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IV Ketamine to Treat Depression · Fit As A Fiddle

0:00
SPEAKER_00: So a lot of people might get this a little mixed up.
0:02
SPEAKER_00: They might consider ketamine a psychedelic.
0:05
SPEAKER_00: It is, in fact, not a psychedelic, although that is hotly debated.
0:08
SPEAKER_00: And it gets looped in with some of those other medications that are not yet legal.
0:13
SPEAKER_00: But ketamine is used every day across the US and across the world off label for its antidepressant and anti-suicidal effects.
0:23
SPEAKER_00: And, you know, fast forward to today, it is the most well-studied drug for depression over the last 30 years with hundreds and hundreds of clinical trials and studies.
0:35
SPEAKER_00: We have at this point, I think, over 400 clinical trials done on IV ketamine for depression and the global efficacy of IV.
0:45
SPEAKER_00: There are other routes of administration, which we can talk about if you like, but good old generic IV ketamine for depression has a 75% rate of efficacy.
0:55
SPEAKER_00: Meaning three out of four people who receive this drug to treat their depression or their bipolar depression, even their postpartum depression, experience relief.
1:05
SPEAKER_01: Hello, everyone.
1:06
SPEAKER_01: I'm your host, Dr.
1:07
SPEAKER_01: Sneha Gazi, a physical therapist, course creator, and mom.
1:12
SPEAKER_01: I own Sneha Physical Therapy, a private practice in New York City, and created the course Master Your Pelvic Floor to help you transform the way you think about and move your body.
1:23
SPEAKER_01: Use discount code FIT20 for a special 20% discount exclusively for my listeners at the link in all show notes.
1:30
SPEAKER_01: Each episode brings phenomenal guests in the health and wellness space who share inspiring tips and tangible advice.
1:38
SPEAKER_01: All things health and wellness starts right here.
1:42
SPEAKER_01: Hello, everybody, and welcome to this week's episode on Fit as a Fiddle.
1:47
SPEAKER_01: Our guest today is Alison Greenberg.
1:50
SPEAKER_01: Allison is the former co-founder of Ruth Health, which is a virtual perineatal care platform.
1:56
SPEAKER_01: It is very wonderfully backed by Y Combinator and had a$3.2 million in venture capital funding.
2:03
SPEAKER_01: And now she is a senior director of growth and partnerships at Ember Health.
2:09
SPEAKER_01: Ember is an institution that provides ibuketamine to treat depression.
2:13
SPEAKER_01: It is the largest ibuketamine practice in the country.
2:16
SPEAKER_01: And Allison comes in not only with a lot of experience and understanding and research behind the clinical side of things, but she combines what we really need in healthcare, which is the understanding of how to grow and run practices to serve the large number of people that we really need to reach, especially in this very underserved field of perinatal wellness and health.
2:42
SPEAKER_01: And so Alison is very important in doing that work.
2:45
SPEAKER_01: So thank you so much, Alison, for joining us today and for being on the show.
2:49
SPEAKER_00: My pleasure, Sneha, Dr.
2:51
SPEAKER_00: Gazi.
2:52
SPEAKER_01: No, you could call me Sneha.
2:54
SPEAKER_01: We've known each other for long enough.
2:55
SPEAKER_01: Yes, we have known each other for long enough.
2:58
SPEAKER_01: Our um topic today obviously is going to be exploring, expanding people's minds on different types of treatments for depression, particularly with ibuketamine, because the second somebody hears ketamine, which me included, I think drugs like recreational drugs.
3:19
SPEAKER_01: And you think of headline news, and we don't understand the pathophysiology or the mechanism in which it can help people recover and rehabilitate people.
3:30
SPEAKER_01: We can only, we usually only like our minds go to that side of things, like bad or fun in some people's minds.
3:38
SPEAKER_01: So we want to kind of tailor this information with a clinical understanding that's research-driven, which I know is something that you're so good at explaining in such a wonderful, you know, way that people can uh help integrate this into their understanding of their wellness plans.
3:55
SPEAKER_01: So without further ado, could you first give us a background on yourself?
3:59
SPEAKER_01: Because we want to know where you came from, why you're doing what you're doing, and what brought you into the space.
4:06
SPEAKER_00: Absolutely.
4:07
SPEAKER_00: Yeah.
4:07
SPEAKER_00: And thanks for that intro, Sneha.
4:09
SPEAKER_00: Um, well, I could even start with how we know each other, which is through the work I did building Ruth Health.
4:18
SPEAKER_00: And I always tell Sneha and anyone who knows her that when we built uh a pelvic floor product doing virtual care for the pelvic floor in the middle of COVID, we interviewed some of the top pelvic floor physical therapists around the country.
4:34
SPEAKER_00: And we wanted to work with Sneha.
4:37
SPEAKER_00: And as an early stage startup before all the venture capital, we couldn't even afford her.
4:42
SPEAKER_00: So it was just such a great introduction into the work you do and really thoughtful conversations that you host, like this one.
4:50
SPEAKER_00: But for my part, my work today and really throughout my career actually started with how I was raised.
4:58
SPEAKER_00: I grew up talking about vaginas at the dinner table.
5:01
SPEAKER_00: And that's because my mom is an OPGYN.
5:04
SPEAKER_00: And so her work as a physician, also the fact that she built a practice in the Philadelphia area where I grew up.
5:13
SPEAKER_00: And not only was it an Obigen practice, it was called women care.
5:18
SPEAKER_00: Uh, it still exists actually within uh the umbrella of Abington Jefferson Health, but it was called women care, women caring for women.
5:26
SPEAKER_00: And she was actually really ahead of her time in only hiring female clinicians to take care of female body patients.
