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Speaker 1: My name is Lily Maddon and I'm a proud Arunda

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Speaker 1: Bunjelung Calcottin woman from Gadighl Country. The Daily oz acknowledges

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Speaker 1: that this podcast is recorded on the lands of the

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Speaker 1: Gadighl people and pays respect to all Aboriginal and Torres

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Speaker 1: Strait Island and nations. We pay our respects to the

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Speaker 1: first peoples of these countries, both past and present.

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Speaker 2: Hello, and welcome to the Daily os It's Sam. Welcome

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Speaker 2: to tda's summer series. I hope you're having a nice

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Speaker 2: couple of weeks over summer, whether you're working, taking some

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Speaker 2: time off, headed to a music festival, or just you know,

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Speaker 2: hanging out with family and friends. This week, we're going

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Speaker 2: to share more of our favorite deep dives from twenty

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Speaker 2: twenty three, from some of our most popular interviews to

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Speaker 2: some stories you might have missed. I guess we're trying

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Speaker 2: to keep your company here over the summer. We'll be

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Speaker 2: back to some regular programming next week. Until then, here

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Speaker 2: is our summer series.

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Speaker 3: Ketamine is commonly used in medicine and by vets as

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Speaker 3: an anesthetic. It's a disassociative drug, meaning it acts on

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Speaker 3: brain chemicals and it can stop the brain from interpreting

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Speaker 3: pain messages. Now it's also being used to treat depression

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Speaker 3: after low doses of the drug were found to quickly

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Speaker 3: and significantly improve depressive symptoms.

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Speaker 4: We know a lot of young people, a lot of

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Speaker 4: TDA listeners, live with depression. But for some people traditional

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Speaker 4: treatment options like antidepressants therapy that doesn't always actually work.

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Speaker 4: So for those people and others who might not be

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Speaker 4: able to take antidepressant medication for other reasons, ketymine treatment

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Speaker 4: could actually change the way mental ill health is treated

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Speaker 4: in Australia. But honestly, I had never actually heard of

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Speaker 4: ketamine being used in this way before this point Zas,

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Speaker 4: So you can imagine I had a lot of questions

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Speaker 4: and I put those to an expert in this field.

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Speaker 4: Dr Adam Bays is a Senior Research Fellow at the

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Speaker 4: Black Dook Institute. He is a clinical academic psychiatrist with

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Speaker 4: a special interest in mood disorders. Doctor Adam Bays, welcome

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Speaker 4: to the podcast.

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Speaker 5: Thanks for having me.

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Speaker 4: First of all, what is ketamine and why is it

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Speaker 4: useful in clinical settings to treat depression.

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Speaker 5: Keetamine is a anesthetic drug that's been around for a

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Speaker 5: long time. About twenty years ago, there was some pivotal

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Speaker 5: studies where there was sub aesthetic doses ketamine, so smaller

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Speaker 5: doses administered to patients with treatment resistant depression. So this

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Speaker 5: is where patients have failed multiple trials or standard treatments

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Speaker 5: oral antidepressant psychological therapies, and it was found to have

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Speaker 5: both a rapid antidepressant effect and also the effect was

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Speaker 5: quite pronounced, so quite a large impact on depression. And

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Speaker 5: since that time there's been more and more research into

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Speaker 5: the area of ketamine for treatment resistant depression and it's

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Speaker 5: been found to be very effective in that patient group.

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Speaker 4: What do we know about the scale of treatment resistant depression?

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Speaker 4: You know, what is it that we understand about it?

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Speaker 5: Obviously, you know depression, it's a complex diagnosis and there's

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Speaker 5: different sort of manner in festations of depression. So there's

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Speaker 5: more mild forms of depression that might be the result

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Speaker 5: of some life circumstances, and then all the way through

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Speaker 5: to the more severe biological forms of depression where there

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Speaker 5: might be a strong family history of depression. It starts

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Speaker 5: need to use medications like antidepressants or other drugs, and

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Speaker 5: you know, in the severe cases, things like electroc convulsive

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Speaker 5: therapy or ECT is still a highly effective treatment. And

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Speaker 5: there's probably around about a third of patients specified as

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Speaker 5: having treatment resistant depression, so it's quite a high number.

