+ Are medications helpful?

Medications can play a role in treating several mental disorders and conditions. Treatment may also include psychotherapy and interventional strategies. In some cases, psychotherapy alone may be the best treatment option. Choosing the right treatment plan should be based on a person's individual needs, medical situation, and under a trained mental health professional’s care.

Information about medications changes frequently. Check the U.S. Food and Drug Administration (FDA) website for the latest warnings, patient medication guides, or newly approved medications. We strongly encourage you to research by name any drug you are currently taking. Useful resources for this are MedlinePlus Drugs, Herbs and Supplements Drugs website. The MedlinePlus website also provides additional information about each medication, including side effects and FDA warnings.

+ Whats the difference between accelerated TMS and regular TMS?

At WIP we provide options for both accelerated and regular theta burst TMS. The difference primarily lies in the rate of treatments and as a result the speed of response. Standard TMS is typically 1 treatment per day for up to 4-6 weeks. Accelerated TMS can be as many as 5-7 treatments per day for 5 days with similar responses. The TMS machine we use can provide each treatment in as little as 3 minutes making the overall experience more convenient and tolerable. Unfortunately, the accelerated TMS protocol is usually not fully reimbursable by insurers while the 4-6 week protocol is.

+ Why IV ketamine and whats the difference with Spravato?

We provide both IV ketamine and intranasal Spravato here at WIP. IV ketamine has some notable advantages including faster acting, higher bioavailability, more control of the dose during an infusion and less costly (primarily due to less frequent visits). Spravato’s primary advantage is for individuals in which obtaining IV access is difficult. Spravato is typically covered by insurers however the frequency of visits are usually more which in turn increases the costs.

+ What are your costs for these interventions?

• Initial psychiatric evaluations range from $438 – $1050.
• Medication management follow up appointments range from $175 - $350.
• TMS is $225 per treatment. Most insurers reimbursement in the range of $200-$300 per treatment. Accelerated TMS is $7500 for the 5 days of treatment and unfortunately is usually not reimbursable under most insurance plans. As of 2023, there does appear to be progress on reimbursements now that Accelerated TMS is FDA approved. Please check with your insurer for a more concrete answer.
• 30 minute complimentary intravenous, intranasal ketamine, and TMS consultations.
• IV Ketamine infusions are $500 per infusion (induction is 6 infusions or $3000 over the course of 2 - 3 weeks).
• Ketamine Assisted Psychotherapy (KAP) sessions are priced between $750 and $950 per session, with variations in cost corresponding to the clinician's level of training and experience.
• Spravato intranasal appointments are $300 per treatment. Inductions are 8 treatments over the course of 4 weeks)
• Adult, Child, Family, Couples Psychotherapy sessions range from $200 – $300.

+ Do you accept insurance for any of these services?

No, we are an out of network provider so we do not accept insurance at this time. However we will provide you with the necessary paperwork needed to obtain reimbursement from your insurance carrier. Our administrative team will be happy to discuss this with you further and in the case of TMS , can help with the process.

+ Can you tell me more about Ketamine?

Ketamine is a general anesthetic agent. It has been used in hospitals for decades and has a proven record of safety. The small doses and methods of administration used to treat psychiatric patients differ widely from those used in hospital operating rooms which allows us to use it in the outpatient setting.

+ Is this treatment FDA approved?

Intravenous Ketamine is not, however nasal esketamine (SPRAVATO™) is FDA approved. They are the same drug (ketamine), absorption rates and the delivery process (intravenous vs intranasal) differs.

+ Will I be treated as an outpatient?

Yes, ketamine infusions for depression are outpatient procedures requiring no hospital admission.

+ Do I need a referral from a psychiatrist?

Ideally yes as we want to make sure oral antidepressants have been unsuccessfully tried. However, a consult with our psychiatrists will be required and if oral antidepressants are an option- they will most likely be tried first.

+ Is ketamine used to treat all patients with depression?

No, mild to moderate depression is successfully treated by mental health professionals with drugs and psychotherapy. The treatment of severe depression is more difficult and requires a higher level of care, such as ECT, TMS, and now ketamine. Ketamine infusion therapy is reserved for those patients with severe depression that is considered otherwise treatment resistant.