5:35
SPEAKER_00: And, you know, it's it got a lot of flack in those days, but she really blazed that trail.
5:41
SPEAKER_00: And I was very fortunate, just like your daughter is, to grow up around strong women and strong clinicians who wanted women's health to get the attention and focus that it deserves.
5:54
SPEAKER_00: So fast forward to finishing college and moving to New York, I made my way through really the business side of healthcare first.
6:03
SPEAKER_00: Um, and so my background is in brand strategy and consulting for highly regulated fields.
6:09
SPEAKER_00: I had clients like Pfizer, Edwards Life Sciences, Stryker, Merck.
6:14
SPEAKER_00: Um and all the while I was really missing the opportunity to actually touch human lives and patient care.
6:23
SPEAKER_00: I was always working for the healthcare businesses.
6:26
SPEAKER_00: Um, and so I kind of found my way through my first couple of businesses, one in conversational AI, and then eventually working on a medical device, trying to reinvent the speculum.
6:38
SPEAKER_00: And in the process of really building that concept for a medical device, which we never ended up taking to market, it opened the floodgates on understanding the many gaps in care that we see here in the US.
6:52
SPEAKER_00: And that's what led to building Ruth Health.
6:55
SPEAKER_00: So, Ruth was a maternity care platform, 100% virtual care.
7:00
SPEAKER_00: We started with the pelvic floor because it was such an unmet need.
7:05
SPEAKER_00: And we found that pelvic floor physical therapy in person was both uh cost-wise and logistics-wise inaccessible for a lot of pregnant individuals and moms.
7:16
SPEAKER_00: And we set out to say, how can we infuse um diaphragmatic breathing and techniques from Pilates and really look at kind of the exercise physiology approach to some pelvic flora dysfunction.
7:30
SPEAKER_00: And so we pioneered a methodology there and then rolled out breastfeeding support, C-section recovery, as well as virtual doulas.
7:38
SPEAKER_00: And it was just an incredible experience to work on a problem that matters so much, not just to me personally, but I think to every woman in my life, whether or not they're a mother.
7:52
SPEAKER_00: And all the while building Ruth was actually not just about maternity care and trying to improve on the state of maternal mortality and morbidity in America.
8:03
SPEAKER_00: I built it in part because I was so passionate about the fact that women's health is a gateway to their equity in society.
8:13
SPEAKER_00: It's a gateway to economic empowerment.
8:16
SPEAKER_00: And so much of women's health is understudied, underfunded, and misunderstood.
8:22
SPEAKER_00: It's what I believe leads to the fact that we don't have equity in government, that we don't have the power we should hold in this world because health is the foundation of everything.
8:33
SPEAKER_00: So that was really an eye-opening journey building Ruth for five years, discovering that, in my opinion, the maternal health crisis is just not solvable by a startup and it's not solvable by anything that's venture-backed.
8:49
SPEAKER_00: I got to know the people working at the grassroots, the people like yourself who are on the ground working with patients every day.
8:56
SPEAKER_00: And it opened my eyes to the fact that there are so many intermingled problems, including mental health, which interestingly enough, our pelvic floor uh specialists were sometimes feeling like therapists and sometimes having their patients just cry during a session, given all the trauma that's stored in the pelvis, and also given the many trials they're going through as postpartum moms.
9:21
SPEAKER_00: And so I wanted my next chapter to really look at the intersection of mental health and women's health.
9:28
SPEAKER_00: And that's how I found Ember.
9:30
SPEAKER_00: So it's been an incredible journey to get to this point.
9:33
SPEAKER_00: And I'm really proud of being a partner at Ember Health and of leading our clinical partnerships as well as growth for the business because uh we get to serve the patients of New York.
9:46
SPEAKER_00: We have five clinics here in New York City.
9:48
SPEAKER_00: Ember's been around for eight years, and we treat patients with depression, bipolar disorder, and that includes treatment-resistant depression, uh, major depressive disorder, and even postpartum depression.
10:00
SPEAKER_00: We treat them with the most efficacious antidepressant that we have legally in this country, and that is IV ketamine.
10:10
SPEAKER_01: Yeah, I love that.
10:12
SPEAKER_01: And I think, firstly, uh, I didn't know that your mom was an OBGYN and that she blazed that trail in Philadelphia.
10:19
SPEAKER_01: And that's really cool.
10:20
SPEAKER_01: I wish I could have a conversation with her on her journey in that era and what it took to do that.
10:25
SPEAKER_01: Wow, what a bold woman.
10:27
SPEAKER_01: And then separately, I need to have uh I need to get a coffee with you on the speculum project.
10:31
SPEAKER_01: I need to know everything later.
10:34
SPEAKER_00: Oh, yeah.
10:34
SPEAKER_00: We we'll we'll unpack that at some point.
10:37
SPEAKER_00: But honestly, I'll give you my mom's number.
10:40
SPEAKER_00: She might even do this podcast.
10:42
SPEAKER_01: I would love that.
10:43
SPEAKER_01: I would like love that.
10:45
SPEAKER_01: Okay, so let's transition into Ideketamine and its uses.
10:50
SPEAKER_01: I would love for you to explain.
10:52
SPEAKER_01: I know I I actually myself learned so much when I attended the Ember Health event that was hosted, I think it was like in the middle of the fall last year.
11:01
SPEAKER_01: And um correct me if I'm wrong, there was like so much information there, but it was I think it was something about how when um babies are uh given um medication for surgeries, they're given ketamine for, you know, whatever orthopedic surgeries or whatever things that they need.
11:18
SPEAKER_01: Is that correct?
11:18
SPEAKER_01: Am I right when I say that?
11:20
SPEAKER_00: It's a very common anesthesia.
11:22
SPEAKER_00: Yeah.
