Ketamine Therapy for Bipolar Disorder

Rakesh Jain, MD, MPH, Psych Congress steering committee member and clinical professor, Department of Psychiatry, Texas Tech University School of Medicine, Austin, discusses ketamine-assisted therapy for the treatment of bipolar disorder as well as proper dosing options. Dr Jain answered questions from Sana Symposium attendees during a live table talk session at the virtual meeting.

Read the transcript:

"What about if used to treat bipolar depression?" Absolutely. This is the first antidepressant, if you want to call it that, that in bipolar depression, has not shown evidence of switching patients unlike SSRIs and SNRIs.

"Lamotrigine is a very commonly used medication in bipolar disorder." Please do keep in mind lamotrigine does appear to soften the positive impact, both in terms of experience for the patient and quite likely for the antidepressant effect of the medication, too.

"What is the lowest effective dose you have experienced? Is microdose or transdose effective?" Yes and yes. When you say trans, let me use a different phrase to describe what you just articulated. Let me call it psycholytic dose. These are doses where I used to think this was a bunch of excess hot air, but having seen it in that, there's truth to it.

There are defenses that we all have, particularly our traumatized patients, particularly our depressed anxious patients that they're completely unaware of. We've known that obviously from psychodynamic literature for a long time. Not until you experience it dissolve in front of your eyes do you realize how well you and I, as human beings, are quite defending.

What you're calling trans, I will just call it psycholytic doses. They are either low dose ion. What would that be? 0.2- or 0.3-mg/kg dose, if it's given IM or even potentially IV, almost never leads to, in most people, a psychedelic experience.

It leads to a psycholytic experience where the person in fully in contact with their sensorium and their cognition. The defense against conversation, bringing up painful topics, accessing parts of their own self that they had defended against becomes very clear.

Sublingual, it's much easier to do. The dose could be as little as 50, if you're starting out to 100 mg. By the way, remember, that sounds like a lot, but the bioavailability of sublingual ketamine is low. It's about 25% to 30%, which means if I've given you 100 mg, I'm really giving you about 25 to 30 mg.

The shape of the pharmacokinetic curve isn't sharp like you get with IM, IV. It will be much more flattened out. That's the lowest effective dose. I have seen 50 mg, absolutely, get the person in the psycholytic range. Though invariably after the first time, the doses have to be 100 mg, 150, or 200.