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Speaker 4: Yeah, that's a really significant number. I think that will

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Speaker 4: come as a surprise to a fair few of our listeners.

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Speaker 4: In terms of treatment options for this difficult to treat depression,

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Speaker 4: are there many options? And you've mentioned DCT. But considering

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Speaker 4: that ketamine treatment is a relatively new kind of phenomenon.

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Speaker 5: There have been exciting advancements also in neurosimulations, so things

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Speaker 5: like transcranial magnetic stimulation or TMS, which is very powerful

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Speaker 5: magnet's brought close to the skull. But ketamine is exciting

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Speaker 5: in the sense that in mental health it's good to

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Speaker 5: have an assortment of different options. Yeah, just gives patients

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Speaker 5: yet another option to get well.

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Speaker 4: A lot of people may have only heard of ketamine

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Speaker 4: used illegally or as an anesthetic. How does this treatment work,

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Speaker 4: how long does it take, and how does it differ

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Speaker 4: in that clinical setting from other uses of ketamine.

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Speaker 5: You would have heard of people recreationally using ketamine, and

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Speaker 5: this is because it can cause that associative effects and

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Speaker 5: have these sort of psychoactive effects, But I guess I'm

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Speaker 5: talking about it very much in a clinical medical setting,

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Speaker 5: where the drug is one hundred percent pure pharmaceutical grade

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Speaker 5: ketamine and it's diministered in a setting and patients are

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Speaker 5: carefully screened. Patients are usually on an antidepressant as well.

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Speaker 5: It can be administered in various ways. It's either usually

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Speaker 5: injected under medical supervision, or there is a form called

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Speaker 5: s ketamine which is intranasal spray. Mean tends to have

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Speaker 5: its maximal antidepressant effect the next day, and then it

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Speaker 5: does tend to wear off, and so patients then have

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Speaker 5: usually a second treatment. At least in the acute course,

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Speaker 5: you're trying to get the patient from being in a

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Speaker 5: major depressive episode. The goal is to get them into

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Speaker 5: remission where they're not no longer meeting criteria for depression.

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Speaker 5: It works quite differently to standard antidepressant treatments like you

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Speaker 5: know your SSRIs or Prozac as the brand name of

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Speaker 5: a famous SSRI, and these act on the serotonin system.

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Speaker 5: This is the kind of feel good neurotransmitter. Kenemine actually

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Speaker 5: doesn't act at least directly on serotonin, but it actually

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Speaker 5: acts on a completely different set of receptors. And I

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Speaker 5: guess the other thing is, yes, it works much more

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Speaker 5: rapidly than standard oral antidepressants. At least in some cases,

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Speaker 5: you can see patients significantly improved the next day. So

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Speaker 5: that's pretty incredible. And I think sometimes people think that

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Speaker 5: the patient might be sort of getting high, it's not that.

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Speaker 5: So while they have the acute effects of ketamine, and

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Speaker 5: they might feel dissociated and have some kind of an

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Speaker 5: unusual experience that wears off within the first hour, and

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Speaker 5: they usually discharged the two hour mark and they feel

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Speaker 5: completely back to you know, they don't have any kind

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Speaker 5: of association. But we're talking about it's actually an antidepressant

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Speaker 5: effect that's more enduring.

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Speaker 4: How is the long term or longer term success then

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Speaker 4: of this treatment measured? If there's that sort of immediate

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Speaker 4: relief of maybe depressive symptoms, is this a treatment that

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Speaker 4: is lifelong for people with treatment resistant depression.