11:22
SPEAKER_00: So it's used for conscious sedation and it's safe enough that even babies can get it.
11:27
SPEAKER_00: Um it's also very commonly used across the world for c-sections as an anesthesia there.
11:33
SPEAKER_01: Yeah, and it's not in America.
11:35
SPEAKER_01: And so my first question is why?
11:40
SPEAKER_00: Yeah, why it's not used more often for C-section?
11:43
SPEAKER_01: No, no, why is it not used in general?
11:45
SPEAKER_01: And why is there less awareness about the medical uses uses of ketamine?
11:50
SPEAKER_01: And I want to just particularly talk about this country.
11:53
SPEAKER_00: Yeah, that's a great question, Sneha.
11:56
SPEAKER_00: And honestly, I like how you're focusing in on this country because things are changing rapidly across the world.
12:02
SPEAKER_00: Um, in Norway, for example, IV ketamine treatments for depression are covered by the national insurance.
12:10
SPEAKER_00: Anyone in Norway can get free care for depression with this drug.
12:14
SPEAKER_00: In France, there was just an approval passed that ketamine would be 100% covered and offered in emergency rooms as an anti-suicidal medication, where it's also very effective.
12:27
SPEAKER_00: Where you see ketamine every day, multiple times a day in the US is in the ER.
12:34
SPEAKER_00: And so that's actually how Ember started is my colleague and our wonderful medical director and co-founder, Dr.
12:40
SPEAKER_00: Nico Grunman, was an emergency medicine physician.
12:44
SPEAKER_00: He worked at Kings County Hospital for years, and he used in the ER every single day bags of ketamine, IVs of ketamine for conscious sedation of patients.
12:56
SPEAKER_00: You know, they come in and they have severe pain.
12:58
SPEAKER_00: Maybe they have a laceration on their face that needs to be treated.
13:02
SPEAKER_00: Um, it's incredibly common because it's so safe, because it's so well understood.
13:09
SPEAKER_00: And ketamine is actually a great drug for that purpose because it was invented in the late 60s, early 70s as an anesthetic and used on the battlefield in Vietnam.
13:20
SPEAKER_00: So we've known about this drug forever, um, or for a long time, but 30 years ago, it was discovered that although ketamine was not FDA approved for mental health, it was not invented as an antidepressant, it was bringing patients antidepressant relief.
13:40
SPEAKER_00: And what patients were noticing was that although ketamine is a sedative and it's actually a dissociative, it has hallucinogenic properties.
13:51
SPEAKER_00: So a lot of people might get this a little mixed up.
13:54
SPEAKER_00: They might consider ketamine a psychedelic.
13:57
SPEAKER_00: It is in fact not a psychedelic, although that is hotly debated and it gets looped in with some of those other medications that are not yet legal.
14:05
SPEAKER_00: But ketamine is used every day across the US and across the world off label for its antidepressant and anti-suicidal effects.
14:15
SPEAKER_00: And, you know, fast forward to today, it is the most well-studied drug for depression over the last 30 years with hundreds and hundreds of clinical trials and studies.
14:27
SPEAKER_00: We have at this point, I think, over 400 clinical trials done on IV ketamine for depression and the global efficacy of IV.
14:37
SPEAKER_00: There are other routes of administration, which we can talk about if you like, but good old generic IV ketamine for depression has a 75% rate of efficacy, meaning three out of four people who receive this drug to treat their depression or their bipolar depression, even their postpartum depression, experience relief.
14:57
SPEAKER_00: And that is an astounding stat when you compare it to the standard of care in the US, right?
15:05
SPEAKER_00: Everyone knows that you go to your clinician and you say you have depression, what are they gonna give you?
15:12
SPEAKER_01: All the things, every single thing is thrown at them one at a time.
15:17
SPEAKER_01: If this doesn't work, then you're taking that.
15:19
SPEAKER_01: And if that doesn't work, you're taking this.
15:20
SPEAKER_01: They go down a loophole and then they come back with some side effects.
15:24
SPEAKER_00: Exactly.
15:24
SPEAKER_00: Yeah.
15:25
SPEAKER_00: And those things, all of those things you're mentioning are pills.
15:28
SPEAKER_00: They're antidepressants, they're SSRIs, they're SNRIs, they might even be mood stabilizers.
15:34
SPEAKER_00: These drugs are important and they do help people, but SSRIs have an average efficacy of 33%.
15:43
SPEAKER_00: Oh, I didn't know.
15:45
SPEAKER_00: So one in three, those are not odds that I like for our patients.
15:50
SPEAKER_00: I would much rather give our patients the odds that we do at Ember, which is actually we beat the global efficacy stat.
15:57
SPEAKER_00: Um, 84% of our patients at Ember experience meaningful relief from the depressive symptoms they're having.
16:05
SPEAKER_00: And we start patients in care with four infusions over two weeks' time.
16:10
SPEAKER_00: We call that the foundation.
16:12
SPEAKER_00: Long-term care looks different for every patient, but after those first four infusions, on average, 40% of our patients are already in remission from their depression.
16:23
SPEAKER_00: So that takes two weeks.
16:26
SPEAKER_00: It is incredibly fast acting as opposed to SSRIs, which take, in some cases, six or more weeks to work.
16:34
SPEAKER_00: And SSRIs, exactly as you mentioned, have a litany of side effects.
16:38
SPEAKER_00: And we know for women in particular, these side effects can sometimes be worse.
16:44
SPEAKER_00: The sexual side effects can be very disruptive to daily life, to intimacy.
16:50
SPEAKER_00: Um, and you know, the challenge with SSRIs for me is that, you know, 70% of our patients are already on them when they start care at Ember.
16:58
SPEAKER_00: It is okay for you to be on antidepressants and start care with ketamine.
