The Deal With Ketamine Treatments

Jen talks to Dr. Robert Meisner, MD, the founding Medical Director of The McLean Ketamine Service about developments in Ketamine for Anxious Depression but how ultimately there is no miracle drug for anxiety and the goal is to get people well enough to see benefits from mindfulness practices for anxiety.

For more information on Dr. Robert Meisner, MD please go to: https://www.mcleanhospital.org/profile/robert-meisner

For more information on Jen Kirkman, the host of Anxiety Bites, please go here: https://jenkirkman.bio.link

and to get the takeaways for this episode please visit: http://www.jenkirkman.com/anxietybitespodcast

Anxiety Bites is distributed by the iHeartPodcast Network and co-produced by Dylan Fagan and JJ Posway.

See omnystudio.com/listener for privacy information.

Episode Transcript

Speaker 1 (00:08):
This is the Anxiety Bites podcast, and I am your host,
Jen Kirkman. Welcome to another episode of Anxiety Bites. I'm
your host Jen Kirkman. Now, normally on this show, I
don't really interview or talk to people about medication and
anxiety because I mean, I mean, I think we all

(00:29):
know there's your valliums and your conic bins and your
at a van and your zan X and your antidepressants.
I mean, and all of that is up to your
discretion and you and your doctor and all that. We
know they're there. But there are some newer treatments for anxiety,
or treatments that are not new in and of themselves
but to the anxiety world. One of them miss ketamine,

(00:50):
and I wanted to talk to someone about it who
was really serious, if that makes sense. I mean, I
could have done this episode a lot sooner if I
wanted to talk to some of the people that have
contacted me that are a little more loosey goosey with
their dolling out of ketamine and the way they talk
about it as this kind of cure all And so

(01:13):
I've been putting off doing this episode until I got
who I think is really the right person to talk
to you about it. And I really enjoyed my conversation
with Dr Robert Meisner. I'm just going to get right
into it. I won't do too much talking up front
here a minute or two more. What I loved about
talking to Dr Meisner is he wanted to go through

(01:35):
at the beginning of the conversation, what is anxiety, what's
happening in our body? What are some things we can
do that aren't medication to deal with it? And you know,
I had told him, well, you know, there's been twenty
something episodes of this podcast, and we know that, and
we we've talked about that. But I realized what he

(01:58):
was saying was was correct, because if you're just coming
to this episode because of the word ketamine, you you
need to hear it from him that the good news is,
I guess, and maybe it's bad news to some who
just do want to believe in a miracle drug, but
the good news is that everything you're probably doing already

(02:18):
or know about doing mindfulness cognitive behavior therapy is really
going to help your anxiety. But there are circumstances where ketamine,
which is normally used for depression, has been showing some
results with anxiety, but everybody is different, and the goal
is not to cure anxiety, but maybe to get your

(02:40):
brain to a place enough where you are able to
get benefits from the mindfulness and the cognitive behavior therapy.
So it's kind of all roads seem to keep leading
back to that anxiety is something that we do, have
it done our control too lesson. But I don't know.

(03:06):
For some people, maybe that's going to be a disappointment
that there isn't this magic thing called ketamine. But I'll
let you all listen and decide for yourselves. But I
enjoyed that Dr Meisner took us through, Like, let's just
start at the beginning. What is anxiety, what's happening in
our body, what's happening in our brain? How is it

(03:28):
fed with our thought patterns and our behaviors? How can
we minimize anxiety? And eventually, if you think ketamine is
something you want to try it, what what actually is it?
What is the drug, what are the treatments like, and
what is the entire process of knowing if it's working?
How long do you do it? What happens when you

(03:50):
go into the clinic you will get all of those answers,
and I'm so grateful for uh Dr Meisner taking the
time to do this show and really giving a lot
of care and thought to this. Now, um, let me
just read you his bio and then we'll get right
into the episode. And again the uh links to everything

(04:14):
you need to know about him will be in the
show notes. But Robert Meisner, m d. Is the founding
medical director of the mcclaim Katamine Service and a child
and adult attending psychiatrist in the emergency department at the
Massachusetts General Hospital. Meisner graduated from Princeton Suma Come Loud
before entering doctoral studies in cultural anthropology at the Harvard

(04:38):
Graduate School of Arts and Sciences. Following preliminary field work
in war torn Uganda. He graduated from Harvard Medical School
and then pursued residency training in anesthesia, critical care, and
pain to study oh boy, this word is epistemological tensions
in contested notions of pain across both geographic and disciplinary boundaries.

(05:02):
He transferred into psychiatry to more directly engage the ideologic
and semiotic tensions between socio cultural, and sub specialized biomedical
conceptions of quote suffering. He now works at the intersection
of different disciplines to safely bring evolving pipeline interventions into
clinical practice through evidence based, data driven translational medicine. Meisner

(05:28):
has previously held appointments in the Faculty of Arts and
Sciences at Harvard, where he served as an acting Residential
dean at Harvard College and as a member of Harvard
College's Administrative Board. He has consulted to approved industry pharmaceutical
neuroscience leaders in pipeline clinical translation and currently serves as
the co chair for the National Network of Depression Centers

(05:52):
Ketamine Task Force, as well as the chief financial Officer
for man Gotta, Inc. He continues to prioritize the des
nation of evidence based quality information regarding emerging therapies through
collaboration with national and international media. Again, I am really
grateful to Dr Meisner for taking the time to talk

(06:13):
to us all today. I hope you learn a lot
and find it to be a fascinating and fun conversation.
And now my conversation with Dr Meisner. I'm here with
Dr Robert Meissner, and I've told you all about him
in the intro, and you wanted to talk at the
top of the episode, which I think is brilliant about

(06:35):
anxiety because I mean, obviously it's an anxiety podcast, but
because we are going to mention and talk about depression
as it pertains to academic treatments, and you wanted to
talk about why we really need to just pause for
a moment think about talk about why anxiety is unique
and you can't really just cluster it all together with depression. Yeah. Yeah,
So thanks John, because I think that we need to

(06:58):
whenever we have a serious discussion about anxiety, we've got
to blow up the idea of anxiety and deconstructed a
little bit. Because we use the word so much, Um,
we're starting to forget a little bit about what it means,
and we're we're in particular, I think that we're missing
the heterogeneity of symptoms that are covered by this broad

(07:19):
term anxiety and sort of popular culture and increasingly in
medicine as well, and so we end up being really imprecise,
and that's a problem because different kinds of anxiety often
need different kinds of treatment, right and also empathically, you know,
if if you have a colleague girl friend and you
want to understand what they're going through, understanding what kind

(07:40):
of anxiety they have is gonna be important. So I
think if we just let's just pause for a moment
and say, what is going on right now in the world.
I'm anxious, You're anxious. Everyone I talked to is anxious,
usually on the street or at work. The conversation kind
of stops there because we all know what we mean.
There's this cultural anxiety, and we're attributing it to many

(08:01):
different things, whether it be COVID or or etcetera, etcetera.
We don't usually get more specific than that unless you're
in the psychiatrist office. But when we talk about our anxiety,
we can be talking about lots of different things. And
here's where I actually think it's really helpful to go
back to kind of like anatomy biology, evolutionary biology stuff. Okay,
I'm loving this, I mean, this is what I like

