WEBVTT - Can ketamine treat depression?

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<v Speaker 1>My name is Lily Maddon and I'm a proud Arunda

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<v Speaker 1>Bungelung Cargoton woman from Gadighl country. The Daily oz acknowledges

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<v Speaker 1>that this podcast is recorded on the lands of the

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<v Speaker 1>Gadighl people and pays respect to all Aboriginal and Torres

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<v Speaker 1>Strait Island and nations. We pay our respects to the

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<v Speaker 1>first peoples of these countries, both past and present.

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<v Speaker 2>Good morning and welcome to the Daily OS. It's Thursday,

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<v Speaker 2>the nineteenth of October. I'm Zara, I'm Emma Gillespie.

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<v Speaker 3>I'm the deputy editor here at the Daily OS.

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<v Speaker 2>You might have noticed that we are changing up the

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<v Speaker 2>regular lineup a bit. There has been a bit of

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<v Speaker 2>flux in the TDA office with a few people taking

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<v Speaker 2>leave at the same time. But I'm so glad to

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<v Speaker 2>be joined by m today again. What are we talking

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<v Speaker 2>about today?

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<v Speaker 3>Very happy to be here today because we've got a

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<v Speaker 3>really interesting one to discuss. We're talking about a new

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<v Speaker 3>treatment option for depression that's been popping up around the

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<v Speaker 3>country in clinics.

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<v Speaker 2>The Royal Melbourne Hospital recently own opened the third public

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<v Speaker 2>clinic in the country to offer kenemine treatment for patients

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<v Speaker 2>with what's called treatment resistant depression. Now that's a type

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

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<v Speaker 3>Yep. So I'm chatting with Black Dog Institute researcher doctor

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<v Speaker 3>Adam Bayes to understand what that means and how it

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<v Speaker 3>all works next.

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

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<v Speaker 2>Biden has met with Israeli PM Benjamin Manetta Yahu in

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<v Speaker 2>Tel Aviv after arriving in the country last night. A

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<v Speaker 2>meeting with Palestinian Authority President Mahmurabas set to take place today,

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<v Speaker 2>was canceled after hundreds of Palestinians were killed when a

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<v Speaker 2>rocket hit a hospital in Gaza. Garz In Health Authority

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<v Speaker 2>said the blast was caused by an Israeli air strike,

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<v Speaker 2>while the Israeli Defense Forces blamed it on a misfire

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<v Speaker 2>by a group called Palestinian Islamic Jihad. On this and

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<v Speaker 2>I quote, Biden said, based on the information we've seen

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<v Speaker 2>to date, it appears the result of an errant rocket

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<v Speaker 2>fired by a terrorist group from Gaza. Biden also announced

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<v Speaker 2>one hundred million US dollars for humanitarian aid in Gaza

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<v Speaker 2>and the West Bank.

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<v Speaker 3>Non fatal strangulation would become a standalone offense under new

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<v Speaker 3>legislation tabled in Victoria on Wednesday. Intentional non fatal strangulation

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<v Speaker 3>without proof of injury could result in up to five

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<v Speaker 3>years imprisonment, which would rise to ten years for more

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<v Speaker 3>serious offenses. The reforms have been tabled to protect victim

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<v Speaker 3>survivors and hold perpetrators to account.

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<v Speaker 2>New laws to increase paid parental leave will be tabled

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<v Speaker 2>in federal Parliament today. Under the proposal, paid parental leave

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<v Speaker 2>would increase to twenty six weeks in July twenty twenty six,

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<v Speaker 2>with incremental increases to parental leave in the years leading

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<v Speaker 2>up to that point. The reforms were first announced by

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<v Speaker 2>the government last year to raise paid parental leave from

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<v Speaker 2>eighteen weeks. New parents will also be allowed to take

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<v Speaker 2>four weeks of concurrent leave, meaning both parents can go

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<v Speaker 2>on paid leave at the same time from twenty twenty six.

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<v Speaker 2>The government says it will send a strong signal that

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<v Speaker 2>both parents play a role in caring for their children.

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<v Speaker 2>And the good news the soccer rows have won something

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<v Speaker 2>I had never yet heard before, the soccer ashes. It

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<v Speaker 2>follows a two nil victory against New Zealand in London.