17:03
SPEAKER_00: But the reason why so many of our patients are looking towards ketamine is because they don't want to be on SSRIs anymore, or they found them to not work.
17:12
SPEAKER_00: And in the worst case scenario, many of our patients do come in with suicidality or suicidal ideation, which is an unwanted side effect of antidepressants.
17:23
SPEAKER_00: No, ketamine is a powerful tool.
17:26
SPEAKER_00: It's an excellent option for patients with major depressive disorder, with treatment-resistant depression, as well as with bipolar in the depressive state, because it is so safe, it is so fast acting with minimal side effects and results that can last over time as long as you have maintenance with the drug.
17:48
SPEAKER_01: I wanted to touch in on you said that there were other ways to administer other than the IV.
17:54
SPEAKER_01: And what are the options and what are the differences and I guess pros and cons?
17:59
SPEAKER_00: Yeah, absolutely.
18:01
SPEAKER_00: So this is a really hotly debated, contested topic in the world of ketamine.
18:08
SPEAKER_00: And I know for most people, they're like, what is the world of ketamine?
18:11
SPEAKER_00: But this is my world.
18:13
SPEAKER_00: Um, at Ember, we lead the way.
18:16
SPEAKER_00: We've built the gold standard in terms of IV ketamine administration.
18:20
SPEAKER_00: And we believe so strongly in IV because over eight years of patient care, over 40,000 infusions, we see that this drug is not only safe, it's the most bioavailable of the forms of ketamine.
18:36
SPEAKER_00: Uh, the other forms include intramuscular or subcutaneous, intranasal ketamine, and oral ketamine, which is like a lozenge.
18:45
SPEAKER_00: All of those forms, besides IV, have a lower efficacy in part because they're less bioavailable.
18:52
SPEAKER_00: IV goes right to the bloodstream.
18:54
SPEAKER_00: It doesn't get filtered out through your organs, it doesn't have a negative impact on your bladder, your kidney, or your liver, like oral can.
19:02
SPEAKER_00: And it's the most well-studied.
19:04
SPEAKER_00: We really understand how this drug works.
19:07
SPEAKER_00: We understand the risks.
19:08
SPEAKER_00: There are very few, but they are real.
19:12
SPEAKER_00: And we even understand that the most common uh side effect or adverse event for patients is nausea.
19:18
SPEAKER_00: And we can put Zofran in the drip.
19:20
SPEAKER_00: So the IV route is just so preferred by patients.
19:25
SPEAKER_00: It's preferred by us because it works the best for patients.
19:28
SPEAKER_00: And it has a 15-minute half-life.
19:31
SPEAKER_00: So our patients are in and out of their appointment at Ember in 90 minutes.
19:35
SPEAKER_00: Those sessions are a lot longer with things like oral ketamine.
19:39
SPEAKER_00: And then I think the most important thing for you to know, Sneha, and for all the listeners to understand, is that there was a boom in oral ketamine around 2017, 2018.
19:51
SPEAKER_00: You saw a lot of companies enter this space.
19:54
SPEAKER_00: They were not run by clinicians, they were scaling fast using venture capital and capital and institutional funding.
20:02
SPEAKER_00: And they were exploding due to marketing, pumping hundreds of thousands of dollars into Google ads and Facebook ads.
20:09
SPEAKER_00: And these companies started to proliferate mail order at home Cademy.
20:16
SPEAKER_00: So I don't know if that sets off alarm bells for you, just thinking about sending a controlled substance to people's homes.
20:24
SPEAKER_00: Um, but it should.
20:26
SPEAKER_00: It really should cause concern.
20:28
SPEAKER_00: Yeah.
20:29
SPEAKER_00: And I mean, you're you're a wonderful evidence-based clinician, but even some wonderful evidence-based clinicians we work with at Ember several years ago started to work with these mail order companies.
20:40
SPEAKER_00: But come October of 2023, the FDA finally released uh some safety guidelines.
20:47
SPEAKER_00: And, you know, we were watching as these at-home ketamine ketamine companies exploded.
20:53
SPEAKER_00: It took the FDA a little while to take note and they did warn against nasal and oral ketamine.
21:00
SPEAKER_00: First of all, because they are uncommon they are compounded.
21:04
SPEAKER_00: IV ketamine is pure and generic.
21:06
SPEAKER_00: It is an uncompounded.
21:08
SPEAKER_00: And second of all, the oral version of ketamine, particularly when you send it to a patient and let them take it whenever they want, often at very high doses, can be extremely damaging to your organ systems, can create a propensity towards addiction.
21:26
SPEAKER_00: We just believe patients should not have unlimited access to this drug.
21:30
SPEAKER_00: And the safety in our protocols comes from the fact that it's always delivered by a licensed medical professional in a clinic setting.
21:38
SPEAKER_00: And so the FDA's guidelines also suggested that ketamine should never be administered without a monitoring medical professional.
21:48
SPEAKER_00: And in some cases, oral ketamine is delivered in the presence of a therapist, which we love our therapist partners.
21:56
SPEAKER_00: We work very closely with our patients' mental health practitioners, including.
22:00
SPEAKER_00: Therapists, but a therapist is not going to be helpful if you experience a very rare but real adverse event from ketamine.
22:08
SPEAKER_00: It could be anaphylaxis if you happen to have an allergy.
22:12
SPEAKER_00: It could be tachycardia because ketamine does elevate the blood pressure and the heart rate.
22:18
SPEAKER_00: It could be vomiting.
22:20
SPEAKER_00: And usually patients are lying down, they're sedated when they're receiving ketamine.
22:25
SPEAKER_00: All of our clinicians at Ember are doctors, nurses, and nurse practitioners, and they're trained in advanced airway management.
