From Resistance to Resilience - A Veteran's Renewal with Ketamine
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Ketamine therapy is proven to assist Veterans with decreasing their thought of self-harm, feelings of hopelessness, depression and enhances their overall quality of life. With access to Ketamine therapy options nation-wide, Veterans would have a lifesaving chance in which VHA should want to play a part in preventing undertreated depression in Veterans, which can lead to poor quality of life, social difficulties, decreased productivity, and increased mortality from suicide. Thus, our Ketamine clinic's mission is to embark on a creditable journey to give all American heroes a second chance at life.
If a Veteran believes Ketamine therapy is right for them, Veterans should contact their local VAMC Primary Mental Health Provider or the Community Care Office to discuss if this is an option and to get evaluation treatment. Visit the VA’s Mental Health Services page (provided in the links section of the problem overview) for more resources and how to find your nearest VA medical center.
Veterans experiencing a mental health emergency are urged to call the Veterans Crisis Line (DIAL 988, then PRESS 1), present to the nearest emergency room, or call 911 immediately. Help is free to all Veterans 24/7, even if they are not enrolled in VA benefits or health care.
Origin:
December 2019, Little Rock VA Clinic (Little Rock Main Street)
Adoptions:
40 successful, 1 in-progress
Awards and Recognition:
Diffusion of Excellence Promising Practice, VHA Shark Tank Winner
Partners:
Mental Health and Suicide Prevention
Recent Updates
Overview
The problem
An estimated 2000 Veterans VISN-wide are diagnosed with Treatment-Resistant Depression, an estimated range of 0.5%-4-7% of the population. Veterans are not only at risk for developing comorbid illness and suicide, with nearly 20% having made a suicide attempt and 2-3 times more likely to have it happen again. Because Major Depressive Disorder is a leading ca
...
An estimated 2000 Veterans VISN-wide are diagnosed with Treatment-Resistant Depression, an estimated range of 0.5%-4-7% of the population. Veterans are not only at risk for developing comorbid illness and suicide, with nearly 20% having made a suicide attempt and 2-3 times more likely to have it happen again. Because Major Depressive Disorder is a leading cause of disability and one of the most common Mental Health disorders in the United States and Worldwide, Veterans throughout all military service have experienced emotional or physical trauma with Suicidal Ideation resulting in a diagnosis of Treatment Resistant Depression. Our facility observed an increase in the number of Veterans measured from 2020 and presently seen in our Mental Health Ketamine Clinic. The significant rise in Patient Health Questionnaire-9 (PHQ-9) scores that monitor Suicidal Ideation and Depressive Behaviors of our Veterans led to the discovery of the problem.
See
more
Links
- For more resources and how to find your nearest VA medical center VA Mental Health Services
- Veterans experiencing a mental health emergency Veterans Crisis Line
The solution
Our team took action to deal with the issues identified in our problem statement by implementing the ONLY, if not first, stand-alone Mental Health Ketamine clinic, which offers Ketamine therapy for Treatment-Resistant Depression to Veterans. Our proactive approach to offering Ketamine therapy to Veterans reduces ideation or behavior and prevents suicide amo
...
Our team took action to deal with the issues identified in our problem statement by implementing the ONLY, if not first, stand-alone Mental Health Ketamine clinic, which offers Ketamine therapy for Treatment-Resistant Depression to Veterans. Our proactive approach to offering Ketamine therapy to Veterans reduces ideation or behavior and prevents suicide among their population. Veterans present to the clinic according to their individualized treatment plan and must complete the Patient Health Questionnaire-9 (PHQ-9), a measurement-based tool used to measure a Veteran’s clinical status and foundation. Once completed, the nursing staff can administer therapeutic levels of Ketamine via intravenous infusion during the induction phase or a maintenance dose via intravenous, intramuscular, or intranasal (Spravato/esketamine) as scheduled, per physician orders.
See
more
Images
Above:
Ketamine
Above:
CAVHS Ketamine Clinic treatment area with new art work paintings from our own Veteran
Above:
Up-close picture of a couple of the paintings completed by our Veteran
Links
- Ketamine—from anesthetic to depression "miracle drug" How Ketamine Drug Helps with Depression
- ABC 24 Memphis News broadcast with CAVHS Ketamine Clinic How psychedelic treatments can help veterans' mental health
The results
With our proactive approach in offering Ketamine therapy for Treatment-Resistant Depression to reduce ideation or behavior and prevent suicide among our Veteran population, the Veterans' initial feedback was uncertainty about Ketamine therapy. After their first treatment, they verbalized that they felt a difference, and following their induction phase, they
...
With our proactive approach in offering Ketamine therapy for Treatment-Resistant Depression to reduce ideation or behavior and prevent suicide among our Veteran population, the Veterans' initial feedback was uncertainty about Ketamine therapy. After their first treatment, they verbalized that they felt a difference, and following their induction phase, they indicated it helped them revitalize.