+ Is it likely that my severe depression will respond to ketamine therapy?

Most patients we see are considered treatment resistant. That is, they have not responded to available antidepressant medications and in many cases have not responded to ECT or TMS. We cannot predict who will respond to ketamine. We will know within the induction phase of treatments if ketamine infusions will help you. If there is no benefit, we will let you know and help decide on an alternative treatment plan that might include referrals to ECT, TMS, or referral to NIH for possible enrollment in experimental medication trials.

+ How many infusions will I need and how long will I feel better?

A total of six is recommended within a 14 - 21 day period. That will maximize the ketamine effect. Thereafter, patients are placed on a maintenance program where they return when they feel it necessary for a single infusion booster. During the maintenance period, the duration of relief following the initial infusions and the first booster, and between subsequent single booster infusions varies between patients. The average duration of relief between booster infusions is 3 to 4 weeks. Unfortunately, there is no way to predict what your needs will be.

+ If ketamine does work, will I be on it for the rest of my life?

We unfortunately do not know the answer to this as there are no long term studies of ketamine or esketamine.

+ Are there any medications that will interfere with ketamine treatment?

Yes. The benzodiazepines, such as Klonopin, Xanax, and Ativan do interfere with ketamine if used daily and at higher doses. Lamictal (lamotrigine) in doses above 100mg/day also can block ketamine efficacy. During your consultation with one of our physicians this will be discussed.

+ Will I have to stop other antidepressant medications?

No, other antidepressant medications do not interfere with ketamine’s mechanism of action. However medications such as lamotrigine and benzodiazepines might need to be tapered down and if possible discontinued.

+ Are there any medical conditions that will exclude me from treatment?

Yes, uncontrolled high blood pressure or heart failure need to be corrected before the use of ketamine.

+ How quickly can I be seen?

True emergencies, with a psychiatric referral, can be seen within a day. But, in general, three to seven days are required to get you onto the schedule. We will however try our best to accommodate any patient’s scheduling needs.

+ This is a lot to absorb. Do you have a short reference for things I should know about ketamine?

○ One of the most efficacious treatments for refractory depression and suicidal ideation currently available. More recently we are seeing benefits in trauma related conditions as well ○ 6 total infusions, ranging from 2 - 3 per week (must be completed w/i 3 wks) ○ Each infusion is 40 minutes long, but total start-finish time is closer to ~75 ○ You cannot drive after an infusion ○ You'll probably need to go home and take a nap before you feel clear headed ○ Most patients who respond to treatment require a single maintenance infusion monthly - quarterly ○ Potentially concerning side effects include dissociation, nausea, transient HTN,interstitial cystitis (rare), and laryngeal spasm (exceptionally rare)

+ Do you also have a quick summary of the practical differences between standard ketamine infusions vs ketamine assisted psychotherapy?

■ More commonly used for self exploration of internal conflicts, history of trauma, psychological distress ■ Appts are booked for 2 hours ■ A therapist is in the room with you for a majority of the time (unless you ask her to leave) ■ A KAP treatment is more expensive than an standard infusion

+ Do you also have a quick reference for preparing for my ketamine treatments?

○ Please don't eat for 3-4 hrs prior to an infusion, but please do come well hydrated ○ Please abstain from any recreational drugs or alcohol the evening prior to and day/evening of an infusion Try your best to get a restful sleep the night before. ○ If journaling has been helpful, it's a good time to journal. ○ Meditating the night before, the morning of and/or walking just before coming to the office might be beneficial to your experience. ○ You might consider dressing in comfortable clothing.

+ What type of music should I listen to for my treatments?

https://open.spotify.com/playlist/0dzvZDZNckuXLizbkP5nUC?si=1ytDbu7 NS5W3d_gJfhxR5w ■ https://open.spotify.com/playlist/6EBtnrgLRXUI0mrvgyJVLc?si=25e07c7ff e5c4b42 ■ https://open.spotify.com/playlist/0dzvZDZNckuXLizbkP5nUC?si=ae44d08 da9a44cd2 ■ https://open.spotify.com/playlist/4ps9SddRPpiT5Sl0Mz6y4h?si=d27254f8 ad7e4963 ■ https://open.spotify.com/playlist/4TyxddhXPv3Xjw5MNQq2wy?si=1802ea 7f152e471c

+ Do you offer psilocybin or other types of psychedelics?