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<v Speaker 2>The Soccer Ashes is a trophy containing the ashes of

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<v Speaker 2>cigars smoked by the captains of Australia and New Zealand

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<v Speaker 2>after a match in nineteen twenty three. The trophy disappeared

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<v Speaker 2>in nineteen fifty four and was rediscovered in a suburban

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<v Speaker 2>garage earlier this year. While this story took quite the turn,

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<v Speaker 2>the soccer Us will play their next match in Melbourne

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<v Speaker 2>in one month. Ketamine is commonly used in medicine and

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

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<v Speaker 2>it acts on brain chemicals and it can stop the

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<v Speaker 2>brain from interpreting pain messages. Now it's also being used

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<v Speaker 2>to treat depression, after low doses of the drug were

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<v Speaker 2>found to quickly and significantly improve depressive symptoms.

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<v Speaker 3>We know a lot of young people, a lot of

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<v Speaker 3>TDA listeners live with depression, but for some people traditional

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<v Speaker 3>treatment options like antidepressants therapy that doesn't always actually work.

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<v Speaker 3>So for those people and others who might not be

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<v Speaker 3>able to take antidepressant medication for other reasons, ketymine treatment

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<v Speaker 3>could actually change the way mental ill health is treated

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<v Speaker 3>in Australia. But honestly, I had never actually heard of

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<v Speaker 3>ketamine being used in this way before this point Zza,

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<v Speaker 3>so you can imagine I had a lot of questions

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<v Speaker 3>and I put those to an expert in this field.

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<v Speaker 3>Dr Adam Bays is a Senior Research Fellow at the

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<v Speaker 3>Black Talk Institute. He is a clinical academic psychiatrist with

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<v Speaker 3>a special interest in mood disorders. Dr Adam Bays, Welcome

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<v Speaker 3>to the podcast.

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<v Speaker 4>Thanks for having me.

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<v Speaker 3>First of all, what is ketamine and why is it

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<v Speaker 3>useful in clinical settings to treat depression.

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<v Speaker 4>Petamine is a anesthetic drug that's been around for a

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<v Speaker 4>long time. About twenty years ago, there was some pivotal

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<v Speaker 4>studies where there was sub aesthetic doses ketamine, so smaller

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<v Speaker 4>doses administered to patients with treatment resistant depression. So this

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<v Speaker 4>is where patients have failed multiple trials or standard treatments

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<v Speaker 4>oral antidepressant psychological therapies, and it was found to have

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<v Speaker 4>both a rapid antidepressant effect and also the effect was

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<v Speaker 4>quite pronounced, so quite a large impact on depression. And

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<v Speaker 4>since that time, there's been more and more research into

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<v Speaker 4>the area of ketamine for treatment resistant depression, and it's

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<v Speaker 4>been found to be very effective in that patient group.

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<v Speaker 3>What do we know about the scale of treatment resistant depression?

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<v Speaker 3>You know, what is it that we understand about it?

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<v Speaker 4>Obviously, you know depression, it's a complex diagnosis and there's

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<v Speaker 4>different sort of manifestations of depression. So there's more mild

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<v Speaker 4>forms of depression that might be the result of life circumstances,

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<v Speaker 4>and then all the way through to the more severe

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<v Speaker 4>biological forms of depression where there might be a strong

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<v Speaker 4>family history of depression. It starts need to use medications

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<v Speaker 4>like antidepressants or other drugs, and in the severe cases,

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<v Speaker 4>things like electroc convulsive therapy or ECT is still a

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<v Speaker 4>highly effective treatment. And it's probably around about a third

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<v Speaker 4>of patients specified as having treatment resistant depression, so it's

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<v Speaker 4>quite a high number.

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<v Speaker 3>Yeah, that's a really significant number. I think that will

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<v Speaker 3>come as a surprise to a fair few of our listeners.

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<v Speaker 3>In terms of treatment options for this difficult to treat depression,

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

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<v Speaker 3>that ketamine treatment is a relatively new kind of phenomenon.

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<v Speaker 4>There have been exciting advancements also in neurosimulations, so things

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<v Speaker 4>like transcranial magnetic stimulation or TMS, which is very powerful

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<v Speaker 4>magnets brought close to the skull. But ketamine is exciting

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<v Speaker 4>in the sense that in mental health it's good to

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<v Speaker 4>have an assortment of different options. Yeah, it just gives

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<v Speaker 4>yet another option to get well.

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<v Speaker 2>A lot of.

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<v Speaker 3>People may have only heard of ketamine used illegally or

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<v Speaker 3>as an anesthetic. How does this treatment work, how long

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<v Speaker 3>does it take, and how does it differ in that

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<v Speaker 3>clinical setting from other uses of ketamine.