(08:25):
to talk about. Yeah. So, so remember a really, really
long time ago, the nervous system of mammals as they evolved.
You know, you had this sympathetic system, which is the
thing that ramps you up and gets ready to fight
or or to run away. And then you have this
parasympathetic system that calmed everything down right. And these two

(08:45):
existed in some kind of yang and yang that that
allowed species to survive and evolved, etcetera, etcetera. And at
some point then you get this and we often you're
gonna hear the word of magdala. That's a part of
the brain that's kind of back, that was a really
important part. We think of fear based responses in that
reptilian brain, and we all still have a mingdalist and

(09:05):
they're really important, and we'll talk about why in a second. Okay,
So then eventually we get this frontal stuff in our head, right,
and that's where you're getting away from the fight or
flight response, and you've got a little more what what
humans consider to be sort of thoughtfulness, empathy, um, the
ability not to just react but to really be mindful. Actually,

(09:27):
so that's sort of the part of the anatomy that
that we're working with here. In anxiety, the fight or
flight response goes on overdrive, right. So instead of it
would be totally appropriate to get really upset if a
tiger appeared next to your car, you'd want your sympathetic
nervous system to really engage, and you'd want your amigdalt

(09:48):
to fire off. Okay. The problem is that We're now
behaving as if there's a tiger in the room when
there is no tiger in the room. So an email
pops up. It's not a tiger. Everything's going to be
just fine. Actually, nothing that's going to happen you in
that moment, and you have a response that's way over
and above what one would expect. We've all been through this, right, Yeah,

(10:12):
So we have these brains, and I call them are
brilliantly stupid heads. It's that frontal stuff that has allowed
us to sort of take over and and evolve. And
yet we have this critically important fight or flight response
and anxiety response to keep us out of danger that
can really intrude into other situations. Likewise, other situations can

(10:36):
tap into that let's call it a network and create
anxious responses that are devastating and totally inappropriate. And so
our heads are both smart and stupid at the same time.
You know, I just want to say you're on my
team here because I always say I know this is
evolutionary and fight or flight, but and we need anxiety
so we don't baseline die. It keeps us safe in

(10:59):
some way, But can we evolve past thinking an email
as a tiger, like, can we just keep the anxiety
we need and can our brain evolve past that without
us having to do all this work? That's my dream.
I'll tell you that there are some people and and
one person who is at a very interesting intersection in

(11:20):
the in many spaces, a woman named Tara brock Um.
In some of her work, she she will talk about
a collective movement towards a different kind of consciousness, okay,
in some of her work, and I think a lot
of her work is is fantastic and will refer to
some of it because I think cool. I love her
work too. Yeah, I I wasn't aware she was saying

(11:41):
that specifically, So that's really exciting with different words, I think,
But I don't think she would disagree with that statement.
So so we have this thing that we call anxiety,
and we all know that we need anxiety to stay alive.
But we all agree that when when an email is
a tiger, something is wrong, right, And I know I'm
gonna at ten tiger emails today and I have to

(12:02):
learn how to choose my response to those emails rather
than let that email trigger a network that automatically and
reactively involves my amygdala and puts me into a state
that I don't not only do I not want to
be in, but I'm probably not at my most productive,
mindful self in that state. Okay, Now that said, you

(12:23):
and I also know that anxiety motivates us to get
stuff done. You know, the work that you have done,
you have done in part because you've channeled the energy
of anxiety. Tell that to somebody who's having a panic attack,
they'll hit you. But tell that to somebody who's contemplating
the role of anxiety and how in some ways they

(12:43):
can leverage it for good. It might be helpful. Be
a little careful with that one with your friends, right,
because it can sound really unempathetic too. Okay, So when
we talk about anxiety, and I just started jotting down
the list just for fun, what we're talking about is
what some people have heard of, like panic disorder. We're
talking about all the phobias that people often know about.

(13:05):
We're talking about social anxiety disorder. We're talking about performance anxiety.
We're talking about generalized anxiety. We're talking about anxiety subtypes
like obsessive compulsive disorder. UM, We're talking about so many
different kinds of distress, all right, And I think that
it's worth saying, Um, you know that many, many of

(13:31):
of these disorders are undertreated. So like a third of patients,
we think about thirty pc of people with social anxiety disorder, Um,
what was So? First of all, probably about half don't
seek treatment. A third of those who do don't actually
respond to the treatments that we have. That's going to
be specific to the anxiety subtype social anxiety disorders. Third

(13:54):
for others, it's it's different. Um. I think that it's
also worth noting that certain kinds of anxiety, like performance anxiety.
So you know, for many, many years I played the
violin a lot, and I was run a lot of performers,
and you know, you'd see people taken something backstage and uh,
and eventually you you'd find out it wasn't an illicit drug.

(14:17):
It was just a beta blocker, which is a really
different kind of anxiety. Right then, the anxiety, and I
think we're going to be talking about mostly today, Most
people in this historical moment I'm finding in clinic are
in incredibly ruminative anxieties. We're in isolation. Their heads are

(14:39):
going around and around, and they're ruminating, ruminating, rumination. What
is rumination? I think of rumination is thinking that sounds
like it's a really good idea because maybe you'll solve something,
but actually it just becomes obsessional and you don't solve anything.
You drive yourself crazy. Okay, let's blow that up a
little bit bigger, all right, remember and this is where
are this is? You know, a and are brilliantly stupid brains.

(15:02):
The thoughts we have in our brains, they're not necessarily real.
Um it's let's phrase, it's a different way. True, yes,
but real. There's a there's a scholar who uses that distinction,
and I think that's that's quite helpful. I'm forgetting who
it is. Do you remember? I think the scholar is
named Jen Kirkman. No o kidding? Um No, I don't,

(15:23):
I don't, but I I I don't know. I probably
learned it from said person. But but I think of
it as like, you know, my thoughts are real, they're
really happening, really worried about this, but they're just not true.
Is that kind of what that means? What you're saying
so exactly, so that these thoughts are happening, they're real
in that way. Okay, so we're not discrediting that we
have thoughts and feelings and emotions, but that doesn't mean
that they're true. And this problem we have, I think,

(15:45):
especially in Western society, is this idea that what we
think in our head is actually a reflection of the
real world is completely unfounded. Right. We don't know that
what we see is actually there. We don't know that
empiricism is actually a valid way of working, of working
through the world. We use it because it works, It
seems to work well enough, but suddenly this world all

(16:09):
feels both true and real and you really get yourself
in trouble if you start ruminating up here, because you
start making stuff out, and you make a lot of
stuff up, and it happens. It's like every time you
go in a room in a circle, you pick up
a little bit more of that not realness, right or
not trueness, whatever you want to call it. And pretty soon,
I mean, think about this in some of the relationships

(16:30):
that that maybe you've been in. If there's been something
ruminating around and you haven't actually spoken to the person,
by the end of that several days of ruminating, you've
constructed a whole new person. Right. And so you know,
there's this exercise that some of our patients do, which
is when they're feeling anxious. And I'm sure you've heard
of this before with other folks. You write down with

(16:51):
the fearence, you do the thing, and then you see
if the fear came true and after showing yourself that
rarely does the fear actually materialize. Right. You know we
haven't talked about that on this podcast. It's an exercise
I did during my anxiety recovery and I've forgotten about it.
A really straightforward example is the tiger email example. So