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Speaker 5: Yeah, it's a great question. I think initially there was

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Speaker 5: certainly hope that patients might say, receive a course of ketamines,

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Speaker 5: to say, a four week course for example, then they'll

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Speaker 5: remain well. Certainly you do see that in some patients

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Speaker 5: clinically though. What we're seeing is some patients go into

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Speaker 5: what we call maintenance treatments, and this might mean that

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Speaker 5: they have a treatment, say every week, or maybe stretched

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Speaker 5: out to every two or three weeks, which keeps them well.

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Speaker 4: As can happen with other medications. Is there a dependency

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Speaker 4: over time or a resistance perhaps over time to ketamine treatment.

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Speaker 5: You can't become addicted as such to a surprise act, right, ketamine?

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Speaker 5: That is actually possible. While we don't tend to see

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Speaker 5: that in clinical settings, it's something to be mindful of,

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Speaker 5: and that's why it's also a restricted substance. We're very

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Speaker 5: cautious about that because we're not wanting to create a

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Speaker 5: further problem for the patient. We put a lot of

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Speaker 5: time into ensuring they're not becoming dependent. It's also why

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Speaker 5: ketamine is administered in the clinic.

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Speaker 4: Are there any other risks or sort of safety concerns

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Speaker 4: associated with receiving the treatment?

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Speaker 5: Yeah, look, there are, and I think like any medication

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Speaker 5: you know, has a side effect profile, and keta means

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Speaker 5: no different. One of the key things that we monitor for.

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Speaker 5: There can be blood pressure increases, certainly acutely as well.

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Speaker 5: Patients you know, can become dissociated, unsteady on their fee.

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Speaker 5: Then in the long run I mentioned risk of dependence.

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Speaker 5: Ketamine can irritate the bladder and sometimes ketamine can affect

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Speaker 5: the liver. You know, ketamine services that are out there,

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Speaker 5: they should be monitoring for accus and cumulative cyber effects.

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Speaker 4: I noted that at least in the clinic that recently

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Speaker 4: opened in Melbourne, that young people are excluded under twenty

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Speaker 4: fives are excluded from accessing the treatment. I guess this

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Speaker 4: ties into kind of broader questions about barriers to access,

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Speaker 4: you know, cost, who can access it, so, you know,

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Speaker 4: the kind of demand versus that.

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Speaker 5: I mean, generally it's eighteen and over purely because there's

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Speaker 5: more data on the safety and effectiveness in that age group.

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Speaker 5: I know there has been a big multisensor study looking

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Speaker 5: at ketamine and younger people that have depression. You mentioned cost.

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Speaker 5: It's a big one because ketamine is it's sort of

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Speaker 5: in this interesting zone where it's you've got the two formulations.

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Speaker 5: The anesthetic who's been around for fifty years. All medications

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Speaker 5: have a kind of license and they have indications. It

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Speaker 5: still remains only licensed for anesthesia. If it's administered for

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Speaker 5: anything other than anesthesia, it's it's off label. Then there's

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Speaker 5: the new formulation which is intranasal s ketamine. So it's

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Speaker 5: a variant of ketamine. But that has been TGA approved

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Speaker 5: in Australia. But the issue is it's not covered by

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Speaker 5: the PBS yet. There's a period of time where the

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Speaker 5: drug companies have to make a case to the government,

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Speaker 5: you know, will you subsidize this drug. So patients can

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Speaker 5: certainly go out and you know, they see their psychiatrist.

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Speaker 5: Their psychiatrists might recommend the internasales ketamine, but it's anywhere

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Speaker 5: between six to eight hundred dollars per dose.

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Speaker 4: Wow.

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Speaker 5: So and the usual dosing, as I said, is twice

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Speaker 5: per week initially for the first four weeks. So that's

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Speaker 5: that's a big cost, right enormoss that's sixteen hundred dollars

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Speaker 5: or more per week per week, and that's because it's

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Speaker 5: not on the PBS. The other thing is when you

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Speaker 5: go and see a doctor, most things have an item number.

