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Ketamine Treatment: The Role of the Nurse

Authors:
Katie Bendel, LMSW
Cara Spagnola MSW, LISW, LCSW

Ketamine is an FDA-approved intervention for treatment-resistant depression and related disorders. Nurses play a vital role in ensuring patients’ optimal response to ketamine before, during and after treatment.

The information in this blog was adapted from a presentation by Ellen Kenik, RN, BSN and Amy Richards, RN, BSN entitled “Ketamine Treatment for Refractory Mental Health Diagnoses: The Role of the Nurse,” presented at the 2022 Pathlight Mood & Anxiety Center Conference.

According to a survey completed by the National Institute of Mental Health (NIMH), an estimated 21.0 million adults in the United States have experienced at least one major depressive episode [1]. This number represents roughly 1 in 10 U.S. adults [1]. Based on the NIMH’s available data, the prevalence of major depressive episode is highest among adult females (10.5%) compared to males (6.2%), and highest among those who report having multiple (two or more) races (15.9%) [1].

Major depression, if left untreated, can severely impair and interfere with an individual’s ability to function from day to day [1]. For those with treatment-resistant depression (TRD), we often consider additional treatment options. When we talk about “treatment resistance” we’re referring to patients that have received first-line and second-line interventions and are still not receiving the level of relief they require [2].

What are first-line treatments?

These are evidence-based therapeutic interventions. At Pathlight, the common evidence-based therapies we attempt include cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), dialectical behavior therapy (DBT), exposure and response prevention (ERP), acceptance and commitment therapy (ACT) and emotion-focused family therapy (EFFT). At Pathlight, our first-line treatment will have included individual therapy, group therapy and family therapy, all of which are rooted in one or more evidence-based therapies.

What are second-line treatments?

If individual, group and family therapy have not worked, our second-line treatment will be medications, or psychopharmacology. Medication options include antidepressants, anxiolytics, antipsychotics and mood stabilizers. Antidepressants are typically attempted first. Selective serotonin reuptake inhibitors (SSRIs) like Prozac (fluoxetine) or Celexa (citalopram), and serotonin and norepinephrine reuptake inhibitors (SNRIs) like Pristiq (desvenlafaxine) and Cymbalta (duloxetine), would fall into this category. Other antidepressants you may have heard of include Molipaxin (trazodone) and Wellbutrin (bupropion), among many others. New antidepressants are constantly being developed [3].

Unfortunately, antidepressants do not provide immediate relieve. The rate at which a patient will start to see relief of symptoms varies. The earliest possible timeframe would be within 1-2 weeks, but it can take up to 16 weeks for patients to see the full benefit of an antidepressant medication [2]. It’s also important to consider that about 60-70% of patients will respond to first-line monotherapy – meaning one drug out of those listed above [2]. Of that 60-70%, up to 50% will not reach full remission [2]. This could mean we need to consider changing medications or attempting a secondary medication, which takes a bit of time and continued assessment.

Why ketamine? Explaining neuropsychiatric interventions

When first-line and second-line treatments aren’t working, we have the option to consider neuropsychiatric interventions. This includes transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT) and ketamine. Ketamine has been used for several years as an alternative analgesic (pain reliever) and anesthetic during procedures, but in March 2019 the Food and Drug Administration (FDA) approved it for patients struggling with TRD [4]. Reduction of refractory depression, anxiety, suicidal ideation and chronic pain are confirmed results of ketamine treatments [5].

We don’t want to get too scientific here, but it’s helpful to know that ketamine creates new pathways in the brain and increases adaptability [5]. Biologically, ketamine resets the emotional reward centers, buffering fear conditioning and reducing cognitive inflexibilities. Behaviorally, it assists in significant neuroplasticity lasting up to 2-3 weeks following a single dose [6]. At the experiential level, it enhances perspective taking and self-reflection. These factors ultimately lead to improvements in depressive symptoms [7].

What can we expect from ketamine?