(17:12):
you haven't even opened your email yet for the day,
and you're having about to have a panic attack because
you know there's gonna be an email in there, at
least one that's gonna set your week on fire. Right,
So you write down what you're feeling to check your email.
Turns out it's all spam. I mean it won't, but
your your week hasn't blown up. Ye be in an
evidence space where we are relying on some empiricism here, right,

(17:35):
despite what I just said, Uh, you kind of can
show yourself that actually these fears are unfounded. So the
reason that we we want to remember that rumination is
different than phobias, is different than panic disorder, is different
than social anxiety, is different than you know. Some anxiety
disorders are actually anxiety. Someone has anxiety that they will

(17:57):
become anxious, so to gore a phobia, people are anxious,
but they will become embarrassed, ashamed, and anxious publicly. So
anxiety about anxiety also snowballs as its own things. So
lots and lots and lots of diversity in the category
of anxiety. That's what we mean by heterogeneity within sort
of the category itself or or the general term what

(18:21):
do we do about it? So we have this range
of tools, and one of them that we're gonna talk
about today is is ketamine. But I would be so
misleading any listener, or any friend, or any family member member,
anybody who's who's suffering from any kind of anxiety if
I didn't mention that we have lost track over and
over again about getting back to certain basics when it

(18:42):
comes to just basic mental health wellness. Right. So, so
that means stuff like practicing mindfulness in some capacity, whether
it's meditation or or a different mindfulness modality. It means
learning how to interrupt those reactive pattern in our thoughts
that just go on autopilot. Right. It means recognizing our

(19:04):
rumination when it's happening and mindfully choosing whether we really
want to go down that path or if it's just
not going to be helpful. It means social connectedness, which
is super important for anxiety. As a side note, there's
a distribution that's gender specific in a certain kind of
anxiety disorder, in which although the cultural stereotype is that women,

(19:27):
the assumption is women suffer from it more than men,
it's actually the exact opposite. But the very simple process
of naming the thing that of what's going on. So
that's fear, that's anxiety, whatever word you have for it,
that in and of itself trads distance between the eye
that's doing the naming. I mean, it's a semiotic, it's
a linguistic thing, really, right. I am a subject naming

(19:50):
some other thing, and there's an implicit space there that
means I'm not identifying with the feeling. I'm not the
same thing. Because I can step away and say here,
this observer person is pointing to that thing there that
is separate, okay, And you're saying that in the case
of anxiety. I don't know if this may be true,
and other mental health areas that sort of um mindful

(20:15):
you know, do this, and mindful meditation being able to
be the observer, I am not my anxiety. That's a
good thing, you're saying, we want that space. Yeah. So,
although a lot of mindfulness is about interconnectivity, in this case,
what we're talking about is not over identifying or even
identifying with the object that we're labeling, because it is

(20:37):
not us. Your fear is not actually who you are.
You're observing this thing called the fear that is transient. Okay,
So there's a space there that is the starting point
for a lot of that kind of meditation and mindfulness approaches,
you know. Creating that space is also a way of saying, okay,
once again, remember what's happening in my stupid, brilliant head

(20:58):
is not necessarily a reflection of what's happening in reality.
And sometimes creating that linguistic space also creates a moment
from a moment of repose where one can introduce that
thought as well. But they're very simple, low tech things
in what would be a tragedy as if people ignore

(21:18):
the basic stuff and just go to give me something
in my arm via I V. It's much less likely
to work. But it also misses our fundamental duty to
do no harmon to do things safely, and to use
the least interventional approach or the approach that is least
likely to cause the most damage um and still achieve

(21:40):
a good effect. So we don't want to forget about
all this stuff that people have known, in some cases
for over a thousand years. It's just we keep forgetting
will be right back. What I find so interesting about
think where you're going with you know, going into things

(22:02):
such as ketamine, is it feels spiritual and ethereal, but
like it's really real in terms of how well it
dovetails with medical Like no, we really have to train
our brains to see it as separate and weirdly, that's
what people who don't even have anxiety or doing in
their you know, mindfulness meditation. But anyway, my my big

(22:24):
babble here is that it's so great to hear you
say that because it it makes anxiety I feel like
less threatening. I feel like when we keep ramping things up.
Now there's ketamine for anxiety, It's like, oh wow, does
that mean that like the things aren't working or you know,
I know that there will be some people that that

(22:44):
need it. Maybe it helps them get there quicker to
you know, like for me, it took twenty years of
doing all this stuff. We're honestly had a lot of
hard times and it probably interrupted a lot of my life.
Perhaps if I'd been able to use a drug that
helped me understand what I was doing. I assume that's
what it doesn't. We'll get to it. But I think
it's so great that you said all that, because you know,

(23:07):
a lot of people can't get ketamine treatment the cost,
the availability. It's like, I don't want people to think
there's this amazing miracle thing coming that's so big, but
you can't have it. So your fact, you know, it's like, um,
but also to say how profound you know these little
things are that we sweep under the rug every time?
Yeah mindfulness? Yeah yeah, but it's like no, no, this

(23:29):
is the answer. You just don't want to believe it
because it's hard, it takes practice. Yeah, yeah, that's so
dead on. I can't tell you the number of times.
And this is especially true for some reason with pediatric populations,
UM and that's a whole another question of ketamine and pediatrics.
But you know, very often parents when they hear about

(23:52):
the various options, the idea of going through years of
therapy versus getting a drug, I mean, it's a no
brainer to them, and they really grasp at that. We
call them magic bullets in medicine. Right. There's actually a
book called No Magic that no Magic Bullet. It talks
about this fallacy that's so seductive in medicine, that will

(24:13):
find the drug that just fixes the thing and then
move on. And we know that in most illness states,
especially in psychiatry, that's just not how it works in
most Okay, Yeah, maybe hard sometimes to get parents to
sort of shift out of that model because they so
desperately don't want to hear that potentially years of therapy

(24:33):
and a lot of effort, you're gonna be it now, Jen,
I'm really and you you nailed it exactly. There are
certain cases in which you can do all this stuff
and you're not doing anything wrong. You're doing it as
best you can, but it's still not the anxiety is
still not breaking. Right. I often tell patients that the
purpose when we use are evolving neuro therapeutics like ketamine.

(24:58):
Sometimes the purpose is not to make them better with
the drug. It's to make them well enough so they
can more fully engage much simpler things and get much
more reward from them. Right, Because sometimes the ketamine is
not going to fix it, but it gives you more
to invest into some of the other stuff we're talking about.

(25:20):
Then suddenly everything comes together really nicely. Right, So tell
me what is katamine? I mean, what is it? Where?
Where does it live in the drug world? I mean
I knew a lot. I knew casually of people that
have used it for depression, and I knew the word,
and then I was started to research it and I
was like, Oh, it's it's more of like in the

(25:41):
L S D family or No, am I wrong? Like
what is it? I have no clue, honestly, So I
think the first thing to say is that some people
include ketamine in the so called quote psychedelic families, some
do not. That's a whole that that's an hour in
and of itself. The psychedelic is pretty problematic because like anxiety,

(26:03):
it covers so much different stuff and it's it's pretty imprecise.
So um, I would think about ketamine as we call
it an n m D A receptor antagonist. That's what
we refer to it as. Now what does that really
mean and is there a way that we can make
that more more understandable from from a mechanistic perspective? There is?

(26:27):
But I think first we got to start with its history.
So Kennedy was actually f D approved first as a
general anesthetic decades ago. It is as a w h
is oh last look or last publication I believe, probably
the most commonly used general anesthetic in the world. But um,
the bigger point being that you know Kennedy has been around.

