Beyond Traditional Treatment: Ketamine and Esketamine in Medical Hospital Psychiatry

Abstract:
In this workshop, 4 ketamine and esketamine clinicians discuss practical management of ketamine and esketamine infusions and integrating these therapies into the general medical hospital setting, including a currently active randomized controlled trial of single ketamine infusions following suicide attempts in the general medical hospital.

Over the past decade, utilization of ketamine and esketamine has become more common for treatment resistant depression and suicidal ideation, and efficacy further demonstrated as comparable to interventions such as ECT and atypical antipsychotic augmentation (Anand 2023; Reif 2023). Yet barriers to access and utilization exist, and most psychiatrists have limited experience with providing this therapy. Interventional psychiatry procedures (ketamine, esketamine, ECT, TMS) have become an outpatient consultation psychiatry role for some CL psychiatrists, and others have attempted to integrate ketamine therapy into inpatient medical settings. Conversely, most CL psychiatrists are likely unfamiliar with outpatient care practices and protocols, as well as limitations and potential opportunities for utility in the general medical hospital. As outpatient maintenance ketamine and esketamine increases, CL psychiatrists will be faced consultations regarding how to manage these maintenance therapies for medically hospitalized patients seeking holistic continuity of care.

Dr. Cenik will discuss ketamine and esketamine pharmacology and clinical evidence of efficacy for treatment resistant depression and suicidal ideation, along with the process of esketamine initiation and maintenance for major depressive disorder.

Dr. Hamm will discuss relative contraindications to ketamine in the medical setting, protocol and practical management for ketamine titration and management of side effects, as well as and the early research of potential utility for single ketamine infusions in an acute care setting for substance use disorders.

Dr. Peterson approaches to navigating maintenance therapy in the medical hospital, including conversion of esketamine to ketamine dosing, converting between routes of administration for ketamine, use of ketamine for in palliative care and pain management contexts in the hospital, barriers to ketamine utilization and treatment initiation in an acute care environment.

Dr. Shivanekar will expand on ketamine induced neuroplasticity and the potential utility of ketamine assisted learning and psychotherapy for a range of psychiatric conditions. She will discuss the abuse potential of ketamine and share her perspectives as a co-investigator from an ongoing randomized controlled trial (n=200) of single dose IV ketamine to rapidly de-escalate depression severity and suicidal ideation in the general medical hospital following suicide attempt (Shivanekar 2022).