22:33
SPEAKER_00: They know what to do if something scary happens.
22:37
SPEAKER_00: That is not going to happen when you're in the presence of a wonderful mental health therapist who simply doesn't have that training.
22:44
SPEAKER_00: So that's why we're super bullish on IV and on doing it in clinic, medically supervised.
22:52
SPEAKER_01: Oh, it makes total sense.
22:54
SPEAKER_01: And it's interesting and shocking to me, this male enchetamine that it ever was a thing and ever like was okay.
23:03
SPEAKER_00: It's still a thing.
23:04
SPEAKER_00: And I don't get it.
23:05
SPEAKER_00: I agree with you.
23:06
SPEAKER_00: It's I think sometimes healthcare moves at the pace of business when really it needs to move at the pace of regulation.
23:15
SPEAKER_00: And vice versa, right?
23:16
SPEAKER_00: Sometimes regulation is holding back innovation.
23:20
SPEAKER_00: Um, but things are starting to play out um in some scary ways.
23:24
SPEAKER_00: And I will say there are two mail order companies that are now involved in lawsuits due to the wrongful death of a patient.
23:31
SPEAKER_00: Um, one of those companies is under DEA investigation.
23:36
SPEAKER_00: So uh it's very sad what happens when these companies take advantage of patients who don't know better.
23:44
SPEAKER_00: Um, it's very sad when therapists work in partnership with these prescribers and don't realize the risk on their license.
23:52
SPEAKER_00: But we see a reckoning coming.
23:55
SPEAKER_00: And what I'm really excited about in the future of this field with ketamine is that we're professionalizing.
24:02
SPEAKER_00: Um, we're starting to adopt broader standards.
24:06
SPEAKER_00: Um, and our medical chief medical officer, our medical director, Nico here at Ember, is actually on the board of ASKP3, which is the American Society for Ketamine Practitioners.
24:17
SPEAKER_00: It's a wonderful organization that's really driving the change in doing evidence-based medicine and trying to clean up the riffraff and the funky stuff that's going on that just is not right for patients.
24:31
SPEAKER_01: Absolutely.
24:33
SPEAKER_01: So just so people can get like a really good visualization.
24:36
SPEAKER_01: I know you mentioned the lying down and the irritated, but what can people expect to say that this is the right intervention for them?
24:43
SPEAKER_01: You spot spoken to their medical provider, they have a plan of care that's interdisciplinary, because we know that you know, depression is not just this is blah, it's gone forever.
24:52
SPEAKER_01: We need to work on managing thoughts and emotions and at the same time incorporate breathing and sleep and movement and nutrition.
24:58
SPEAKER_01: It's like a full body thing.
25:00
SPEAKER_01: But say that this is definitely going to be the key thing.
25:03
SPEAKER_01: They've tried a lot of things, it's not working out.
25:06
SPEAKER_01: We need to go down this route to help this person.
25:09
SPEAKER_01: What can they expect?
25:11
SPEAKER_01: So they call your office and then what happens?
25:13
SPEAKER_00: Yeah, absolutely.
25:15
SPEAKER_00: So we'll walk through it kind of first person.
25:18
SPEAKER_00: I'm a patient, I experience major depressive disorder, and I'm stuck.
25:24
SPEAKER_00: Maybe I have a therapist, maybe I have a psychiatrist, I might even have a pelvic floor physical therapist or a nutritionist.
25:32
SPEAKER_00: I might have multiple members of my care team or none at all.
25:36
SPEAKER_00: But in whatever state I'm in, I am stuck.
25:39
SPEAKER_00: I have most likely, but not always, tried other medications.
25:44
SPEAKER_00: Um, I may be unwilling to take SSRIs because I've heard from friends that they made them feel worse, that they made them suicidal, that they made them feel numb.
25:55
SPEAKER_00: Um, before I begin care at Ember, I may call and I would talk to an intake coordinator or one of our physicians.
26:04
SPEAKER_00: Um, so we offer an intake call to any potential patient with a doctor at Ember.
26:09
SPEAKER_00: And it's a conversation to figure out fit.
26:12
SPEAKER_00: Are we a fit for the patient?
26:14
SPEAKER_00: Are they a fit for us?
26:16
SPEAKER_00: The other path to care, and this is actually where the majority of our patients come from, are referrals.
26:22
SPEAKER_00: And so Ember is trusted by thousands of clinicians across New York City.
26:27
SPEAKER_00: I think because we've been doing this for almost a decade, um, we've built a really sterling reputation.
26:33
SPEAKER_00: And not just that, but relationships.
26:35
SPEAKER_00: Um, I lead clinical partnerships and I hold some of these myself, as well as Nico and Tiffany, our co-founders.
26:42
SPEAKER_00: I mean, I love the providers that I work with every day because they are fantastic therapists, excellent psychiatrists, mental health nurse practitioners, and even primary care providers, um, nutritionists, acupuncturists.
26:58
SPEAKER_00: They're all clinicians that appreciate an interdisciplinary approach to care.
27:04
SPEAKER_00: And so, whenever a clinician refers the patient, or if the patient self-refers, either way, we won't start a patient in care without at least one mental health provider.
27:15
SPEAKER_00: So nobody's coming in off the street and just asking for ketamine.
27:19
SPEAKER_00: We screen pretty vigorously.
27:22
SPEAKER_00: We ask a lot of questions about both mental and psychological health.
27:26
SPEAKER_00: We ensure that the patient has baseline depression.
27:28
SPEAKER_00: And if the patient, the ember doctor, and at least one mental health clinician on their care team are all on board, we'll even talk to their other practitioners.
27:39
SPEAKER_00: So maybe their PT or maybe their nutritionist or acupuncturist want to be part of that team, but it's typically their mental health providers.
