Psychiatric Compounding: Should Your Pharmacy Offer Ketamine for Depression?

Psychiatric Compounding: Should Your Pharmacy Offer Ketamine for Depression?

i-syringe“I lived in pain,” 36-year-old San Diego resident Paul told NPR last September. After trying numerous antidepressants, acupuncture, cognitive behavioral therapy and electric shock therapy, Paul’s life changed when he discovered that he could take off-label ketamine for depression treatment.

Within a matter of days, an infusion of ketamine or compounded ketamine derivatives had Paul on his knees weeping with relief, lacking the cloud of depression and the sting of anxiety for the first time in his adult life. Where once he’d had thoughts of suicide, now Paul’s treatment-resistant major depression responded to the experimental therapy.1

Ketamine is an N-methyl-D-aspartate (NMDA) receptor agonist known mostly for its painkilling, anesthetic and mind-altering properties, but new and exciting evidence suggests that pharmacists can also offer it as a rapid-onset, highly-effective antidepressant.

Ketamine Shows Rapid Results Treating Major Depression and Bipolar Disorder

Depression medication that’s widely available today works primarily on adjusting serotonin or norepinephrine levels to achieve more balance. Ketamine, however, primarily affects the glutamate pathway, opening the door to more research into different approaches to depression treatment.

Some researchers have looked at ketamine’s ability to treat chronic pain to try to unlock its antidepressant properties. Because ketamine’s effects happen after the drug is no longer in the body’s system, researchers suspect that ketamine’s antidepressant qualities come from a “signaling cascade.”

This is very similar to the process induced when ketamine is used to treat chronic pain, where the low-dose ketamine induces glutamate neurotransmission, which through a cascading series of events leads to more connectivity between neurons in the prefrontal cortex, potentially improving the processes controlled there and lessening depressed feelings.2

Since the actual cause of depression isn’t proven or well understood, currently formulated medications became primary treatments simply because they work better than other treatments. Many tricyclic antidepressants come with a host of unpleasant side effects like nausea, dry mouth, insomnia, constipation, weight gain and blurry vision.3

Into this landscape comes ketamine, a drug that has been shown to have far fewer side effects and work much more rapidly and effectively than currently available antidepressants. The cautious optimism in doctors, psychiatrists and patients suffering from major depression is currently borne out by results in several studies, including:

  • Significant decreases in Montgomery-Asberg Depression Rating Scale (MADRS) scores among tested emergency department patients4
  • Excellent tolerability ratings
  • No significant increase to Young Mania Rating Scale (YMRS) or Brief Psychiatric Rating Scale (BPRS) scores
  • Anecdotal evidence of rapid onset as quickly as 2 hours to one day following infusion
  • Anecdotal evidence of effects lasting between one week and one month5

It’s too early to cite limited studies in non-controlled environments and a heap of anecdotal evidence as indications that ketamine is a miracle antidepressant in the rough, but results have fueled its popularity. The use of ketamine for depression is already widespread and growing as an off-label treatment.

The National Institute of Mental Health is actively recruiting for clinical trials to test ketamine’s efficacy as a rapid-onset antidepressant, and more controlled research will likely follow. Working with clinicians and physicians to let them know that your compounding pharmacy has ketamine for depression treatments available could be an excellent boost for your pharmacy and patients alike.6

What to Know if You’re Considering Ketamine for Depression at Your Pharmacy

Since ketamine infusions for depression are off-label treatments, patients are likely to fall into two camps: those who come specifically to your pharmacy because you offer ketamine treatment, or people who are unaware of the possibility of taking ketamine for depression.

The latter folks may even think of it primarily as a commonly abused nightclub scene drug, in which case your pharmacists may have to provide some patient education around ketamine’s results and its any analgesic uses.

Taking ketamine for depression also isn’t a cure-all for everyone. Doctors familiar with prescribing ketamine as a depression treatment are familiar with its potential to act as a hallucinogenic in adults. They also know that it doesn’t work for all patients—some cases of major depression or bipolar disorder prove to be resistant even to the strength of ketamine.

The ketamine infusion itself can also have side effects such as irritation at the infusion site. Testing is primarily focused now on proving or disproving ketamine’s efficacy, and there haven’t been widespread experiments with altering delivery methods to reduce side effects or even improve systemic uptake. While the future should hold more exploration of the many ways compounding ketamine could benefit patients who cannot receive intravenous serial infusions, the treatment showed excellent tolerability when tested.

Still, doctors and pharmacists work with ketamine all the time in anesthetic settings and it is considered to be so safe that it’s the drug of choice for children with broken bones or other major trauma.

For pharmacists who have experience working with patients suffering from treatment-resistant major depression or bipolar disorder, exploring ketamine as a potential treatment avenue will put you on the cutting edge of psychiatric pharmacology. It also might do no less than help save or change your patient’s life.

Working with a patient’s health care team, pharmacists play a crucial role in helping to determine the right course of action for treating depression. Patients with drug-resistant major depression or bipolar disorder in particular should have a pharmacist on their team, helping to evaluate which disease pathways should be treated next, stay informed about possible new treatments and help customize medication for their needs.

If you’re a pharmacist interested in learning more about our ketamine API for treating patients with major depression or bipolar disorder, please contact us. Pharmaceutica North America is a premier provider of high-quality APIs and compounding kits to help pharmacies provide the highest level of effective patient care.

Show 6 footnotes

  1. “Club Drug Ketamine Gains Traction As A Treatment For Depression,” Feb. http://www.npr.org/sections/health-shots/2015/09/28/443203592/club-drug-ketamine-gains-traction-as-a-treatment-for-depression
  2. “Ketamine – More mechanisms of action than just NMDA blockade,” June 2014, http://www.sciencedirect.com/science/article/pii/S2210844014200062
  3. “Ketamine and depression: too much too soon?” Dec. 14, 2015, http://www.medicalnewstoday.com/articles/303959.php
  4. “A preliminary naturalistic study of low-dose ketamine for depression and suicide ideation in the emergency department,” May 5, 2011, http://journals.cambridge.org/action/displayAbstract?aid=8334096&fileId=S1461145711000629
  5. “Serial infusions of low-dose ketamine for major depression,” Feb. 20, 2013, http://jop.sagepub.com/content/early/2013/02/20/0269881113478283.abstract
  6. “Rapid Antidepressant Effects of Ketamine in Major Depression,” Sept. 15, 2015, https://clinicaltrials.gov/ct2/show/NCT00088699
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