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<v Speaker 4>We would have heard of people recreationally using ketamine, and

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<v Speaker 4>this is because it can cause that dissociative effects and

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<v Speaker 4>have these sort of psychoactive effects. But I guess I'm

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<v Speaker 4>talking about it very much in a clinical medical setting,

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<v Speaker 4>where the drug is one hundred percent pure pharmaceutical grade

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<v Speaker 4>ketamine and it's diministered in a setting and patients are

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<v Speaker 4>carefully screened. Patients are usually on an antidepressant as well.

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<v Speaker 4>It can be administered in various ways. It's either usually

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<v Speaker 4>injected under medical supervision, or there is a form called

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<v Speaker 4>sketamine which is intranasal spray. So the ketamine tends to

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<v Speaker 4>have its maximal antidepressant effect the next day, and then

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<v Speaker 4>it does tend to wear off, and so patients then

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<v Speaker 4>have usually a second treatment. At least in the acute course,

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<v Speaker 4>you're trying to get the patient from being in a

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<v Speaker 4>major depressive episode. The goal is to get them into

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<v Speaker 4>remission where they're not no longer meeting criteria for depression.

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<v Speaker 4>It works quite differently to standard antidepressant treatments like you know,

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<v Speaker 4>your SSRIs or Prozac as the brand name of a

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<v Speaker 4>famous SSRI, and these act on the serotonin system. This

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<v Speaker 4>is the kind of feel good neurotransmitter. Ketemine actually doesn't

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<v Speaker 4>act at least directly on serotonin, but it actually acts

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<v Speaker 4>on a completely different set of receptors. And I guess

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<v Speaker 4>the other thing is, yes, it works much more rapidly

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<v Speaker 4>than standard oral antidepressants. At least in some cases, you

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<v Speaker 4>can see patients significantly improved the next day. So that's

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<v Speaker 4>pretty incredible. And I think sometimes people think that the

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

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<v Speaker 4>So while they have the acute effects of ketamine and

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<v Speaker 4>they might feel dissociated and have some kind of an

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<v Speaker 4>unusual experience that wears off within the first hour, and

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<v Speaker 4>they usually discharged the two hour mark and they feel

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<v Speaker 4>completely back to you know, they don't have any kind

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

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<v Speaker 4>effect that's more enduring.

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<v Speaker 3>How is the long term or longer term success then

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<v Speaker 3>of this treatment measured. If there's that sort of immediate

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<v Speaker 3>relief of maybe depressive symptoms, is this a treatment that

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<v Speaker 3>is life long for people with treatment resistant depression.

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

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<v Speaker 4>certainly hope that patients might, say, receive a course of ketamines,

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<v Speaker 4>to say, a four week course for example, then they'll

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

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<v Speaker 4>what we're seeing is some patients go into what we

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<v Speaker 4>call maintenance treatments, and this might mean that they have

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<v Speaker 4>a treatment, say every week, or maybe stretched out to

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<v Speaker 4>every two or three weeks, which keeps them well.

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<v Speaker 3>As can happen with other medications. Is there a dependency

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<v Speaker 3>over time or a resistance perhaps over time to ketamine treatment.

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<v Speaker 4>You can't become addicted as such to a surprise act,

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<v Speaker 4>right ketamine. That is actually possible. While we don't tend

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<v Speaker 4>to see that in clinical settings, it's something to be

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

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<v Speaker 4>We're very cautious about that because we're not wanting to

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<v Speaker 4>create a further problem for the patient. We put a

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

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<v Speaker 4>also why ketamine is administered in the clinic.

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<v Speaker 3>Are there any other risks or sort of safety concerns

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<v Speaker 3>associated with receiving the treatment?

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<v Speaker 4>Yeah, look there are, and I think like any medication

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<v Speaker 4>you know, has a side effect profile, and keta means

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<v Speaker 4>no different. So some of the key things that we

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<v Speaker 4>monitor for. There can be blood pressure increases, certainly acutely

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<v Speaker 4>as well. Patients you can become dissociated, unsteady on their fee.

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<v Speaker 4>Then in the long run I mentioned risk of dependence.

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<v Speaker 4>Ketamine can irritate the bladder and sometimes ketamine can affect

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<v Speaker 4>the liver. You know, ketamine services that are out there,

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<v Speaker 4>they should be monitoring for accus and cumulative cyber effects.