(26:49):
It was synthesized by chemist, you know decades ago, was
FDA approved as a as a general anesthetic? It was.
It was actually discovered in the sixties and approved by
the FDA and I seventies, so it's been around for
a really long time. It's a really dirty drug. By dirty,
dirty doesn't mean bad. It means it hits a lot
of different receptors. That includes opiate receptors, right, which is

(27:14):
a concern because we also know a ketamine is a
substance of abuse. There are epidemics of addiction and or
I should say there are epidemics of use disorders of katamine,
especially in parts of Asia right now, and they're continue
to be pockets of it culturally in the US. Um
and can I ask a question and when people are

(27:34):
abusing it, are they is it in pullform? Or they
shooting it or they snorting? Like how how do they
get the substancent liquid? Is it just about any anything?
Often it's taken by mouth on the street, but I
have heard of people doing other things with it as well.
And you know, it's a it's a highly controlled substance
by the government. It's it's illegal to sell it or

(27:57):
to give out unless you have you know, to unless
is being prescribed. So it's a drug that has been
around for a long time and that we understand, but
that we really have to have a lot of respects
for because although it has been around a long time,
there's still a lot of things we don't understand about it,
especially in these new indications A and B. It does
hit a lot of different receptors and that makes coming
up with the mechanism for how it works a little

(28:20):
bit tricky. In the history of ketamine's evolution, remember you
know it kind of it was discovered as a general
and created and then approved as a general anesthetic. Veterinary
medicine ended up picking it up eventually, and it's also
fairly easy to administer, so it doesn't do a certain
general of other general anaesthetics to do. For example, it
doesn't depress respiratory rate. I mean, this is actually quite sad.

(28:44):
During the Vietnam War, there's some good history that you know. Basically,
you know, teenagers were given ketamine to give to each
other in the battlefield because it was a way to
alleviate pain or give some anesthesia without potentially putting someone
into respiratory failure. So there's a dark side to to
the use of kenemy and in conflict zones too, and

(29:05):
dark side or light side, depending on on one's perspective.
So it continues to kind of stick around, continues to
be used in o RS, and then in the two
thousands people start doing studies and noticing that it's having
effects on what traditionally has been in the round the psychiatry,
all right, And so what they're noticing first is that
people who are really quite depressed suddenly after getting kenemine,

(29:27):
like their depression kind of seems to be gone and
there's a lot of what's turned into folklore about exactly
you know, what happened and when, um. But at the
end of the day, we ended up accumulating more and
more data that showed, especially and most of the early
stuff was especially for depression, that Kennemine appeared to engage

(29:48):
a novel mechanism, meaning a mechanism that had not really
been used by previous medications to treat depression. I started
our clinic when I felt the evidence base had reached
a point where it was actually unethical not to offer
this even though the FDA has not approved regular academy
and it never will, because it was a proof of
something else that's off patent. And then as acrenemy and

(30:11):
kim along, which is actually approved, we can talk about
the difference between the two. So you asked, like, you know,
what is this stuff? What does it do? It comes
down we think, okay, we think it comes down to
something called synapter genesis. If you think about the brain.
And let's go back to like our the biological description

(30:33):
that we gave before. We've got sort of this front
part of our head and there's a lot of pretty
sophisticated stuff up there, and then you've got an amygdala
in the back that's very reptilian but super important for
that few responds during and you have this thing called
a prefrontal cortex. So when are really sophisticated prefrontal cortex,

(30:54):
it's actually called the ventral lateral prefrontal cortex. When that's
really active, it puts the brakes on the connectivity between
the that reptilian fear based AMGLA and the frontal lobe,
which is where a lot of our higher order think
it goes. Okay, so it's gonna it's gonna reduce the
anxious inputs coming from the emygdala. By comparison, if you

(31:18):
really ramp up that dorsal anterior cingulate cortex in the
frontal lobe, you can actually end up increasing communication between
the magdala and the frontal lobe. And we're thinking of
these more now is networks rather than circuits, which is
why this language is a little bit inadequate, But that's
sort of some of the basic biology of it. In

(31:39):
terms of anatomic structure, what we think ketamine is doing
is by inducing a surge in a neurotransmitter called glutamate. Okay,
by inducing a glutamate surge. We think it's allowing neurons
to create the possibility for new connections with other neurons,

(32:00):
hence the term synapter genesis, meaning the genesis the creation
of more synapsis. And the hypothesis, roughly speaking, is that
if you're able to do that in the right networks
and those networks are reinforced. There's a phrase, you know,
neurons that fired together, wired together. Um, you that is adorable.

(32:21):
And I should say I did not make that up.
I have no idea who did. But you know, I
think what we're seeing, what we think is happening with
Kenemine is basically the final common denominator, probably being synapter genesis,
and that is relevant to so many things, including depression
and anxiety. Now, I have a really dumb question when

(32:42):
you're creating, when Katemine is creating these new neurons that
fire together and wired together, just this is like baseline caveman,
dum Is it always good? Do you know what I mean?
There's never a chance of them creating bad neural pathway
And I know it's not neural pathways, but is it?
You know what I mean? Yeah, how do we know
they're not going to create more neurotic things. Right, So

(33:07):
that is a wonderful and complex question that the bottom
line is, I don't know for sure. What I can
tell you is that empirically it seems. And this is where,
by the way, when we describe mechanisms as doctors and scientists,
we're making a lot of stuff out based on a
lot of assumptions, right, Which is not to say that

(33:27):
people aren't doing their best. We're doing our very best,
but these are our guesses based on you know, empical
observations and mechanisms. Okay, So with regard to your question,
you know, the evidence suggests that when you give a
depressed person or possibly an anxious depressed person kennamin and
you see a response, well that would suggest that you're

(33:49):
not reinforcing those depressed networks. So you know, by like
trial and error, I mean not that you're looking to
prove prove my dumb question, but you can just see it. However,
I want to be careful not to say that bad
things can happen, because I can tell you that in
the Kenemine abuse literature, a lot of bad things happen
to the brain, right, um, a lot of bad things

(34:11):
and to other parts of the body as well, and
we don't have super longitudinal data on ketamine in its
uses in psychiatry either. Okay. One of the reasons why
it's important that people not just go running to their
nearest Kenemine clinic when they get anxious and if they
go through a really tearful, thought out formal process um

(34:33):
one of in other words, a reason not to just
jump from I've never been on a medication, I've now
been diagnosed with anxiety. I'm going to kenemy is because
there are a lot of unknowns and uncertainties about these
medicines that it's going to be a long time before
we know the answers to ye. We'll continue the interview
on the flip side of a quick message from our sponsors.

(35:01):
I have a question. So when I was in my
early twenties, I had depression and and anxiety blah blah,
and so I went to a talk therapist and she said,
you probably need medication. You should go to a psychiatrist.
You probably have a chemical imbalance. And I've talked about
this on other episodes, but you know, it's mid nineties.
I don't really know anyone else on medication. Someone says

(35:23):
chemical imbalance. I think, well, I made the appointment with
the psychiatrist. They're gonna shave my head, put on some receptors,
they're gonna find this chemical amounts, they're gonna get blood drawn.
And this guy just looks at me says, yeah, prozact,
you've a chemical imbalance by and like, the hell do
you know? And so I feel like with ketamine um if,
I come in and I'm like, look, I've been on
every antidepress and it's not getting better. Let's try this.

