find a possible solution • A team comes together to ensure safety and sound clinical care • An Innovative practice develops • The team becomes a resource to others and engages in Knowledge Translation

10. Questions?

11. Baseline Assessment • Completed within 2 weeks prior to first treatment • Baseline Physical examination on provided sheet • Weight • Urinalysis • Urine drug screen • hCG (serum or urine) • Blood work (CBC, electrolytes, AST, ALT, GGT, TSH) • ECG • Vital Signs • Medical Consult when necessary • Second psychiatrist consult

12. Psychological Assessments • Pre-Treatment, Weekly & End of Acute Course • Quick Inventory of Depressive Symptomatology (QIDS) • Perceived Deficits Questionnaire (PDQ) • Zung Self-Rating Depression Scale • Suicide Risk Screen/Assessment (if acutely suicidal) • Montreal Cognitive Assessment (MOCA) – • Pre-treatment Only

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