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<v Speaker 3>I noted that at least in the clinic that recently

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<v Speaker 3>opened in Melbourne, that young people are excluded under twenty

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<v Speaker 3>fives are excluded from accessing the treatment. I guess this

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<v Speaker 3>ties into kind of broader questions about barriers to access,

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<v Speaker 3>you know, cost, who can access it, so you know

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<v Speaker 3>the kind of demand versus that.

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<v Speaker 4>I mean generally it's eighteen and over purely because there's

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<v Speaker 4>more data on the safety and effectiveness in that age group.

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<v Speaker 4>I know that there has been a big multisensor study

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<v Speaker 4>looking at ketamine and younger people that have depression. You

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<v Speaker 4>mentioned cost. It's a big one because ketamine is it's

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<v Speaker 4>sort of in this interesting zone where it's you've got

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<v Speaker 4>the two formulations. The anesthetic who's been around for fifty

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<v Speaker 4>years or Medica have a kind of license and they

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<v Speaker 4>have indication. It still remains only licensed for anesthesia. If

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<v Speaker 4>it's administered for anything other than anesthesia, it's it's off label.

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<v Speaker 4>Then there's the new formulation, which is intranasal s ketamine,

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<v Speaker 4>so it's a variant of ketamine. But that has been

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<v Speaker 4>TGA approved in Australia. But the issue is it's not

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<v Speaker 4>covered by the PBS yet. There's a period of time

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<v Speaker 4>where the drug companies have to make a case to

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<v Speaker 4>the government, you know, will you subsidize this drug. So

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<v Speaker 4>patients can certainly go out and you know, they see

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<v Speaker 4>their psychiatrist. Their psychiatrists might recommend the internasales ketamine, but

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<v Speaker 4>it's anywhere between six to eight hundred dollars per dose.

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<v Speaker 3>Wow.

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<v Speaker 4>So and the usual dosing, as I said, is twice

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<v Speaker 4>per week initially for the first four weeks. So that's

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

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<v Speaker 4>or more per week per week, and that's because it's

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<v Speaker 4>not on the PBS. The other thing is when you

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<v Speaker 4>go and see a doctor, most things have an item

0:13:00.440 --> 0:13:03.800
<v Speaker 4>So for example, if you go and have your appendix removed,

0:13:04.080 --> 0:13:07.599
<v Speaker 4>there'd be a sort of item number. Medicare reimburses you

0:13:07.720 --> 0:13:10.400
<v Speaker 4>or covers that. Right. So for ketamine treatment, which as

0:13:10.440 --> 0:13:12.840
<v Speaker 4>I explained, you know it involves coming in to the

0:13:12.880 --> 0:13:16.000
<v Speaker 4>clinic there, you monitored, you've seen by a psychiatrists. Is

0:13:16.040 --> 0:13:19.040
<v Speaker 4>two hours of monitoring, and you discharge. There's no item

0:13:19.120 --> 0:13:21.000
<v Speaker 4>number for that, not just the drug, but for the

0:13:21.040 --> 0:13:24.000
<v Speaker 4>whole process. There's no item number. So again, all of

0:13:24.040 --> 0:13:26.959
<v Speaker 4>that clinical time is paid for out of pocket by

0:13:26.960 --> 0:13:29.960
<v Speaker 4>the patient. So at the moment we are in a

0:13:30.000 --> 0:13:34.120
<v Speaker 4>situation where, other than there's a few public clinics where

0:13:34.120 --> 0:13:37.439
<v Speaker 4>it's sort of subsidized by whatever funds the hospital might have,

0:13:37.760 --> 0:13:39.240
<v Speaker 4>the patient pays out of.

0:13:39.160 --> 0:13:40.800
<v Speaker 3>Pocket waiting for that magic number.

0:13:40.920 --> 0:13:43.080
<v Speaker 4>Yeah, it's a big issue really because you know, it

0:13:43.160 --> 0:13:47.040
<v Speaker 4>speaks to you know, inequality and equity, and particularly I

0:13:47.040 --> 0:13:49.760
<v Speaker 4>guess younger people are less likely to have the funds.

0:13:50.000 --> 0:13:53.560
<v Speaker 3>Do you think there's any stigma associated with the idea

0:13:53.800 --> 0:13:57.960
<v Speaker 3>or the reputation of ketamine that may have impacted access.

0:13:58.600 --> 0:14:02.560
<v Speaker 4>I think there is some stigma in the sense of certainly,

0:14:02.559 --> 0:14:05.240
<v Speaker 4>whenever I read a newspaper article, or at least up

0:14:05.320 --> 0:14:07.920
<v Speaker 4>until a few years ago, it would always say horse tranquilizer,

0:14:08.040 --> 0:14:11.720
<v Speaker 4>which is I always found a bit sensationalist because ketamine

0:14:11.800 --> 0:14:14.280
<v Speaker 4>is used as a regular anesthetic in human It was.