(35:44):
Is there a test um unlike these other things people
give like, do you actually see my chemical imbalance? So
the short answer in the clinical setting right now is no.
The longer answer, and we're actually in the talking about
this right now, are looking for biomarkers that may tell
us if someone is likely to be a responder versus

(36:06):
not a responder. Lots and lots and lots of biomarkers.
This is a huge issue right now in drug development
in general rights as a new class of medicines, a
new pipeline comes forward of which some of us consider
Academy and Academy to be among the first um in
this pipeline. So, no, we don't have a test, and

(36:27):
in clinical practice you'll almost you'll never go into a
doctor's office and have them show you, you know, um,
a picture of all your neurotransmitters and and and where
the chemical imbalances. Our language is really messy around this.
In psychiatry, I get the chemical imbalanced metaphor, but it's
probably way more complicated than that. I mean, imbalance is

(36:49):
so vague, right, and there's a reason, and there's so
many chemicals. It's like are we talking Saratona, We're talking,
do you know? Yeah? Yeah, So I think chemical imbalance
is are very poor as it was our best attempt,
and but a very poor substitute for a much more
precise um description. The problem is that defining that what's
actually happening with a lot of precision um that there

(37:13):
isn't a five minute elevator pitch for that, unfortunately, so
we resort to these kinds of metaphors. So I have
a question, like if I'm on a plane, I know
I've got my little Klonopin prescription dissolvable half milligram for
when I'm having like an absolute panic attack on a
plane and all my stuff isn't working. That I do
and it just need to be comfortable. A pop it

(37:34):
It stops the panic and I can get on with
my whatever I'm doing. But it doesn't prevent future panic attacks.
Obviously it's as needed. So it seems like ketamine is
a whole different thing where you're going to get a
treatment and can you explain what it what the treatment
feels like, um, And then can you explain like how
it might prevent later or I'm assuming it does do

(37:58):
preventative or can right, Yeah, So now maybe it's a
good time for us for me to tell you a
little bit about why you're hearing mostly about kenemine with depression,
and it almost sometimes feels like then there's a footnote
about the anxieties with I mean, and then we can
talk about the experience and what it's in and you know,
sort of step by step what it feels like. So

(38:19):
most of the studies on ketamine have been done with depression. Um.
What I have found in our service is that almost
everyone that I see doesn't just have depression. Depression and
anxiety to me are two sides of the same coin. Okay,
So I mean, occasionally you'll see somebody who will absolutely

(38:42):
deny one or the other and I'm like, remarkable, I
never see this. Now that's partly because if you know,
we're we're a psychiatric center of referral, so we get
tend to get pretty tough cases. But a lot of
people are struggling with, you know, both anxiety and depression. Now,
it is true that most of the research i'm ketamine
uh falls into the depression category at this point. However,

(39:06):
there are a number of studies that have looked up
specifically at anxiety. So for example, one study on anxiety
and ketamine that had eleven depressed subjects, so this was
anxiety and depression, showed that their anxiety rating decreased by
in most of the subjects decreased by about half, which is,

(39:26):
you know, not bad. Carlos Serati UH showed showed some
interesting potential for ketamine for anxiety and at two thousands
and six paper for O c D. There's been some
good work done by a number of different people for
social anxieties. Or there's a really interesting study that showed
that about six out of eighteen subjects with social anxiety

(39:48):
disorder responded um interesting and this is where the footnote
comes up. You know, having six out of eighteen subjects.
We see there are small studies six out of eighteen
subjects for spawned. You know, that's not terrible. It's not
as good as we like, but it's not terrible. But
when they did a different score, when they did what's

(40:08):
called the visual analog scale, that's where you point to
the faces like happy, sad, anxious and say which one
you are? Yeah, zero out of seventeen patients really showed
any difference before and after treatment on that measurement. So
on the validated scientific instrument, anxieties seem to get better
for a significant number of patients. But on the visual

(40:30):
analog scale, which I just think is so you know,
it's just sort of so intuitive. I have an intuitive
trust of it. To some extent, nobody really changed. There's
a great paper by a really close friend of mine.
I was in her wedding. Um, so I'm biased, but
she shows that anxious depression may actually respond better than

(40:52):
depression itself treatments. Yes, it's really cool paper. Um have
we seen that play out? I'm not sure yet, but
I think it's It's a really reassuring thing to be
able to share with folks, because again, um, very often
the more you peel and investigate a person's anxiety. Very

(41:14):
often you find depressions somewhere in there too. But the
fundamental idea is that even if we don't see, and
this is true of so many SEC medications, if if
we had visuals here, I can show you some graphs
with depression scores that are just stunning that you know,
the patient's depression seems to just almost disappear after a

(41:36):
treatment or two. Right And it's a real risk right
now in in social media and in messaging because a
lot of people come into consoles thinking that's what's going
to happen and doesn't. Okay, but it has been shown
to happen. Um even if we can't quite get that
same thing with just pure anxiety. Again, if you can
take some of the edge and the intractability of it

(41:59):
to open up space and bandwidth for this other stuff,
then you've done a good thing. And and I also
want to mention that you know you mentioned drugs and
drugs and drugs and trials of drugs. Um. What many
places will do is use a definition of treatment refractory
illness before they recommend academine or there are some places

(42:21):
that are more aggressive and will simply look for, you know,
an attempt or two with the medication that clearly failed.
There's a lot of debate right now about when kenemine
should be used and when it should not. Generally, academic
centers are going to be more conservative, and private centers
just philosophically are going to be a little bit more

(42:42):
liberal or aggressive. Okay, but just so you know, in
most academic centers, teams are going to want to see
that first line stuff didn't work first. I do think
we make a mistake if for a person who is
otherwise an ideal candidate, we wait for twenty medicines because

(43:02):
you've lost how many years of trying medicine is doing
intense therapy and not living your life, and now your
job is even harder, like in terms of the ketamine
is going to do even more than it was going
to do three years ago when they walked in right exactly.
So there's some balance here that we're all still trying
to figure out. A lot of it is safety driven
and uncertain and you know, a lot of what we

(43:24):
talked about in other lectures is how do you navigate
uncertainty and the therapeutic pipeline when the statistics on depression,
anxiety and suicide should be headline news every day, right,
So it's a real problem, and yet we have a
lot of uncertainty about what's in the pipeline. We're really
excited about it, but we also don't know a ton

(43:45):
about it yet, and figuring out ethically what you can
offer when is really tricky and it is a whole
session of itself. Anxiety bites will be right back after
a quip little message from one of our sponsors. So

(44:08):
take me through. Like, so now I'm a candidate for ketamine.
So here I come. I'm going to my first appointment.
Like what actually happens? How many appointments? What does it
feel like? Because I'll tell you this, I've never and
I know it's not. I'm just casually throwing out the
word LSD and psychedelics, which I know it's not, but
because you said it's dirty drug touches a lot of receptors.