It works fast! Upward of 50-70% of individuals with TRD who receive a single dose of Ketamine will experience a complete remission of their depressive symptoms within 40 minutes to 24 hours [3].  When we think about significant suicidal ideation and need for immediate intervention, this result is a game changer [8].] However, the effects are short lived. Most patients who respond to a single dose of ketamine will experience complete relapse into their depressive symptoms within 5-14 days [7].  However, ketamine’s effect can be sustained and prolonged if additional infusions (twice per week) are given so that relapse is prevented. After 4 weeks, the relapse timeframe is pushed out to 27-29 days [7].

What is the role of the nurse in ketamine treatment?

“Psychiatric-mental health nurses play a vital role in the assessment, referral to treatment, and ongoing monitoring of patients receiving ketamine infusion therapy for psychiatric disorders. Through their nursing experience in psychiatric mental health, they ensure that patients who receive ketamine infusion therapy achieve the best possible mental health outcomes in a safe and therapeutic manner that promotes their long-term recovery.” - American Psychiatric Nurses Association (APNA) President, Gail Stern, RN, MSN, PMHCNS-BC [9].

Before treatment

Before ketamine treatment can start, the prescribing physician will determine appropriateness for patients based on their history and individual circumstances. Such medical conditions as high blood pressure are considered as ketamine can increase blood pressure [7]. A history of substance abuse is also considered, as ketamine can be misused and has an unfortunate risk of abuse [10]. After evaluation and clearance for treatment, the patient will complete consent forms with the physician to make sure they understand the potential risks and benefits. After this, nursing takes over to provide further education about ketamine administration and the treatment process.

Patients understandably often have a lot of questions about ketamine treatment. Nurses can help make sure patients continually feel supported throughout the entire treatment process. In particular, patients with major depression may feel hopeless about seeing improved symptoms. Nurses can continue to provide hope and encouragement that the patient will start seeing some relief soon.

Nursing staff will also coordinate with the physician, pharmacy and treatment team to make treatment manageable. Ketamine treatments can take 90-120 minutes [11]. For this reason, nurses at ERC Pathlight will help the patient and treatment team plan accordingly, such as by making sure ketamine treatment doesn’t back up to things like family therapy or group sessions in which the patient needs to be fully immersed. Nursing staff also help administer assessments to the patient before, during and after treatment to ensure the patient is safe and the expected progress is being made.

During treatment

Ketamine can be administered through a variety of different routes. The amount of medication absorbed by one’s system, its availability and its usability are defined as “bioavailability” [11]. Ketamine has the best bioavailability when it is absorbed directly into the bloodstream, which can be done parenterally (intravenously) or intranasally (like through a nose spray) [11]. Here at ERC Pathlight, we administer ketamine intranasally.

When it is time to administer the dose of ketamine, the nurse will bring the prepared medication to the patient after another medical staff member signs off that it is the correct amount. There will be tissues available, and water or a lozenge to help distract from the taste if treatment drips into the throat. The nurse helps the patient practice exaggerated breathing to ensure they are getting as much ketamine as possible. The spongelike applicator will be put into the nostril of the patient’s choosing, whichever is more comfortable, and the nurse will release the mistlike spray as the patient takes a deep breath.

It is important to have a low-stimuli environment when ketamine is being administered. Some Pathlight locations have specific rooms in which ketamine treatment is applied. It can be helpful for patients to have calming activities to do while receiving treatment, like coloring, watching a movie, listening to music, knitting or just resting. During administration, the nurse monitors the patient and side effects. Common side effects include sedation, dissociation, dizziness, nausea, vertigo, anxiety, increased blood pressure, and changes in reaction time and motor skills [12].

After treatment

Nurses are present to help safely guide the patient through any possible side effects. The nurse monitors cognitive and physical functioning until the patient gets back to baseline. This includes limb movement, vital signs, pupillary response (how our eyes respond to light), evidence of nystagmus (shaking eyes), and COMA scale. Patients are not released until they are at baseline or no longer feeling the effects of the ketamine. They may feel uncomfortable, not like themselves, euphoric or out of control. Returning to baseline after treatment is important, as it helps ensure the patient is safe and that they feel supported.

Lastly, nurses at ERC Pathlight take patients through a self-reported anxiety and depression scales 24 hours after administration to assess progress.

