Treatment Resistant Depression, or TRD, is a form of Major Depressive Disorder in a patient who has previously taken or is currently taking traditional antidepressant medications but continues to experience depression. Even after weeks of taking medication and increasing dosages, the medication isn’t effective at relieving the symptoms of depression. Patients who take antidepressant medications but cannot continue them due to medication side effects are also classified as having TRD.
Initial screening is done through the use of validated scales as well as a clinical interview.
Data is collected on prior antidepressant and psychotropic medication history and side effects, as well as information on the severity of symptoms, history of inpatient hospitalization, and prior suicide attempts.

Validated screening tools and DSM IV diagnostic criteria are used for each patient.
Patients are also screened for undiagnosed bipolar disorder, a history of psychosis, and past or present substance use disorders.
A thorough psychiatric history, including co-occurring mental and physical health disorders, is collected and integrated into the treatment plan.
The patient’s prescription monitoring report is reviewed prior to initiating treatment to ensure a patient doesn’t have a history of controlled prescription substance abuse and isn’t currently taking controlled substance that could increase the risks of treatment.
Patients are screened for early-life trauma using an adverse childhood experience scale. Childhood trauma is a known factor that makes patients more sensitive to the dissociative side effects from ketamine and esketamine, and knowing this ahead of time allows us to be cautious with dose and provide extra support to keep patients comfortable during treatment.

Patients are screened to ensure they do not have physical health conditions that might put them at greater risk during ketamine treatment.
Patients with hypertension are referred to their primary care provider for treatment before initiating ketamine treatment or if concerns arise during a ketamine treatment.
Patients are educated about medications they are currently taking that may increase sedation or blood pressure, and they are asked to hold these medications on the day of treatment.
Patients are closely monitored during treatment. This includes monitoring blood pressure and heart rate prior to beginning treatment. Blood pressure, heart rate and oxygen level are also monitored during treatment, at peak medication concentration, and prior to discharge from the clinic.

Ketamine and esketamine aren’t first line treatments for depression. By the time a patient considers these treatments, they are likely to have moderately severe to severe depression, and many patients may have thoughts of suicide. We consider risk of untreated illness versus risk of treating with these medications as part of treatment planning and patient consent.
Mental health and medical records are requested and reviewed as needed.
Collaboration with specialists (cardiology and neurology) is conducted to obtain “clearance” for treatment when indicated.
Participation in psychotherapy is recommended for all patients receiving ketamine treatment.

Treatment side effects are screened at every visit to inform ongoing care.
The patient’s medication list is reviewed and updated as needed.
Suicidal ideation is screened at every visit, with appropriate steps taken to support the patient and avoid self-harm.
Patients are not allowed to receive Spravato in conjunction with ketamine infusion or externally prescribed oral ketamine.
While ketamine has not been studied for safety in pregnant women, animal studies have indicated it could be harmful to a developing fetus. Risks of a fetal exposure to ketamine are minimized by ensuring patients know to use reliable birth control, asking patients when their last menstrual period was and doing a pregnancy test if there is a concern for pregnancy.
Patients must be at or near their baseline mental status and able to safely move around and care for themselves before discharge.
A driver must sign the patient in and out to reduce the risk of post-treatment accidents. Violations of the driving policy can result in termination from treatment with ketamine or esketamine.

All ketamine treatments are supervised by a specialty-trained, licensed physician (board-certified psychiatrist). All esketamine treatments are supervised by a board-certified psychiatrist or an advanced practice practitioner with specialty REMS (risk evaluation and mitigation system) certification.
The care team includes specialty-trained psychiatrists who are responsible for ordering and supervising treatments. Additional care team members include advance practice practitioners, licensed nurses and medical assistants. Everyone on the care team receives extensive hands-on, specialty training to support patients and manage treatment side effects. All team members maintain Basic Life Support (BLS) certification and familiarity with emergency response protocols, including monitoring patients at risk of respiratory depression and falls.