(44:28):
But I may, Um, I've never tripped. I've never done
any drug like that. As an anxious person, I don't
want to leave my reality, right. Um. I don't even
like pot just like no, no, no, glass of wine
is fine with me because I know exactly what's going
to happen, but so but at the same time, I'm
very attracted to this, Like I have this fantasy that

(44:48):
when I'm, you know, eighty years old, ninety and in hospice,
that I want to do psychedelic therapy for death anxiety. Um,
and I'm hoping I a. But at the same time,
the anxiety of death I have to me, like is
the same anxiety of psychedelics that I have. Like, I
don't want to go to a weird place. So would

(45:10):
I be a bad candidate for ketamine or what happens
during during the session, Well, let me tell you what happens,
and then you can tell me. Okay, yeah that's a
good point. Yeah, okay, Um, So and I'll get real,
I'll be real practical. So let's skip over the medical
clearance stuff and the logistical stuff. So, so you come

(45:31):
into the room. Um, a blood pressure cuff and a
pulse leximeters that measures heart rate and your oxygen saturation
is put on the finger. This is really simple stuff
that just takes a second. UM, and you're in a
chair of stretcher and there's a nurse with you and
a small like pediatric I V is placed in by
the way, I'm talking about ketamine. Okay, I'm not talking

(45:52):
about s kenemine, because s ketamins FDA approval. It has
two approvals. The one that has it has been used
the most for thus far is treatment refractoring major depressive disorder. Okay,
it's a proved for tier M d D. It is
also helpful to some extent in my experience in anxiety.

(46:15):
But the FDA label and the approval is for tier
M d D, and then there's also a suicide suicidal
indication as well. I'm going to talk more about I
V kenemine because it doesn't have enough the approval in psychiatry,
and um we do. Sometimes I will use I V
kenemine because I have a little bit more flexibility in
dosing with patients who are concurrently anxious and depressed. Sometimes

(46:40):
I won't. Sometimes I'll still use sketemine. So the IVY
goes in and um, you know, vitals are checked. People
often are anxious before their first infusion, especially right Um.
Most people we got are like you because actually a
history of substance abuse is potentially a reason why you
would not want to recognize kind of mean to someone

(47:01):
you don't want to. There's a lot of debate about
this in the field too. Right, So again, this technically
is an opiate and we're in an opiate epidemic, so
you have to be careful about making sure that you're
treating the right patients. You don't want to create a problem,
and there's some there there's some real debate in the

(47:22):
field about about how to think about that. Again, academic
centers are going to be on more conservative side usually
generally speaking, a little bit different in private sectors. So, um,
the infusion starts, the academine goes in, and here is
where what most people experience is a combination of one
of the following some perceptual changes. So colors may seem

(47:47):
really vivid, noises may seem louder or softer, altered sense
of time, the forty minute infusion may seem really really
long or really really short. Some people get a little
disinhibited in goofy all, though I wouldn't say that's the majority. Um,
Some people get kind of kinda depend and I think
this may have something to do with what they're bringing

(48:08):
into the room at the time. Some get pretty tearful,
and it's a kind of cathartic experience. Some patients experienced dissociation,
So this is a dissociative anesthetic, meaning that classic dissociation.
The example is if you've ever been and unfortunately patients
the PTSD, you often experience this. It's it's a kind

(48:29):
of defense mechanism. But something's bad happening to you, the
mind will arrange itself. So essentially you are watching yourself
as if from if there's a camera up there, you're
up there watching it happen to you. Right, So that
can happen during academy where people feel dissociated or from
their body. Another similar thing is something called the realization,

(48:50):
oh yeah, that's I don't I didn't get that just
walking around and not my favorite Yeah, yeah for sure.
The and we call this psychoto mimesis because is some
of this stuff is a little psychotic like, right. And
in fact, when people study psychosis, one way they try
to create a state physiologically that in some ways approximate

(49:13):
psychosis and mice or rats is by giving them ketemy
and I can I can see your anxiety going up
right now. The reason I'm not falling off my chair
every time I talk about this is because that stocks
when the infusion ends, usually within a couple of minutes.
Some people don't experience dissociation or psycholomoysis at all. So

(49:37):
the range of what people experience is extremely broad. It's
pretty rare that I have somebody coming to be like
Dr Miser, that was awesome. Can I come tomorrow too?
That does not happen. It sounds like a lot of
work that you're going through. When you're sitting there, you're
not getting a you're not getting high for an out.
It is not for most people a high experience for

(50:00):
most people. They're also not saying I am never coming
back that that has been said. A few people say
I'm never ever doing that again. Some people say, you know,
that was really uncomfortable. Can we take this one step
at a time and I don't have to like to
sign up for everything all at once? Right? Of course,
The answer isn't. Of course, it's one step at a time.
And I have had patients who are like, you know,

(50:22):
we've done kenneen is is wonderful, and that typically the
response is quite fast. If you don't get a fast response,
the probability of a meaningful response goes down dramatically. Wow,
So you kind of know right away in a way,
which is one of the reasons why we like it. Yeah,
that's great. I mean how many how many two to
three month trials on a necessary do you need more

(50:43):
before you go crazy? And it's sometimes you're like, I
don't know, am I better? Am I not? Because you know,
you're dealing with like life too, right, So you might
be on a drug trial exactly, and it's like, oh,
then a pandemic happens and you're like, wait, a mind
depressed because I'm depressed or I'm in lockdown, like I
don't know. But so then all right, so I do
my one. What I mean, I go home? Now what
am I going to feel differently? Like, let's say I

(51:04):
have panic attacks? Uh? Driving? What I maybe potentially not
have one that night in a situation where I normally would, Yeah,
it's possible. We typically use three to four infusions. Is
are are what we call the challenge or that it's
like the litmus test to see if there's a response
we have seen and in the literature there are there
are good examples of people whose depression and anxiety improves

(51:29):
pretty significantly after just the first infusion. Are two Okay, now,
if you stop there, it will get bad again. So
what you need to do at the very least is
a series to prolong the effect and then either be
in a maintenance protocol where you come back every so often,
or in our service, since we have a sketeine with

(51:51):
an f D approval which has its own maintenance protocol.
In our service we use I V ket any. We
use a booster model where we how to keep people
out of the clinic for as longer time as possible
and only bring them back when symptoms return. Okay, so
what does that look like scheduling wise or a seam academy.
This is the non FDA approved one, our interpretation of

(52:14):
the literature at this point. Keep in mind this is
a moving target, so the protocol could change two weeks
from now. It's two infusions a week usually for about
three weeks, and then two to three treatments after that
between about you know, one and two weeks apart. We
consider that to be the induction or the acute phase,

(52:37):
and if there's been substantive response and relief, we then
stop and ask the patient to let us know if
symptoms start creeping back and they feel like a booster series,
which is usually between one and three treatments, is needed. Now,
what we can't predict is how long that so called
wellness interval is going to be. Right, So I had

(52:58):
some patients for whom you know, if it's just four weeks,
I'm a little uncomfortable continuing with I V ketamine when
it's not FDA approved, and when you have a maintenance
drug in sketemine, which is meant to be done in
the maintenance phase every week or two. If you get
three or four months of relief and they need three

(53:19):
booster infusions, I'm more comfortable with that. Just from an
exposure perspective. Could some people get like years of relief?
Some yes, but that is not that should never be
the expectation. Um, it would be, and it is in
the cases I can think of where it appears that
that has happened, I consider to be an extraordinary event

(53:42):
and very very good luck. And I think it has
something to do with the sub type of depression and
or anxiety that was happening. Um, it is much more
typical that some kind of call it a booster or
call it maintenance treatment will be needed, you know. So
just to tell you what's going on on the streets here,
non doctors talking. What I've heard just casually from people

