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

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Speaker 1: Bungelung Cargoton 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: Good morning and welcome to the Daily OS. It's Thursday,

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Speaker 2: the nineteenth of October. I'm Zara, I'm Emma Gillespie.

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Speaker 3: I'm the deputy editor here at the Daily OS.

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Speaker 2: You might have noticed that we are changing up the

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Speaker 2: regular lineup a bit. There has been a bit of

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Speaker 2: flux in the TDA office with a few people taking

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Speaker 2: leave at the same time. But I'm so glad to

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Speaker 2: be joined by m today again. What are we talking

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Speaker 2: about today?

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Speaker 3: Very happy to be here today because we've got a

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Speaker 3: really interesting one to discuss. We're talking about a new

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Speaker 3: treatment option for depression that's been popping up around the

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Speaker 3: country in clinics.

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Speaker 2: The Royal Melbourne Hospital recently own opened the third public

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Speaker 2: clinic in the country to offer kenemine treatment for patients

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Speaker 2: with what's called treatment resistant depression. Now that's a type

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Speaker 2: of depression that doesn't respond to antidepressant medication or other treatments.

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Speaker 3: Yep. So I'm chatting with Black Dog Institute researcher doctor

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Speaker 3: Adam Bayes to understand what that means and how it

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Speaker 3: all works next.

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Speaker 2: But first, m here's what's making headlines. US President Joe

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Speaker 2: Biden has met with Israeli PM Benjamin Manetta Yahu in

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Speaker 2: Tel Aviv after arriving in the country last night. A

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Speaker 2: meeting with Palestinian Authority President Mahmurabas set to take place today,

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Speaker 2: was canceled after hundreds of Palestinians were killed when a

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Speaker 2: rocket hit a hospital in Gaza. Garz In Health Authority

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Speaker 2: said the blast was caused by an Israeli air strike,

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Speaker 2: while the Israeli Defense Forces blamed it on a misfire

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Speaker 2: by a group called Palestinian Islamic Jihad. On this and

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Speaker 2: I quote, Biden said, based on the information we've seen

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Speaker 2: to date, it appears the result of an errant rocket

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Speaker 2: fired by a terrorist group from Gaza. Biden also announced

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Speaker 2: one hundred million US dollars for humanitarian aid in Gaza

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Speaker 2: and the West Bank.

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Speaker 3: Non fatal strangulation would become a standalone offense under new

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Speaker 3: legislation tabled in Victoria on Wednesday. Intentional non fatal strangulation

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Speaker 3: without proof of injury could result in up to five

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Speaker 3: years imprisonment, which would rise to ten years for more

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Speaker 3: serious offenses. The reforms have been tabled to protect victim

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Speaker 3: survivors and hold perpetrators to account.

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Speaker 2: New laws to increase paid parental leave will be tabled

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Speaker 2: in federal Parliament today. Under the proposal, paid parental leave

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Speaker 2: would increase to twenty six weeks in July twenty twenty six,

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Speaker 2: with incremental increases to parental leave in the years leading

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Speaker 2: up to that point. The reforms were first announced by

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Speaker 2: the government last year to raise paid parental leave from

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Speaker 2: eighteen weeks. New parents will also be allowed to take

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Speaker 2: four weeks of concurrent leave, meaning both parents can go

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Speaker 2: on paid leave at the same time from twenty twenty six.

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Speaker 2: The government says it will send a strong signal that

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Speaker 2: both parents play a role in caring for their children.

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Speaker 2: And the good news the soccer rows have won something

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Speaker 2: I had never yet heard before, the soccer ashes. It

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Speaker 2: follows a two nil victory against New Zealand in London.

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Speaker 2: The Soccer Ashes is a trophy containing the ashes of

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Speaker 2: cigars smoked by the captains of Australia and New Zealand

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Speaker 2: after a match in nineteen twenty three. The trophy disappeared

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Speaker 2: in nineteen fifty four and was rediscovered in a suburban

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Speaker 2: garage earlier this year. While this story took quite the turn,

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Speaker 2: the soccer Us will play their next match in Melbourne

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Speaker 2: in one month. Ketamine is commonly used in medicine and

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Speaker 2: by vets as an anesthetic. It's a disassociative drug, meaning

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Speaker 2: it acts on brain chemicals and it can stop the

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Speaker 2: brain from interpreting pain messages. Now it's also being used

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Speaker 2: to treat depression, after low doses of the drug were

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Speaker 2: found to quickly and significantly improve depressive symptoms.

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Speaker 3: We know a lot of young people, a lot of

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Speaker 3: TDA listeners live with depression, but for some people traditional

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Speaker 3: treatment options like antidepressants therapy that doesn't always actually work.