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Speaker 5: So for example, if you go and have your appendix removed,

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Speaker 5: there'd be a sort of item number. Medicare reimburses you

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Speaker 5: or covers that.

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Speaker 1: Right.

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Speaker 5: So for ketamine treatment, which as I explained, you know,

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Speaker 5: it involves coming in to the clinic. There, you're monitored,

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Speaker 5: you've seen by a psychiatrists. Is two hours of monitoring

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Speaker 5: and you discharge. There's no item number for that, not

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Speaker 5: just the drug, but for the whole process. There's no

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Speaker 5: item number. So again, all of that clinical time is

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Speaker 5: paid for out of pocket by the patient. So at

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Speaker 5: the moment we are in a situation where, other than

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Speaker 5: there's a few public clinics where it's sort of subsidized

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Speaker 5: by whatever funds the hospital might have, the patient pays out.

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Speaker 4: Of pocket waiting for that magic number.

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Speaker 5: Yeah, it's a big issue really because you know, it

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Speaker 5: speaks to you know, inequality and equity, and particularly I

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Speaker 5: guess younger people are less likely to have the funds.

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Speaker 4: Do you think there's any stigma associated with the idea

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Speaker 4: or the reputation of ketamine that may have impacted access.

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Speaker 5: I think there is some stigma in the sense of certainly,

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Speaker 5: whenever I read a newspaper article, or at least up

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Speaker 5: until a few years ago, it would always say horse tranquilizer,

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Speaker 5: which is I always found a bit sensationalist. Because ketamine

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Speaker 5: is used as a regular anesthetic in human It was.

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Speaker 4: Only researching for this podcast that I realized that horse

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Speaker 4: tranquilizer wasn't the original.

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Speaker 5: Purpose, so it's a bit sensationalist. And whereas ketamine is

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Speaker 5: used day and day out in surgeries, it's used in

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Speaker 5: children for the purposes of anesthesia. I guess the recreational use,

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Speaker 5: et cetera. It has become a bit more controversial. But

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Speaker 5: you know, it's a medicine like any other medications, and

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Speaker 5: if you just look at the science, it does seem

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Speaker 5: to be effective in treement resistant depression. But feel get

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Speaker 5: opioids and things like that pain medications misused, So any

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Speaker 5: drug really can be misused. But I think the key

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Speaker 5: thing is for us in health is providing access to

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Speaker 5: it in such a way that's safe. It's in a

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Speaker 5: controlled setting, it's not going to be diversion to recreational users,

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Speaker 5: and it's not going to cause further problems for patients.

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Speaker 4: Your colleague, professor Colleen lou She described accessibility to be

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Speaker 4: the next challenge for the treatment. Where do you see

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Speaker 4: ketamine treatment moving in Australia in the next five to

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Speaker 4: ten years.

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Speaker 5: Yeah, that's an excellent question. Look, I think the accessibility

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Speaker 5: question really it's getting this MBS item number, the Medicare

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Speaker 5: item number is going to be critical. If that gets up,

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Speaker 5: that will mean a broader section of the community can

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Speaker 5: access the treatment. I imagine it will become rolled out

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Speaker 5: into public mental health. Obviously, there need to be an

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Speaker 5: infrastructure there and all the appropriate training and all the

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Speaker 5: knowledge that goes into this. Because it is quite a

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Speaker 5: specialized treatment, it will become more mainstream for treatment resistant depression.

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Speaker 5: There is enough data now to say that it's effective

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Speaker 5: and safe. I think it'll be also getting it out

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Speaker 5: into regional senses as well. That'll be exciting to see

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Speaker 5: it rolled out and available to more people.

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Speaker 3: I think that was a really interesting chat. I know

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Speaker 3: I learned a lot from it. If you did too,

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Speaker 3: send it to a friend, it might be a conversation starter.

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Speaker 1: You never know.

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Speaker 3: Have a great day and we'll be back again tomorrow.