By Amanda Batterbee, PMHNP-BC, MSN, BSN, RN – March 2024
As the president and owner of North Springs Psychiatry & TMS Center, I’m excited to share with you our innovative approach to treating patients with mental health conditions, as well as protocols we are working on developing. As a provider, I am particularly interested in interventional-based treatments such as transcranial magnetic stimulation (TMS) and ketamine infusions. While I also practice psychopharmacology, the trends I see in my clinic when treating treatment resistant Major Depressive Disorder and OCD are that interventional treatments are more effective, have significantly improved tolerability as compared to traditional pharmacological approaches, and improve robustness of resiliency. I see fewer depression relapses over the years of following my clients. I also feel confident in treating Bipolar Depression episodes as well as chronic PTSD symptoms with TMS and ketamine.
Over the years I have collected data and worked on developing treatment algorithms and protocols using a combination of TMS and ketamine. As I compile the data, I look forward to sharing data comparisons of TMS vs TMS + ketamine vs traditional psychopharmacology.
In the upcoming weeks and months, I will be sharing specific data and protocols that we use in my clinic. Here are treatments and protocols we are using at North Springs Psychiatry & TMS Center. I will be posting articles I have written with specifics for assessing and determining appropriateness of treatment.
1. Patients seeking treatment for Major Depressive Disorder who have failed the required treatment trials based on their individual insurance requirements (failed defined as intolerable side effects, inefficacy, or partial efficacy) are screened for appropriateness of TMS and ketamine. If appropriate, I recommend initial treatment with TMS (we are using the MagStim Horizon 3.0 system). Upon completion of acute phase (first 20 treatments) and during the taper phase, I recommend initiating the ketamine infusion protocol of 6 infusions over 3 weeks. Dosing is initially based on weight of 0.5 mg/kg and adjusted based on tolerability and response. I will be discussing my experience in treating with racemic ketamine vs esketamine in upcoming articles as well. After the 6 infusions, I recommend patients receive monthly infusions for a minimum of 3 months.
2. Our ketamine protocols are based on safety and close monitoring. During infusions, patients are monitored 1:1 with a Registered Nurse who is highly trained in monitoring neurological status and vital signs. We have developed protocols for managing hypertension as well as recommendations for the patient environment during ketamine treatment. I strongly believe that ketamine is a highly effective intervention for chronic mental illness. However, I am concerned about the increasing use of ketamine to “treat” conditions that are not chronic, as well as the lack of clinical care and medical monitoring that is crucial when prescribing ketamine.
3. Our telehealth ketamine program is newly developed and includes close patient monitoring. Patients are evaluated and assessed for appropriateness of treatment. Extensive education is provided on the risks, benefits, and requirements of treatment. All ketamine patients are required to sign a contract that outlines procedures and policies. Patients understand if they fail to follow the requirements, they will be discharged from the ketamine program. For our telehealth patients, oral ondansetron and labetalol are prescribed before initiating treatment. Patients are required to have access to a blood pressure cuff that also monitors their pulse. They are required to have a “sober sitter” who is an unimpaired adult available for emergencies. This adult must be visible on camera to the provider/RN monitoring the patient during the appointment and is also educated on risks and emergency protocols. Patients are able to self-administer an oral troche or lozenge under monitoring of a medical provider. Patients remain on a telehealth appointment with audio and visual capabilities while they are monitored for approximately 90-120 minutes. During the session, the RN instructs the patient when and how to monitor vital signs as well as directs the patient on when and how to take PRN ondansetron and/or labetalol if necessitated. Our telehealth patients attend 6 appointments over 3 weeks during which they self-administer their ketamine under monitoring of a medical professional. We then recommend monthly ketamine appointments.
4. Recently, I have been interested in the possibility of the potentiation of ketamine when co-administered with Auvelity (bupropion/dextromethorphan) which also targets glutamate receptors and regulates glutamate similarly to ketamine. Anecdotally, I started to notice a significant difference in patients who started Auvelity in combination with racemic ketamine as opposed to patients who initiated treatment with only racemic ketamine. We know that esketamine is recommended (and required by most insurance companies) to be co-administered with an antidepressant, which provides a solid hypothesis that there is benefit to co-administration of a rapid acting antidepressant and racemic ketamine. My team has been working on collecting qualitative and quantitative data and I’m excited to present my initial findings.
Providing individual, personalized, and specialized care using genetics and interventional psychiatry is highly rewarding and continues to ignite my professional passion for pursuing modern approaches to psychiatric care. The positive response I’ve received from patients as well as the quantitative improvements I see continues to be the driving force for the care I provide. Thank you for following our journey here at North Springs Psychiatry & TMS Center!