27:46
SPEAKER_00: And once we've established care with that person, the care team forms in a circle around the patient.
27:53
SPEAKER_00: Every new patient at Ember starts with that foundation of care that I mentioned.
27:57
SPEAKER_00: So it's four infusions over two weeks' time.
28:00
SPEAKER_00: That's actually a loading phase for the medicine.
28:04
SPEAKER_00: So that's how we get enough ketamine into your system to determine if you're a positive treatment responder or not.
28:11
SPEAKER_00: And 84% of people are that positive treatment responder.
28:15
SPEAKER_00: For the 16% who aren't, we're probably not going to continue care.
28:20
SPEAKER_00: And we're just going to accept that not every brain responds to ketamine, but most do.
28:26
SPEAKER_00: And so after that first four infusions, we pause for two weeks.
28:31
SPEAKER_00: Um, we're learning how the patient does, how they react.
28:34
SPEAKER_00: We're also taking a PHQ9 score, which is a measure of depression that's very widely used in psychiatry.
28:41
SPEAKER_00: And at the end of the four infusions, we're checking in with their providers because we really value the input of their therapist, their psychiatrist, even their acupuncturist who see the patient in a different setting than we do.
28:56
SPEAKER_00: And so together we determine how do we want to look at long-term care?
29:00
SPEAKER_00: How do we want to approach maintenance?
29:02
SPEAKER_00: And so some patients will come back every two to three weeks for infusions if they're very acute, if they're still struggling in a pretty big way.
29:12
SPEAKER_00: Average patient at Ember comes back around every four to six weeks for long-term care.
29:16
SPEAKER_00: And then we may stretch it out and sort of taper as time goes on and if they're doing well.
29:22
SPEAKER_00: And then other patients only come back when they need us, only when they feel their depressive symptoms return because they're doing so well.
29:31
SPEAKER_00: But an average patient is in our care for about one to two years.
29:34
SPEAKER_00: And then with respect to the infusion experience, because that I think that was part of your question, and that everyone always wants to know like, what does it feel like?
29:42
SPEAKER_00: What's going to happen?
29:43
SPEAKER_00: So the infusion that lasts for 40 minutes with a 15-minute washout period is part of your 90-minute appointment.
29:52
SPEAKER_00: But the arc of care for every patient visit is so thoughtfully choreographed.
29:59
SPEAKER_00: And that's really thanks to our chief patient experience officer, Tiffany Frankie.
30:04
SPEAKER_00: Um, Tiffany is our co-founder, she's the business partner and life partner of Nico.
30:08
SPEAKER_00: Um, so we are still a family-owned practice.
30:11
SPEAKER_00: And Tiffany has truly brought this down to a science, how to be safe and supportive as a setting for care.
30:19
SPEAKER_00: So before the infusion, the patient is in the infusion suite with their doctor.
30:24
SPEAKER_00: We place the IV, we do some light intention setting.
30:28
SPEAKER_00: Intention is really important for this care because of how ketamine works on the brain, which we'll get to in a minute.
30:35
SPEAKER_00: And then we have uh noise canceling headphones, music that the patient can select.
30:41
SPEAKER_00: Music is a really powerful part of this experience.
30:45
SPEAKER_00: We use a lot of music that is designed for a ketamine infusion, that is designed for the altered state, is what we call it.
30:53
SPEAKER_00: And then we also have custom blended aromatherapy that we can smell and help the patient kind of use their senses and feel embodied before they go into their infusion.
31:03
SPEAKER_00: And so during that infusion, that altered state looks different for every single patient.
31:09
SPEAKER_00: I can share some themes that are common.
31:13
SPEAKER_00: Um, you know, it might be an experience of gaining perspective.
31:18
SPEAKER_00: It might feel profound and beautiful.
31:20
SPEAKER_00: There may be vivid visuals.
31:23
SPEAKER_00: Um, there also may be very little going on.
31:26
SPEAKER_00: And sometimes for our patients, sort of like taking a nap, it's just a relaxation moment.
31:32
SPEAKER_00: It's time to quiet and slow down.
31:35
SPEAKER_00: For a smaller percentage of patients, and we've actually quantified this, around 10% of all infusions at Ember are described by the patient as psychologically difficult.
31:47
SPEAKER_00: For those patients, and I think really relevant to the populations that you and I have both worked with, I'll give an example of maybe a patient with birth trauma.
31:56
SPEAKER_00: They may relive that birth trauma and they may kind of visualize the painful and difficult experience that was giving birth to their child.
32:06
SPEAKER_00: Um, this can be very hard for patients.
32:09
SPEAKER_00: It is the minority, but it's something that we prepare them for.
32:13
SPEAKER_00: And there is always an ember clinician in the room at all times.
32:17
SPEAKER_00: Although the patient is typically wearing an eye mask, which allows them to go deeper, it also helps with any potential nausea.
32:24
SPEAKER_00: We sometimes hold a hand with consent for touch.
32:28
SPEAKER_00: We're there to reassure the patient.
32:30
SPEAKER_00: And then as they come out of the infusion, which for most people is actually a very joyful and interesting or introspective experience, post-infusion, we're going to hold space, do some therapeutic communication, although we're not doing therapy.
32:45
SPEAKER_00: Um, offer them some custom blended herbal tea, and then we transition them over to our rest and recovery area where they can reflect, they can sit and kind of re-integrate.
32:56
SPEAKER_00: And then patients, once they're medically cleared to leave the room, can go about their day.
33:01
SPEAKER_00: So this is a powerful treatment for patients who still work full-time, you know, have a job, have kids, have dependents, need to continue with their daily life and aren't really open to the more interventional forms of interventional psychiatry, things like ECT, uh, electroconvulsion, convulsive therapy, um, TMS, transcranial magnetic stimulation, um, or even other treatments like spravato that are just more time-intensive and less effective.