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Speaker 3: So for those people and others who might not be

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Speaker 3: able to take antidepressant medication for other reasons, ketymine treatment

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Speaker 3: could actually change the way mental ill health is treated

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Speaker 3: in Australia. But honestly, I had never actually heard of

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Speaker 3: ketamine being used in this way before this point Zza,

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Speaker 3: so you can imagine I had a lot of questions

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Speaker 3: and I put those to an expert in this field.

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Speaker 3: Dr Adam Bays is a Senior Research Fellow at the

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Speaker 3: Black Talk Institute. He is a clinical academic psychiatrist with

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Speaker 3: a special interest in mood disorders. Dr Adam Bays, Welcome

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Speaker 3: to the podcast.

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Speaker 4: Thanks for having me.

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Speaker 3: First of all, what is ketamine and why is it

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Speaker 3: useful in clinical settings to treat depression.

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Speaker 4: Petamine is a anesthetic drug that's been around for a

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Speaker 4: long time. About twenty years ago, there was some pivotal

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Speaker 4: studies where there was sub aesthetic doses ketamine, so smaller

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Speaker 4: doses administered to patients with treatment resistant depression. So this

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Speaker 4: is where patients have failed multiple trials or standard treatments

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Speaker 4: oral antidepressant psychological therapies, and it was found to have

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Speaker 4: both a rapid antidepressant effect and also the effect was

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Speaker 4: quite pronounced, so quite a large impact on depression. And

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Speaker 4: since that time, there's been more and more research into

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Speaker 4: the area of ketamine for treatment resistant depression, and it's

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Speaker 4: been found to be very effective in that patient group.

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Speaker 3: What do we know about the scale of treatment resistant depression?

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Speaker 3: You know, what is it that we understand about it?

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Speaker 4: Obviously, you know depression, it's a complex diagnosis and there's

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Speaker 4: different sort of manifestations of depression. So there's more mild

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Speaker 4: forms of depression that might be the result of life circumstances,

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Speaker 4: and then all the way through to the more severe

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Speaker 4: biological forms of depression where there might be a strong

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Speaker 4: family history of depression. It starts need to use medications

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Speaker 4: like antidepressants or other drugs, and in the severe cases,

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Speaker 4: things like electroc convulsive therapy or ECT is still a

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Speaker 4: highly effective treatment. And it's probably around about a third

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Speaker 4: of patients specified as having treatment resistant depression, so it's

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Speaker 4: quite a high number.

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Speaker 3: Yeah, that's a really significant number. I think that will

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Speaker 3: come as a surprise to a fair few of our listeners.

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Speaker 3: In terms of treatment options for this difficult to treat depression,

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Speaker 3: are there many options? And you've mentioned DCT, but considering

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Speaker 3: that ketamine treatment is a relatively new kind of phenomenon.

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Speaker 4: There have been exciting advancements also in neurosimulations, so things

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Speaker 4: like transcranial magnetic stimulation or TMS, which is very powerful

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Speaker 4: magnets brought close to the skull. But ketamine is exciting

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Speaker 4: in the sense that in mental health it's good to

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Speaker 4: have an assortment of different options. Yeah, it just gives

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Speaker 4: yet another option to get well.

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Speaker 2: A lot of.

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Speaker 3: People may have only heard of ketamine used illegally or

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Speaker 3: as an anesthetic. How does this treatment work, how long

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Speaker 3: does it take, and how does it differ in that

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Speaker 3: clinical setting from other uses of ketamine.

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Speaker 4: We would have heard of people recreationally using ketamine, and

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Speaker 4: this is because it can cause that dissociative effects and

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Speaker 4: have these sort of psychoactive effects. But I guess I'm

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Speaker 4: talking about it very much in a clinical medical setting,

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Speaker 4: where the drug is one hundred percent pure pharmaceutical grade

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Speaker 4: ketamine and it's diministered in a setting and patients are

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Speaker 4: carefully screened. Patients are usually on an antidepressant as well.

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Speaker 4: It can be administered in various ways. It's either usually

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Speaker 4: injected under medical supervision, or there is a form called

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Speaker 4: sketamine which is intranasal spray. So the ketamine tends to

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Speaker 4: have its maximal antidepressant effect the next day, and then

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Speaker 4: it does tend to wear off, and so patients then

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Speaker 4: have usually a second treatment. At least in the acute course,

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Speaker 4: you're trying to get the patient from being in a

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Speaker 4: major depressive episode. The goal is to get them into

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Speaker 4: remission where they're not no longer meeting criteria for depression.

