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Super excited to present this episode to you. I had Dr. Steven Mandel on episode 137 of the podcast to talk about the amazing and life-saving treatment of Ketamine infusions, which have been shown to be an incredibly effective treatment for depression, suicidality, and trauma that doesn’t respond well to other treatments. In this episode, we talk more about the difference between these IV infusions of Ketamine and a new player in the game, Ketamine nasal spray. Recently, an Esketamine nasal spray called Spravato was approved by the FDA for use in individuals with treatment-resistant depression. We explore what this means for your treatment and for your wallet.

Welcome back Dr. Steven Mandel

I open by welcoming Dr. Mandel back to the show and he gives us a brief recap on his background and work, as well as the history and development of ketamine and ketamine infusions. To hear more about this, check out episode 137 where Dr. Mandel and I dive deep into this amazingly effective treatment for depression, suicidality, PTSD, and bipolar.

The development of Esketamine nasal spray

Dr. Mandel talks about the recent development of an Esketamine nasal spray which has been approved by the FDA for use in individuals with treatment-resistant depression. He talks about the difference between s-ketamine and r-ketamine and how these are separated, allowing for the development of an esketamine nasal spray. We discuss the success rates of this spray in comparison to ketamine infusions and the more widely used SSRI’s. Dr. Mandel highlights how the IV ketamine treatments in his clinic have an 83% success rate, compared to around 40% success rate for the new esketamine nasal spray. In comparison, SSRI’s have an approximate 60% success rate to begin with, but only around 40% sustain that benefit after a few months. He also highlights how SSRI’s take at least 8 weeks to build up to a sufficient level and also tend to increase obesity and reduce libido, which ketamine does not.

Ketamine works in hours, not weeks

We talk more about the differences between “full” ketamine, known as racemic ketamine, and s- and r-ketamine and whether splitting the two changes the function of either. Dr. Mandel tells us how S-ketamine was initially chosen as it may produce less psychoactivity – the dissociation often experienced when taking ketamine was first thought of as a bad side-effect. However, it would seem that dissociation may be one of the factors that promote the transformation we’re seeking.

Dr. Mandel talks about the use of both IV infusions of Ketamine and the new esketamine nasal spray in his clinic. His practice is certified to administer both – however, after being given the facts most clients opt for the IV infusions given their success rate and effectiveness. Furthermore, the nasal spray requires you to stay at the clinic for two hours after administration and costs significantly more, although this is more likely to be covered by insurance (but see next paragraph). We talk about this in more detail and Dr. Mandel talks us through the treatment process and experience for the esketamine nasal and how this differs from the IV infusions. A key difference is how the nasal spray is episodic (i.e. you take the spray and wait for it to be absorbed into your bloodstream), whereas IV infusions are continuous throughout the treatment session and therefore there is much more control over the dose. Dr. Mandel describes this in detail and outlines the differences a patient may experience, as well as how the IV option is in his opinion, the better option in the long-term, especially when accompanying therapy.

The costs of ketamine

We dive deeper into the costs of this treatment, what “FDA approved” really means and how you may have a better chance of having your treatment costs reimbursed if you opt for Spravato Esketamine nasal spray because it is promoted and approved. Despite this, insurance companies can cover the costs of treatments that aren’t FDA approved, but it can be more difficult to win these cases. However, Dr. Mandel describes how this has become a very dynamic area – insurance companies are beginning to realize how IV Ketamine Infusions are often more cost-effective than their nasal spray counterparts as they have a higher success rate and often result in less long-term treatment being needed, reducing costs of insurance companies. Therefore, they are starting to cover these treatments despite them not being FDA approved – however, there’s still a long way to go. We talk about this in detail and how you can approach your insurance company about covering the costs of IV infusions. However, it can still be a very difficult case to win. Dr. Mandel expresses his frustrations with this, given how lethal depression is.

The role of Esketamine and the rise of Alternative treatments

We talk about the role of the nasal spray in health settings and how this may differ from intravenous methods. For example, the nasal spray is easier to administer and much more portable. However, Dr. Mandel also explains how due to the history of abuse seen with ketamine, the potential for this treatment has been limited – ketamine nasal sprays still have to be both prescribed and administered by a physician. We chat about this in more detail and the realization that we still have a lot of work to do in understanding the potential, lifesaving benefits of Ketamine – Dr. Mandel shares further examples from recent studies to demonstrate this.

Dr. Mandel and I chat more about the rise of research and exploration into different options for treatment-resistant depression, many of which have been around for a very long time but were often put to one side given their reputation and misuse. We talk about this shift in detail, covering treatments including the likes of Psilocybin and MDMA.

In the public eye

Moving on, we discuss the work that still needs to be done in spreading the knowledge and understanding of ketamine, not just to the wider public, but to care providers as well. There are still many who aren’t aware of ketamine as a treatment option, and often those who do know about it are told by their physicians that it is a final option when nothing else works. Dr. Mandel explains why this shouldn’t be the case. Furthermore, we look at the positive impact the launch of esketamine nasal spray had on giving knowledge to the public on the use of ketamine for treatment-resistant mental illness, despite the fact that the nasal spray doesn’t work as well. Its approval was a step in the right direction and gave the public an opportunity to find out the facts for themselves. We talk about this in more depth. Dr. Mandel also explains the strict processes and criteria patients still have to meet in order to qualify for esketamine, which makes it a treatment option that is still difficult to access.

Final thoughts – Finding a Ketamine provider

Importantly, Dr. Mandel highlights how there has been an influx in the opening of ketamine clinics and treatment centers, many of which do not have a patient’s best interests at heart and are often not a safe place to go. Dr. Mandel is working on a certification for clinics to achieve, but in the meantime, he offers advice on what to look out for if you are thinking of searching for a ketamine clinic – personalized service and treatment programs tailored to you. If a provider gives special offers, takes ‘walk-ins’ or is not interested in your health or psychological history, or if they do not conduct any evaluation on you before beginning treatment, then it is a clinic that should be avoided.

We finish up by summarising the positives of ketamine treatment and cautions that should be considered when searching out a provider and Dr. Mandel talks about how a qualified team is needed in any clinic which provides ketamine treatments in order for it to provide quality care. Furthermore, ketamine is a treatment, not a cure, and is more successful when combined with other treatments for sleep, nutrition, exercise, talking therapy and more. We end by talking about how ketamine can changes lives and be used to lift the spirit and motivation of an individual to help them engage in other therapies, providing the strength the carry on.

With that, we come to the end of our interview. I would like to thank Dr. Steven Mandel once again for coming on the show – it’s been great! You can find out more about Dr. Mandel’s work and clinic over on the Ketamine Clinics of Los Angeles website, where you can also get in touch with any questions you may have.

Sponsor:

This episode of Hardcore Self Help is sponsored by Future.

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