Psilocybin is currently an investigational drug and is not yet approved by the FDA for clinical use. We are actively working to be a clinical trial sight. Please contact either Dr. Reddy or Dr. Raczynski if you have further questions regarding psychedelics. Ketamine is a dissociative type of psychedlic that we currently use for the treatment of many mental health conditions.

+ What is TMS?

Transcranial Magnetic Stimulation (TMS) is an outpatient procedure used in patients with hard-to-treat depression.In this procedure, the patient is completely awake and seated in a chair. The magnetic coil of the machine is placed near the front, left side of the head. The machine sends magnetic pulses into the brain through this coil and causes it to create brief electrical currents. This therapy creates changes in the way the brain cells (neurons) interact in specific parts, or circuits, of the brain that controls mood.

+ When do you use TMS?

TMS is approved by the U.S. Food and Drug Administration (FDA) for treatment-resistant depression and Obsessive Compulsive Disorder (OCD) in patients who fail to improve after treatment with two antidepressants.In some patients, antidepressants fail because they do not relieve the symptoms of depression. Other patients may not be able to tolerate the side effects of antidepressants. Some are not able to take them because of other medications or conditions. TMS is sometimes used off label for various other mental health conditions including PTSD. Watch a video to learn more.

+ Why Accelerated TMS?

A six-week protocol for TMS is already approved by the FDA for the treatment of depression. However, a recent study at Stanford University, entitled Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression (SAINT-TRD) demonstrated that when TMS was delivered in a more intensive schedule and accelerated pace, it provided remission from depression in 90% of patients in as little as 3 to 5 days. These results were published online April 7, 2020 in the American Journal of Psychiatry. Washington Interventional Psychiatry now offers such an accelerated brain stimulation treatment for depression.

In the Stanford study, patients underwent 10 sessions per day of 10-minute treatments, with 50-minute breaks between treatments. Each treatment was a modified version of “Theta Burst” TMS, which requires specialized equipment to deliver. After a day of therapy, one study participant’s mood score indicated she was no longer depressed, while it took up to five days for other participants. On average, three days of the therapy were enough for participants to experience relief from depression.

+ How Safe is Accelerated TMS Therapy?

The only side effects of this new, rapid TMS approach were fatigue and some discomfort during treatment. Of particular note: In order to test safety, the researchers evaluated the participants’ cognitive function before and after treatment. They found no negative side effects. Instead, they discovered that the participants’ ability to switch between mental tasks and to solve problems had improved — a typical outcome for people who are no longer depressed. And one month after the therapy, 60% of participants were still in remission from depression.

+ How do I prepare for TMS?

All patients are evaluated by our psychiatrists to make sure they are a good candidate for TMS. Some people cannot have TMS because it uses powerful magnets. Your doctor will need to know if you have any metal objects in your body, such as the following:

• Aneurysm clips or coils in your head, neck, or upper body.
• Arterial stents in your upper body
• A cardiac pacemaker

If your doctor decides that TMS is a good treatment option for you, you do not need to do anything to prepare.

+ What are some of the side effects of TMS?

TMS is a safe procedure with minimal side effects. The most common side effect is headache, and this can be treated with over-the-counter medication. Some patients may experience a slight burning sensation in the scalp under the magnet during the procedure. A few patients may have facial twitches during their TMS session, but the machine can be moved slightly to relieve these twitches.

+ What if TMS doesn’t help me? Do I have any options?

TMS is one of several options available to you, if you have hard-to-treat depression. This therapy works very well for some patients, with an overall success rate at about 50 to 60%. Remission rates from a successful TMS treatment typically last 6 months to 1 year. If you have failed two different treatments of antidepressants and psychotherapy, you may be eligible to have intravenous ketamine, intranasal Spravato, or electroconvulsive therapy (ECT). Ketamine and ECT are for treatment-resistant depression, and are also safe, nonsurgical options that work quickly to relieve symptoms. You may also benefit from botox therapies for hard-to-treat depression. Keep in mind that all these treatments are used for off label mental health conditions with varying rates of success.