(54:05):
talking about it is oh, yeah, yeah, you do this
and it cures you for life. And that's like what
the lay people around are saying. And I think that
this has been so eye opening for me because it's like,
this isn't that, this is like what you said, this
is to take really acute case of anxiety, and like,

(54:26):
let's just get you to somewhere where you can start
doing the things we're supposed to do for anxiety. Like
this is amazing. I literally when I first started talking
to I was like, Oh, it's the thing you do
three times and you never have it again. My field
is to blame. I mean, we did a lousy job
at the very beginning emphasizing that those papers that were
published where just a few were given and there was
a huge response, those are not longitudinal papers. There's a

(54:49):
real problem in science reporting and and the problem is
with doctors, not the reporters. We need to communicate to
science reporters that in certain studies that we're looking at,
um that ration may be very very low in the outcome.
You know that the score may be very low in
a good way. But it's only been a week. Right
when it gets translated into a tiny blurb in a newspaper,

(55:11):
you missed that extremely important point, right, And so yeah,
a lot of people aren't there requesting consoles because they
think it's the magic bullet, and there is no magic bullet.
Do you think that? Like, So I'm there, I'm getting
my academic treatment at work, and one of these people
it does well with is one of the things that's
happening is that like almost the way people do talk
about a psychedelic experience where they're like, oh my god,

(55:33):
I took this drug and I realized we're all one,
you know, all this stuff where you're like, well I
knew that anyway, Like do I do? I come home
and then start to have an easier time being the observer.
So I'm really glad you asked. One of the differences,
I think UM exists, and I think this is going
to get better defined as the next couple of years evolved.

(55:55):
One of the differences between Kademine and say, some of
the psilocybin of the world some of the other pipeline
stuff that that are also being work done is when
you read descriptions of how something like a psilocybin or
um some of those similar compounds. When you read about

(56:17):
how people seem to feel better after there is a
kind of insight oriented shift that seems to be a
significant part of many people's experience who have a good one. Okay,
um in ketamine. It is very rare in my mind,

(56:37):
it has only happened once that someone came out of
an infusion and said, I understand things in a different way.
Now I know what I need to do. I'm going
to go do it, and that's it now. In this
particular case, the patient made a decision, a major life
decision that we actually would not have advised making during

(56:57):
an infusion. UM. I don't know that it was the
right decision or not, but they chose to move forward
with that decision. That's not typically the way things go
at this dosing of kenemine. That idea does seem to
tap into what may be happening with some of the
pipeline developments in the psilocybins and other similar compounds in

(57:20):
the world, but we don't see that so much with
this kind of modeling and kenemine. Okay, got it, But
it is something where as I'm getting better because of
the treatments, it's doing something to my brain that maybe
is not so like flashbulb obvious, but it's it's helping me,
uh maybe not ruminate as much or think, you know,

(57:43):
there's nothing that can be done for me. Yeah. So
we think that through that thing called synaptogenesis, where you
can you know, create the possibility for new communication between
neurons UM. We think that for for some reason that
through that process. We know that symptoms in patients who

(58:04):
are what we call responders, you know, their suicidality often
improved dramatically. Uh, their mood may improve significantly. UM sleeps
a little bit trickier. UM sleep is in my experience,
has been something that's been a little bit harder when
it's a function of depression to adjust energy you know,
will often go up UM and hadonia, the inability to

(58:27):
enjoy things that will go down. And it's a good thing. Right.
So so you're seeing and anxiety often decreases, so you're
seeing sort of this. We know this synapto genesis thing
is happening. We know this is modulated by this neurotransmitter
glutamate and this surge that happens in the synapse, and
then we see these results coming in and and I

(58:47):
should say, we say that it's about a fifty percent
response rate. And that's a little hand wavy because to
really define exactly what we mean by response all comers,
you're going to see numbers all over the board, and
a lot of it has to do with how sick
people are coming in. Percent improvement always in part depends

(59:08):
on how bad or good you started out at. Right,
So the devils and the details and that stuff is
a generic is a generic percent and it's not perfect,
but it's a reasonable way I think to communicate the
response rate and then to go into details a little
bit more into consol based on a person specific sort

(59:29):
of gestalt presentation, so that back to your point, Yeah,
it's less of an insight oriented Oh my gosh, I
just realized my mom really did love me, right, and
I'm I'm I'm purposely being a little sarcastic here. It's
the treatments that did that, of course, are much more sophisticated. Um,
and it's a little bit more about something happening we

(59:49):
think neurobiologically. That then allows these symptoms of depression, anxiety
to subside. And it does again seem with the caveat
that most of the work that more work has been
done in depression and anxiety, that well, anxious depression may
be especially right for this kind of treatment. Um, most
of the remarkable work that we've seen has been more

(01:00:12):
in depression and anxiety, although we've seen anxiety improve as well.
I do want to say one thing though about break
through anxiety. Okay, and this and and this is gonna
make everybody's anxiety go up for a second, but that's okay.
We're gonna invite our anxiety to be with us for
a moment and just hang out, and we can be
separate things and just be present with each other. So,

(01:00:34):
sometimes what happens when someone has anxiety and depression and
gets not just ketemy, but you know, I've seen this
happen in East electric convulsive therapy other treatments as well,
is the depression starts to get better, in the anxiety
suddenly skyrockets. So what what is up with that? So
if you think about this, and I think it's helpful

(01:00:55):
as a as a kind of sort of logical approach
to make sense of the world. If you think about this,
evolutionarily speaking, why is it that this stuff exists. Well,
there's lots of different reasons that people have hypothesized, but
one of them is that one role that depression plays
is to push anxiety down. So if depression is a
site of hype co arousal and anxiety is hyper arousal,

(01:01:19):
depression is a really bad way of reducing the hyper
arousal of anxiety and pushing it down. It thus follows
that if you take away that break or that pusher,
the anxiety is gonna skyrocket. That literally happened to me. Yeah.
Once once I got um, you know, I had kind
of both things. And once I got my anxiety, I mean,

(01:01:42):
once I got my depression wrangled, which was the first
thing here comes anxiety, I didn't have my little uh yeah,
you know, cushion to go back to. And I used
to love as an anxious person who more hasn't had
more anxiety than depression. I loved when I would get
depressed because in a weird way, I would feel relaxed, fearless,
and away like who gives a shape? Yeah, yeah, no,

(01:02:04):
I I see it in you know, the clinical setting
pretty frequently actually, And what I also see though, is
that over time there's a kind of you know, the
body does so many things, especially the brain, behind the
scenes that we don't understand or may not even be
able to see at this point, and it does seem

(01:02:25):
to come to a kind of equilibrium where it then
adjusts and the anxiety tends to come down. And I
think that the literature is going to a should be
a bit careful because this is also an area of
review and research, and we don't know what it's going
to say for sure. By clinically speaking, I do see
that quite a bit. So although there's that kind of
scary point of breakthrough anxiety, there's often that also quite

(01:02:47):
reassuring point where it then sort of comes back down
into a much more comfortable equilibrium. To anyone out there
who may want to investigate this, where should they I
don't mean like physically, where should they go? Or maybe
I do Where should they begin? Do you recommend they
go to a more like you said, um, oh god,
what was the word you said? That's more conservative? Oh

(01:03:09):
so an academic practice, So yeah, so I have. I
think that's just to two thoughts. One is the place
to start is always with your primary prescribing psychiatrist or
psychotherapist to talk about, you know, why you're thinking about it,
and and get their sense because you want that alliance
with your primary treatment provider to be really strong, and