Thank you to our nurses

Nurses play a critical role in mental health care. At ERC Pathlight, we are lucky to have them on our team. They provide quality care and live-saving treatment to our patients on a daily basis. Psychiatric-mental health (PMH) registered nurses (RNs), who are specially trained to diagnose and treat mental illnesses and disorders, are a critical part of our country’s mental health resource network. Without them, many people would lack access to mental health care. If you are a nurse, thank you! We appreciate everything you do for our communities.

Sources

  1. U.S. Department of Health and Human Services. (n.d.). Major depression. National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/statistics/major-depression
  2. Tundo, A., de Filippis, R., & Proietti, L. (2015). Pharmacologic approaches to treatment resistant depression: Evidences and personal experience. World Journal of Psychiatry, 5(3), 330–341. doi.org/10.5498/wjp.v5.i3.330
  3. Chen, J. (2022, March 9). How ketamine drug helps with depression. Yale Medicine. https://www.yalemedicine.org/news/ketamine-depression
  4. Food and Drug Administration. (2019). FDA approved new nasal spray medication for treatment-resistant depression; available only at certified doctor's office or clinic Retrieved from https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified
  5. Alshammari, T. K. (2020). The ketamine antidepressant story: New insights. Molecules, 25(23), 5777. https://doi.org/10.3390/molecules25235777
  6. Irwin, S. A., & Iglewicz, A. (2010). Oral ketamine for the rapid treatment of depression and anxiety in patients receiving hospice care. Journal of Palliative Medicine, 13(7), 903-908. doi: 10.1089/jpm.2010.9808
  7. Albott, C. S., Lim, K. O., Forbes, M. K., Erbes, C., Tye, S. J., Grabowski, J. G., Thuras, P., Batres-Y-Carr, T. M., Wels, J., & Shiroma, P. R. (2018). Efficacy, safety, and durability of repeated ketamine infusions for comorbid posttraumatic stress disorder and treatment-resistant depression. Journal of Clinical Psychiatry, 79(3), 17m11634. https://doi.org/10.4088/JCP.17m11634
  8. Zigman, D., & Blier, P. (2013). Urgent ketamine infusion rapidly eliminated suicidal ideation for a patient with major depressive disorder: A case report. Journal of Clinical Psychopharmacology, 33(2), 270–272. doi: 10.1097/JCP.0b013e3182856865
  9. AANA. (2019). Ketamine infusion therapy for psychiatric disorders position statement issued by American Association of Nurse Anesthetists and American Psychiatric Nurses Association. Retrieved from https://www.aana.com/news/press-releases/2019/08/28/ketamine-infusion-therapy-for-psychiatric-disorders-position-statement-issued-by-american-association-of-nurse-anesthetists-and-american-psychiatric-nurses-association
  10. Lee, T. SH., Liu, Y. H., Huang, Y. J., et al. (2022). Clinical and behavior characteristics of individuals who used ketamine. Scientific Reports, 12, 801. https://doi.org/10.1038/s41598-022-04832-9
  11. Andrade, C. (2021, August 19). Ketamine for depression, 4: In what dose, at what rate, by what route, for how long, and at what frequency? Journal of Clinical Psychiatry, 78(7), e852-e857. doi: 10.4088/JCP.17f11738
  12. Acevedo-Diaz, E. E., Cavanaugh, G. W., Greenstein, D., Kraus, C., Kadriu, B., Zarate, C. A., & Park, L. T. (2020). Comprehensive assessment of side effects associated with a single dose of ketamine in treatment-resistant depression. Journal of Affective Disorders, 263, 568–575. https://doi.org/10.1016/j.jad.2019.11.028
Written by

Katie Bendel, LMSW

Katie believes that recovery and wellness are best developed and reinforced by community with others, and connection to core values such as authenticity, creativity, persistence, and trust. Her goal…
Written by

Cara Spagnola MSW, LISW, LCSW

Cara has over 10 years of experience working with children and families in a variety of settings. She learned along the way that connection, education, and support help alleviate the stigma and…