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Speaker 4: It works quite differently to standard antidepressant treatments like you know,

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Speaker 4: your SSRIs or Prozac as the brand name of a

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Speaker 4: famous SSRI, and these act on the serotonin system. This

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Speaker 4: is the kind of feel good neurotransmitter. Ketemine actually doesn't

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Speaker 4: act at least directly on serotonin, but it actually acts

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Speaker 4: on a completely different set of receptors. And I guess

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Speaker 4: the other thing is, yes, it works much more rapidly

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Speaker 4: than standard oral antidepressants. At least in some cases, you

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Speaker 4: can see patients significantly improved the next day. So that's

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Speaker 4: pretty incredible. And I think sometimes people think that the

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Speaker 4: patient might be sort of getting high, it's not that.

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Speaker 4: So while they have the acute effects of ketamine and

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Speaker 4: they might feel dissociated and have some kind of an

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Speaker 4: unusual experience that wears off within the first hour, and

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Speaker 4: they usually discharged the two hour mark and they feel

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Speaker 4: completely back to you know, they don't have any kind

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Speaker 4: of association, but we're talking about it's actually an antidepressant

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Speaker 4: effect that's more enduring.

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Speaker 3: How is the long term or longer term success then

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Speaker 3: of this treatment measured. If there's that sort of immediate

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Speaker 3: relief of maybe depressive symptoms, is this a treatment that

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Speaker 3: is life long for people with treatment resistant depression.

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Speaker 4: Yeah, it's a great question. I think Initially there was

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Speaker 4: certainly hope that patients might, say, receive a course of ketamines,

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Speaker 4: to say, a four week course for example, then they'll

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Speaker 4: remain well. Certainly you do see that in some patients. Clinically, though,

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Speaker 4: what we're seeing is some patients go into what we

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Speaker 4: call maintenance treatments, and this might mean that they have

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Speaker 4: a treatment, say every week, or maybe stretched out to

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Speaker 4: every two or three weeks, which keeps them well.

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Speaker 3: As can happen with other medications. Is there a dependency

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Speaker 3: over time or a resistance perhaps over time to ketamine treatment.

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Speaker 4: You can't become addicted as such to a surprise act,

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Speaker 4: right ketamine. That is actually possible. While we don't tend

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Speaker 4: to see that in clinical settings, it's something to be

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Speaker 4: mindful of, and that's why it's also a restricted substance.

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Speaker 4: We're very cautious about that because we're not wanting to

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Speaker 4: create a further problem for the patient. We put a

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Speaker 4: lot of time into ensuring they're not becoming dependent. It's

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Speaker 4: also why ketamine is administered in the clinic.

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Speaker 3: Are there any other risks or sort of safety concerns

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Speaker 3: associated with receiving the treatment?

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Speaker 4: Yeah, look there are, and I think like any medication

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Speaker 4: you know, has a side effect profile, and keta means

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Speaker 4: no different. So some of the key things that we

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Speaker 4: monitor for. There can be blood pressure increases, certainly acutely

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Speaker 4: as well. Patients you can become dissociated, unsteady on their fee.

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Speaker 4: Then in the long run I mentioned risk of dependence.

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Speaker 4: Ketamine can irritate the bladder and sometimes ketamine can affect

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Speaker 4: the liver. You know, ketamine services that are out there,

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Speaker 4: they should be monitoring for accus and cumulative cyber effects.

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Speaker 3: I noted that at least in the clinic that recently

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Speaker 3: opened in Melbourne, that young people are excluded under twenty

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Speaker 3: fives are excluded from accessing the treatment. I guess this

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Speaker 3: ties into kind of broader questions about barriers to access,

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Speaker 3: you know, cost, who can access it, so you know

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Speaker 3: the kind of demand versus that.

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Speaker 4: I mean generally it's eighteen and over purely because there's

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Speaker 4: more data on the safety and effectiveness in that age group.

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Speaker 4: I know that there has been a big multisensor study

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Speaker 4: looking at ketamine and younger people that have depression. You

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Speaker 4: mentioned cost. It's a big one because ketamine is it's

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Speaker 4: sort of in this interesting zone where it's you've got

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Speaker 4: the two formulations. The anesthetic who's been around for fifty

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Speaker 4: years or Medica have a kind of license and they

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Speaker 4: have indication. It still remains only licensed for anesthesia. If

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Speaker 4: it's administered for anything other than anesthesia, it's it's off label.