33:32
SPEAKER_01: Wow, that was I like was right there with you, just holding your hands and doing it, felt like a little spa date.
33:39
SPEAKER_01: I know that's not at all what you're trying to achieve, but that vibe and that energy of just peace and calm, I guess, is what I was kind of feeling from what you were saying.
33:49
SPEAKER_00: Yeah.
33:49
SPEAKER_00: And I mean, it's our our clinics are clinics.
33:52
SPEAKER_00: They are, you know, completely filled with all the things that you need to clinically monitor.
33:58
SPEAKER_00: We have heart rate monitors and pulse oximeters in the infusion suite.
34:01
SPEAKER_00: Obviously, we have a pump.
34:03
SPEAKER_00: Actually, I have one right here so I can even show you.
34:06
SPEAKER_00: Um, you know, it's this is medical equipment and these are medical clinics.
34:11
SPEAKER_00: But the thing with Ember is that we believe in set and setting.
34:16
SPEAKER_00: And so it needs to not feel clinical, but it needs to be evidence-based and have the clinical tools that we need to deliver great care to patients.
34:25
SPEAKER_00: Um, but it's funny because the experiential aspects of ketamine are only the beginning of how this drug works.
34:33
SPEAKER_00: And so a lot of people say, Wow, am I gonna leave the clinic feeling less depressed?
34:39
SPEAKER_00: You may.
34:40
SPEAKER_00: Uh, and a lot of patients do, especially with these first four infusions, the change can be so significant for some patients.
34:49
SPEAKER_00: It can be the first time they felt relief in years, if not decades.
34:54
SPEAKER_00: But how ketamine works on the brain is a rapid reset where the patient feels sometimes just like physical relief in the brain.
35:02
SPEAKER_00: Then there's the experiential aspects, the altered state, and the ability to kind of go deeper into the subconscious, um, to work out themes that are maybe holding you back or just to see something beautiful and feel like a part of a whole.
35:18
SPEAKER_00: It's the adaptive benefits of ketamine that make it so powerful.
35:24
SPEAKER_00: And those adaptive benefits can be described in one word.
35:27
SPEAKER_00: It's like my favorite word in the world, neuroplasticity.
35:31
SPEAKER_01: Ooh, I love that word.
35:34
SPEAKER_01: Yes.
35:34
SPEAKER_01: And so for neuroplastic neuroplasticity, for people who are um like, what does that mean?
35:40
SPEAKER_01: It's the ability for our brain to literally have the capacity to change and alter and grow in a way that serves us, is essentially the way that you could encapsulate that.
35:51
SPEAKER_01: And it can, you can do it in multiple ways.
35:53
SPEAKER_01: And this seems like it's a wonderful way to do it.
35:56
SPEAKER_01: That's the least invasive, time consuming, and also provides such a great statistical benefit for this particular population and for this particular reason.
36:05
SPEAKER_01: I'm trying to think, Allison, if I have any other questions, I'm trying to pretend to be a listener or an audience member and see if they have a question or something that they would like to know.
36:15
SPEAKER_01: Because I know you covered that it's like one or two years, average patient care, that it may be continued beyond that based on patients' needs.
36:24
SPEAKER_01: I don't know.
36:24
SPEAKER_01: I think you did a really good job.
36:26
SPEAKER_01: You went on, you went on every uh lane that I feel like uh I would have wanted you to go into to cover everything about this.
36:34
SPEAKER_01: I guess one piece that patients might want to know if they can still do is um I know you mentioned you can be on your SSRIs and all of these things while doing the ketamine, but are there certain contraindications or certain things that mix with ketamine badly?
36:53
SPEAKER_01: Yes.
36:54
SPEAKER_00: There are.
36:55
SPEAKER_00: Um, there's a couple of pretty strict rule-out criteria for us at Ember.
37:00
SPEAKER_00: I mean, I will flag that if you have listeners across the country, um, people who are interested in this care, but they're not in New York City, because currently all five of our clinics are in New York, in Brooklyn, and in Manhattan.
37:12
SPEAKER_00: Um there's a lot of different kinds of clinics out there, and some of them don't screen very carefully.
37:20
SPEAKER_00: At Ember, we do, uh, and we take the screening process quite seriously.
37:25
SPEAKER_00: So people are often surprised at how many folks we turn away because we only want to treat you safely and we only want to treat you for what this is medically indicated for.
37:35
SPEAKER_00: So what that means is that appropriate candidates for this drug have depression, have bipolar depression, but they could have many comorbid mental health issues.
37:46
SPEAKER_00: We treat a lot of patients with comorbid PTSD, OCD, eating disorders.
37:52
SPEAKER_00: A lot of our patients have anxiety or ADHD, and many of them have chronic health conditions that we can still treat.
38:01
SPEAKER_00: Everything from women's health conditions like PMDD, endometriosis, PCOS, some of those conditions actually patients feel relief from their other symptoms besides depression, which is really cool.
38:15
SPEAKER_00: All the way to patients with chronic issues, chronic illness, autoimmune disorders.
38:21
SPEAKER_00: We've treated patients with terminal cancer, with Parkinson's, in palliative care, um, multiple sclerosis.
38:28
SPEAKER_00: These patients can benefit greatly because their baseline depression, they improve, but sometimes their other symptoms are also improving.
38:37
SPEAKER_00: And that's due to that neuroplastic effect.
38:40
SPEAKER_00: Um, but who we can't treat.
38:43
SPEAKER_00: So anybody with active psychosis, anyone with active mania or a history of mania, so bipolar in the manic state, we cannot treat schizophrenia and schizoaffective disorder.