0:14:14.280 --> 0:14:18.000
<v Speaker 3>Only researching for this podcast that I realized that horse

0:14:18.000 --> 0:14:20.480
<v Speaker 3>tranquilizer wasn't the original purpose.

0:14:21.480 --> 0:14:24.800
<v Speaker 4>It's a bit sensationalist. And whereas ketamine is used day in,

0:14:24.880 --> 0:14:28.080
<v Speaker 4>day out in surgeries, it's used in children for the

0:14:28.120 --> 0:14:31.440
<v Speaker 4>purposes of anesthesia, I guess the recreational use, et cetera.

0:14:31.600 --> 0:14:34.440
<v Speaker 4>It has become a bit more controversial. But you know,

0:14:34.480 --> 0:14:37.280
<v Speaker 4>it's a medicine like any other medications, and if you

0:14:37.400 --> 0:14:39.480
<v Speaker 4>just look at the science, it does seem to be

0:14:39.800 --> 0:14:43.960
<v Speaker 4>effective in treatment resistant depression. But if you get opioids

0:14:43.960 --> 0:14:47.720
<v Speaker 4>and things like that, pain medications are misused, So any

0:14:48.080 --> 0:14:50.320
<v Speaker 4>drug really can be misused. But I think the key

0:14:50.320 --> 0:14:54.560
<v Speaker 4>thing is for us in mental health is providing access

0:14:54.600 --> 0:14:56.560
<v Speaker 4>to it in such a way that's safe. It's in

0:14:56.600 --> 0:14:59.520
<v Speaker 4>a controlled setting, it's not going to be diversion to

0:14:59.560 --> 0:15:02.880
<v Speaker 4>recreation users, and it's not going to cause further problems

0:15:02.920 --> 0:15:03.480
<v Speaker 4>for patients.

0:15:03.640 --> 0:15:08.640
<v Speaker 3>Your colleague, Professor Colleen lou She described accessibility to be

0:15:08.920 --> 0:15:12.520
<v Speaker 3>the next challenge for the treatment. Where do you see

0:15:12.640 --> 0:15:16.760
<v Speaker 3>ketamine treatment moving in Australia in the next five to

0:15:16.840 --> 0:15:17.440
<v Speaker 3>ten years.

0:15:17.760 --> 0:15:21.560
<v Speaker 4>Yeah, that's an excellent question. Look, I think the accessibility

0:15:21.640 --> 0:15:25.920
<v Speaker 4>question really it's getting this MBS item number. The Medicare

0:15:25.920 --> 0:15:28.520
<v Speaker 4>item number is going to be critical. If that gets up,

0:15:28.520 --> 0:15:31.680
<v Speaker 4>that will mean a broader section of the community can

0:15:31.760 --> 0:15:35.160
<v Speaker 4>access the treatment. I imagine it will become rolled out

0:15:35.360 --> 0:15:38.360
<v Speaker 4>into public mental health. Obviously, there need to be an

0:15:38.440 --> 0:15:41.960
<v Speaker 4>infrastructure there and all the appropriate training and all the

0:15:42.040 --> 0:15:44.720
<v Speaker 4>knowledge that goes into this. Because it is quite a

0:15:44.720 --> 0:15:49.760
<v Speaker 4>specialized treatment, it will become more mainstream for treatment resistant depression.

0:15:50.360 --> 0:15:53.400
<v Speaker 4>There is enough data now to say that it's effective

0:15:53.400 --> 0:15:55.720
<v Speaker 4>and safe. I think it'll be also getting it out

0:15:55.760 --> 0:15:59.160
<v Speaker 4>into regional senses as well. That'll be exciting to see

0:15:59.200 --> 0:16:01.560
<v Speaker 4>it rolled out and available to more people.

0:16:03.200 --> 0:16:05.880
<v Speaker 2>I think that was a really interesting chat. I know

0:16:05.960 --> 0:16:08.240
<v Speaker 2>I learned a lot from it. If you did, too,

0:16:08.560 --> 0:16:11.360
<v Speaker 2>send it to a friend. It might be a conversation starter.

0:16:11.480 --> 0:16:13.520
<v Speaker 2>You never know. Have a great day, and we'll be

0:16:13.560 --> 0:16:14.400
<v Speaker 2>back again tomorrow