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Speaker 4: Then there's the new formulation, which is intranasal s ketamine,

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Speaker 4: so it's a variant of ketamine. But that has been

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Speaker 4: TGA approved in Australia. But the issue is it's not

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Speaker 4: covered by the PBS yet. There's a period of time

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Speaker 4: where the drug companies have to make a case to

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Speaker 4: the government, you know, will you subsidize this drug. So

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Speaker 4: patients can certainly go out and you know, they see

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Speaker 4: their psychiatrist. Their psychiatrists might recommend the internasales ketamine, but

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Speaker 4: it's anywhere between six to eight hundred dollars per dose.

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Speaker 3: Wow.

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Speaker 4: So and the usual dosing, as I said, is twice

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Speaker 4: per week initially for the first four weeks. So that's

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Speaker 4: that's a big cost, right ENRMS. That's sixteen hundred dollars

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Speaker 4: or more per week per week, and that's because it's

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Speaker 4: not on the PBS. The other thing is when you

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Speaker 4: go and see a doctor, most things have an item

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Speaker 4: So for example, if you go and have your appendix removed,

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Speaker 4: there'd be a sort of item number. Medicare reimburses you

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Speaker 4: or covers that. Right. So for ketamine treatment, which as

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Speaker 4: I explained, you know it involves coming in to the

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Speaker 4: clinic there, you monitored, you've seen by a psychiatrists. Is

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Speaker 4: two hours of monitoring, and you discharge. There's no item

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Speaker 4: number for that, not just the drug, but for the

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Speaker 4: whole process. There's no item number. So again, all of

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Speaker 4: that clinical time is paid for out of pocket by

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Speaker 4: the patient. So at the moment we are in a

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Speaker 4: situation where, other than there's a few public clinics where

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Speaker 4: it's sort of subsidized by whatever funds the hospital might have,

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Speaker 4: the patient pays out of.

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Speaker 3: Pocket waiting for that magic number.

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Speaker 4: Yeah, it's a big issue really because you know, it

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Speaker 4: speaks to you know, inequality and equity, and particularly I

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Speaker 4: guess younger people are less likely to have the funds.

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Speaker 3: Do you think there's any stigma associated with the idea

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Speaker 3: or the reputation of ketamine that may have impacted access.

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Speaker 4: I think there is some stigma in the sense of certainly,

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Speaker 4: whenever I read a newspaper article, or at least up

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Speaker 4: until a few years ago, it would always say horse tranquilizer,

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Speaker 4: which is I always found a bit sensationalist because ketamine

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Speaker 4: is used as a regular anesthetic in human It was.

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Speaker 3: Only researching for this podcast that I realized that horse

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Speaker 3: tranquilizer wasn't the original purpose.

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Speaker 4: It's a bit sensationalist. And whereas ketamine is used day in,

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Speaker 4: day out in surgeries, it's used in children for the

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Speaker 4: purposes of anesthesia, I guess the recreational use, et cetera.

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Speaker 4: It has become a bit more controversial. But you know,

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Speaker 4: it's a medicine like any other medications, and if you

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Speaker 4: just look at the science, it does seem to be

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Speaker 4: effective in treatment resistant depression. But if you get opioids

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Speaker 4: and things like that, pain medications are misused, So any

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Speaker 4: drug really can be misused. But I think the key

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Speaker 4: thing is for us in mental health is providing access

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Speaker 4: to it in such a way that's safe. It's in

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Speaker 4: a controlled setting, it's not going to be diversion to

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Speaker 4: recreation users, and it's not going to cause further problems

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Speaker 4: for patients.

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Speaker 3: Your colleague, Professor Colleen lou She described accessibility to be

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Speaker 3: the next challenge for the treatment. Where do you see

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Speaker 3: ketamine treatment moving in Australia in the next five to

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Speaker 3: ten years.

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Speaker 4: Yeah, that's an excellent question. Look, I think the accessibility

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Speaker 4: question really it's getting this MBS item number. The Medicare

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Speaker 4: item number is going to be critical. If that gets up,

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Speaker 4: that will mean a broader section of the community can

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Speaker 4: access the treatment. I imagine it will become rolled out

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Speaker 4: into public mental health. Obviously, there need to be an

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Speaker 4: infrastructure there and all the appropriate training and all the

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Speaker 4: knowledge that goes into this. Because it is quite a

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Speaker 4: specialized treatment, it will become more mainstream for treatment resistant depression.

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Speaker 4: There is enough data now to say that it's effective

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Speaker 4: and safe. I think it'll be also getting it out

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Speaker 4: into regional senses as well. That'll be exciting to see

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Speaker 4: it rolled out and available to more people.

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Speaker 2: I think that was a really interesting chat. I know

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Speaker 2: I learned a lot from it. If you did, too,

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Speaker 2: send it to a friend. It might be a conversation starter.

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Speaker 2: You never know. Have a great day, and we'll be

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Speaker 2: back again tomorrow