38:56
SPEAKER_00: Those are all conditions where even if depression co-occurs, it's not going to be a fit for treatment.
39:03
SPEAKER_00: And then we screen pretty carefully for certain medical conditions that involve the heart.
39:09
SPEAKER_00: Because, like I mentioned, ketamine does elevate your blood pressure and your heart rate.
39:13
SPEAKER_00: So we definitely want patients who are not suffering from chronic heart conditions, um, anything serious in the cardiac zone.
39:22
SPEAKER_00: Uh, but yeah, generally speaking, I mean, it's people are always shocked when they hear this.
39:27
SPEAKER_00: We treat adolescents, 14 and up.
39:30
SPEAKER_00: We always work with their adolescent psychiatrists.
39:33
SPEAKER_00: So they need extra layers of their care team, but adolescents are great responders to this drug.
39:38
SPEAKER_00: And we can treat postpartum depression, including women who are breastfeeding or chest feeding.
39:44
SPEAKER_00: So because of the half-life of ketamine, it's actually out of your breast milk pretty quickly, much more quickly than something like a glass of wine.
39:54
SPEAKER_00: So we have a protocol for this, and our patients essentially time it correctly, pump and dump the next engorgement after your infusion.
40:03
SPEAKER_00: And so this is such a great intervention there because it's not going to limit mother-baby bonding or take away from all the hard work that is breastfeeding.
40:12
SPEAKER_01: Wow, I love that.
40:13
SPEAKER_01: I remember learning about that as being a really cool, because there's so many med, and moms often come and being like, There's so many things I can't do.
40:20
SPEAKER_01: There's so many things you can do.
40:22
SPEAKER_01: And so this is a great tool.
40:24
SPEAKER_01: Allison, this has been so wonderful.
40:26
SPEAKER_01: Where do people find information about Ember Health if they want to go reach out to you guys, get more information, book an appointment, do that consultation?
40:35
SPEAKER_00: Sure.
40:35
SPEAKER_00: Yeah.
40:35
SPEAKER_00: So you can go to our website at emberhealth.co, Ember like the Embers of a Fire, E-M-B-E-R.
40:43
SPEAKER_00: There's a button that says get started on our website where you can book an intake call anytime.
40:48
SPEAKER_00: You can self-schedule, or you can call us.
40:51
SPEAKER_00: Um, I always encourage people, if you think ketamine treatment might be right for you, you can reach out yourself, but also talk to your mental health professionals about it.
41:00
SPEAKER_00: Um, sometimes patients are the ones who educate therapists and psychiatrists.
41:05
SPEAKER_00: Um, this care has been around for a long time, but there's a lot of reasons why people don't know about it.
41:10
SPEAKER_00: And that's why I love the work that I get to do is just educating people like we're doing now.
41:16
SPEAKER_00: And then anyone who's curious can also reach out to me directly.
41:19
SPEAKER_00: So um Allison, A-L-I-S-O-N at emberhealth.co.
41:24
SPEAKER_00: And on our website, it's not just how you get in touch, there's a litany of information, so many resources.
41:30
SPEAKER_00: And you can also learn more about neuroplasticity and how ketamine literally regrows neurons and how we harness that.
41:40
SPEAKER_00: Uh, because we didn't quite go there, but I think the last piece of the neuroplasticity story is really that in the neuroplastic window after you get your ketamine infusion is when depression starts to shift.
41:53
SPEAKER_00: And so it is in that neuroplastic window, typically 24 to 72 hours after each infusion, and then up to two weeks later, is when your brain is actually ripe for change in habits, behaviors, self-talk, and in the patterns that are depressive for you.
42:13
SPEAKER_00: So you can learn all about the neuroscience on our website and then check out our YouTube channel for real patient stories.
42:19
SPEAKER_00: Um, some of our amazing patients who volunteered to go on camera and talk about their experience with depression and how ketamine care at Ember really helped.
42:30
SPEAKER_01: I love that.
42:30
SPEAKER_01: Thank you so much, Allison.
42:32
SPEAKER_01: I'll drop all of that in the show notes so people can take a look and get in touch with you guys.
42:37
SPEAKER_01: Thank you for the work that you do.
42:39
SPEAKER_01: Thank you for driving this information, for educating us and providing this extremely important um care that seems like it's just so underserved.
42:50
SPEAKER_01: And and I think what I love about you is the multidisciplinary uh approach that you take to everything is like how it's screened so well and how many people are involved.
42:58
SPEAKER_01: It's not, it's not just a one and done get in and out.
43:01
SPEAKER_01: Like you said, the neuroplasticity, that that ripeness for change, it happens through other therapeutic approaches with movement, with breathing, with working with a psychiatrist, working with uh a mental health therapist.
43:12
SPEAKER_01: And so what I want people to take away from this is not only what the ketamine's use is in depression, particularly in other adjacent conditions, but also how safe it is and how accessible it can be in certain areas of the world and the US, of course, but in New York City, we've got some great opportunity.
43:33
SPEAKER_01: And so thank you, Allison, for your time and for being here with us today.
43:37
SPEAKER_00: Thank you, Sneha.
43:39
SPEAKER_00: This was a lot of fun.
43:40
SPEAKER_01: Thank you all for tuning in and investing in yourself and your well-being.
43:44
SPEAKER_01: If you listened to the show today and gained anything out of it, share it far and wide.
43:49
SPEAKER_01: It means a world when you rate and review the show.
43:53
SPEAKER_01: Don't forget to use your exclusive 20% discount code FIT20 when you sign up for our signature course Master Your Public Floor, linked in the show notes.
44:03
SPEAKER_01: See you again next week with an exciting new guest and topic.