(01:03:31):
you want to make the decision together. Okay, and they
may have they may know nothing about it, in which
case you'll learn together and they may know a ton
about it. Okay. The second thing, actually, I'm gonna give
you three if that's okay. Yeah, you want to be
really careful when you're kicking the program where you're receiving care.
I am very worried about inappropriate uses of ketamine. That

(01:03:55):
is the f D a cryptian anesthetic ketamine, not as ketamine,
which is empty approved for the treatment of r m
d D and has a suicidal indication as well. There's
not I don't believe enough oversight in terms of protocols
and safety and prescription and use and dispensation of kenemine

(01:04:16):
and ivy kenemine, MPO Academy, etcetera. So you want to
center that it has good oversight, that is, that feels safe,
that practices, you know, evidence based medicine, that isn't adding
on lots of non evidence based extras from the menu, Like,
you know, you can go and do an infusion center
and you know, click what vitamin you want. I was

(01:04:37):
just gonna say, I'm hearing a lot of vitamins mixed
in and it's always that always gives me the IX,
that always feels a little Yeah. Basically, you want to
look for an evidence based place. And if you're like,
what's the evidence based for X, and they're like, we're
not sure, but we think it's really cool, don't you
don't go there? Okay? Um. I think that the other

(01:04:58):
thing is, you know, increasing the insurances covering some of
these treatments at some places but not at others. So
you want to work all that out so you don't
end up getting too excited and then end up three
months down the road everything is set up and then
you realize, oh my gosh, I can't. I can't insurances
and covering and I can't pay for it. That's been
a major letdown and it's a tricky field to navigate.

(01:05:21):
I think that the data driven, evidence based approach to
all of this treatment in a safe environment is what's
most important. Collaboration with your primary psychiatrist or therapist is
an important part two. So you want a team that's
going to be able to do that if necessary. The
final thing that I'll just say for for everybody and

(01:05:43):
for all of us during this really weird, weird time, um,
And I mean this in a spirit of genuine optimism.
I don't think there has ever been a time in
modern history when it could have been better to be

(01:06:04):
depressed or anxious. Because there's new stuff now here currently
and in the pipeline that's moving quickly, that appears to
bring novel mechanisms and new agents to a field that's
really been quite stagnant form a very long time. And
in that regard, we are very lucky, and our patients

(01:06:26):
are very lucky, um, because there is new stuff coming
and new stuff here, and I do believe it's going
to change the face of these illnesses. There's not going
to be a magic bullet. I don't believe in magic
bullets in general. But it is a better time than
it was, certainly thirty years ago to be anxious and depressed.

(01:06:51):
I hope you learned a lot from my conversation with
Dr Robert Meiser. Let's go over the takeaways, and there are, oh,
there are takeaways in this one. I learned so much.
All right, here we go are stupidly no, sorry, I
can I even do this right? I mean, I'm leaving
it in. I'm not editing it up. You're at The
takeaways are brilliantly stupid. Brains can like the idea of

(01:07:15):
ruminating because it feels like you could solve something, but
actually you're just causing yourself anxiety and driving yourself crazy.
The thoughts we have in our brains are real, but
not necessarily true. People with anxiety in Western society is
mistakenly think that the thoughts in their head actually are
a reflection of the real world. An exercise for coping

(01:07:39):
with anxiety and fear right down the fear, Do the
thing that you're afraid of, see if that fear comes true,
and then write the results. This is to show yourself
that rarely does an anxious fear actually materialize. Dr Meisner
believes that we've lost track over and over again about

(01:08:00):
getting back to certain basics when dealing with anxiety, like
practicing mindfulness in any modality, which is basically learning to
interrupt the reactive patterns in our thoughts that go on autopilot,
recognizing our rumination when it's happening and mindfully choosing not
to go down that path, keeping social connections and the

(01:08:21):
simple process of naming the thing that's going on, the fear,
the anxiety that creates a distance between the eye that's
doing the naming and the thing. Mindfulness is just about interconnectivity,
not over identifying or even identifying with the object that

(01:08:42):
we're labeling as fear or anxiety, because it is not us.
Your fear is not actually who you are, and you're
observing this thing called to fear, and that is transient.
Sometimes creating a linguistic space of what's happening in my
stud bit brilliant Head is not necessarily a reflection of

(01:09:02):
what's happening in reality, can create a moment of repose.
There is no magic bullet in medicine or in curing anxiety.
The purpose when using evolving neurotherapeutics like ketamine is not
so much to make a patient better with the drug.
It's to make them well enough so that they can

(01:09:24):
fully engage much simpler things and get more reward from them.
Ketamine is not a psychedelic, but it is an n
m d A receptor antagonist. Ketamine was f d A
approved as a general anesthetic decades ago. It's been around
four decades. Ketamine is a dirty drug, which doesn't mean

(01:09:46):
that it's bad, but it means that it hits a
lot of different receptors, and that includes opiate receptors. Ketamine
is most known for treating depression, but most people with
depression do all to have anxiety. What ketamine is thought
to be doing is inducing a surge in a neurotransmitter

(01:10:06):
called glutamate, which allows neurons to create the possibility for
new connections with other neurons, which is the term synapter genesis,
which is relevant to depression and anxiety. Synapta genesis simply
means the genesis or the creation of more synopses. There
is a phrase neurons that fire together, wire together. Dr

(01:10:30):
Meisner cautions don't go running to the nearest ketamine clinic.
Don't jump from I've never been on medication, but I've
just been diagnosed with anxiety. I'm going to ketamine. There
are a lot of unknowns and uncertainties about these medicines
that will take time for all of the answers to
be understood. Generally, academic centers are going to be more

(01:10:51):
conservative with administering ketamine, and private centers philosophically are going
to be a little bit more liberal with administ string.
During Academine IVY infusion treatment, people can experience perceptual changes.
Colors may seem vivid, noises may seem louder or softer.
There can be an altered sense of time. Some people

(01:11:12):
may get disinhibited, some people can get tearful, and some
people can experience dissociation or de realization. Academie infusion is
not an experience where people get high and want to
come back for more. Typically, actamine patients are given three
or four infusions as a litmus test to see if

(01:11:33):
there is any response. Some people improved after just the
first infusion or two. It's two infusions a week for
about three weeks, and then two to three treatments after
that between one and two weeks apart. That's the induction
or the acute phase. If there is a substantive response
and relief, the process is stopped and patients are asked

(01:11:56):
to monitor if any symptoms come back. For a stable
booster series, which is usually between one and three treatments,
there isn't a way to predict how the so called
wellness interval is going to be in patients receiving ketamine treatments.
Some people do get years of relief with ketamine treatments,

(01:12:17):
but that should never be the expectation. It would be
considered an extraordinary event and very good luck for that
to happen. Anxious depression maybe especially right for ketamine treatment.
Most of the remarkable work that Dr Meisner has seen
has been more in depression and anxiety, although he's seen

(01:12:39):
anxiety improve as well. That's it for this week's episode
of Anxiety Bites. As always, if you would like to
email the show, I will read it on a future
listener email episode, and I would love for you to
write an Anxiety Bites weekly at gmail dot com. Let
me know if you have any questions or if you
have any inspirational stories about your own recovery that linked

(01:13:00):
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(01:13:23):
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