Private/Community Healthcare Organizations charge approximately $400 to $800 per treatment or $1600 to $4800 upfront for a complete series of IV Ketamine for the treatment of depression because private insurance does NOT cover Ketamine therapy since it is deemed “off-label” use. For the calendar year 2022, there were a total of 1,099 Ketamine treatments (923 IV, 45 Esketamine (Spravato), and 131 IM injections) performed, saving CAVHS approximately $861,400.00. See more
Private/Community Healthcare Organizations charge approximately $400 to $800 per treatment or $1600 to $4800 upfront for a complete series of IV Ketamine for the treatment of depression because private insurance does NOT cover Ketamine therapy since it is deemed “off-label” use. For the calendar year 2022, there were a total of 1,099 Ketamine treatments (923 IV, 45 Esketamine (Spravato), and 131 IM injections) performed, saving CAVHS approximately $861,400.00. See more
Images
Above:
PHQ9 End of Induction Score Comparison
Above:
PHQ9 Current Score Comparison
Above:
Item 9 End of Induction Score Comparison
Above:
Item 9 Current Score Comparison
Above:
Veteran's quote
Above:
Veteran's quote
Above:
Veteran' s quote
Files
- Ketamine overview MD PowerPoint Presentation: Ketamine
Links
- VA's Mental Health Service resources and how to find your nearest VA medical center VA's Mental Health Services page
Metrics
- 70% of our Veterans showed >50% reduction in PHQ-9 score after their induction period.
- Amongst our Veterans with baseline Suicidal Ideation (SI), 56% of them exhibited a decrease in SI after their Ketamine therapy induction phase.
- With repeated Ketamine infusion therapy 86% of Veterans clinically have shown significant improvement in Treatment Resistant Depression due to the enhanced therapeutic benefit.
- VA annual drug costs for treating 100 Veterans with Esketamine is $1,157,000 -$3,729,600.
- While estimated VA annual drug costs for treating 100 Veterans with IV Ketamine is $1,500.
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Images
Above:
PHQ-9 & Item-9 Scores Comparison
Above:
2023 estimated cost
Above:
2023 estimated costs
Above:
2023 Ketamine estimated costs per 3000 vials
Above:
2023 Esketamine estimated drug costs
Implementation
Timeline
-
Months 1-2
• Assemble local stakeholder /leadership team• Develop a Ketamine Therapy Clinic pilot strategy specific to meet the needs of the location• Acquire designated space for the clinic area, required equipment, and staff members• Plan meetings with discipline-leadership to finalize training curriculum -
Months 2-4
• Educate and train new/existing staff members (ex. Psychiatrist, Nurse, Pharmacist)• Set schedule for consultation of Veterans that meet criteria for Ketamine therapy• Train MSA staff for the setup of scheduling new and existing Veterans for Ketamine Therapy on the clinic grid. -
Months 4-5
• Set up clinic with required equipment and supplies needed to implement the new Ketamine therapy clinic and staff -
Months 5-6
• Go-Live with the Ketamine therapy clinic• Look for opportunities to redesign procedures or processes that meet the needs of your facility.
Departments
- Veteran experience
- Medical Informatics
- Mental health care
- Psychiatry
- Pharmacy
- Administration
- Central supply
- Information technology
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
|
PROCESSES |
|
TOOLS |
|
Links
- An overview of research on the use of Ketamine or Esketamine for depressive disorders, PTSD, or suicide. Compendium: Evidence on Ketamine or Esketamine Use for Depressive Disorders, PTSD, or Suicide
- To provide general guidance on ensuring access to intravenous ketamine for the treatment of treatment resistant major depressive disorder or severe suicidal ideation under a National VA protocol that will facilitate collection of safety and effectiveness outcomes via a prospective medication use evaluation (MUE). Ketamine Infusion for Treatment Resistant Depression and Severe Suicidal Ideation National Protocol Guidance
Optional Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
|
TOOLS |
|
Files
- PROTOCOL FOR ADMINISTRATION OF INTRANASAL ESKETAMINE (SPRAVATO) TREATMENT FOR MENTAL HEALTH INDICATIONS CAVHS Protocol: Esketamine for Depression 09.08.2023
- Esketamine education booklet Esketamine CIII Booklet
Links
- To provide general guidance on ensuring access to intranasal esketamine for the treatment of major depressive disorder (MDD) under a National VA protocol that will facilitate collection of safety and effectiveness outcomes via a prospective medication use evaluation (MUE). Intranasal Esketamine for Depression National Protocol Guidance February 2022
Support Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
|
PROCESSES |
|
Files
- NSG Procedure & Medication Administration Note Template Ketamine/Esketamine Nurse Note
- Ketamine/Esketamine NSG monitoring sheet RN monitoring sheet
- Patient Handout PHQ-9 & C-SSRS PHQ9 & CSSRS
- Ketamine Therapy for TRD Trifold patient brochure Ketamine Therapy for TRD
- PROTOCOL FOR ADMINISTRATION OF INTRAVENOUS/INTRAMUSCULAR KETAMINE TREATMENT FOR MENTAL HEALTH INDICATIONS CAVHS Protocol: Ketamine for Treatment-Resistant Depression
- Intravenous Ketamine Intravenous Ketamine Patient Brochure
- Intramuscular Ketamine Intramuscular Ketamine Patient Brochure
Risks and mitigations
| Risk | Mitigation |
|---|---|
| Funding/Resources | Recommend expanding our Ketamine clinic to offer Ketamine therapy to Veterans in and surrounding states. Because when it comes time for appointments, we have found that travel limitations are our most significant impediment. Being able to offer Ketamine therapy treatments throughout other VA facilities so that all Veterans with Treatment Resistant Depression can enroll in a VA Ketamine Clinic to receive this essential treatment. Ketamine therapy has positive results for the Veterans as it returns their joy and purpose in life. Most importantly, Veterans will be able to receive treatment close to their homes resulting in travel limitations are no longer an issue. |
| Designated space/location | Recommends that the facility to allocate a private and quite open space for a treatment area that can accommodate all required equipment plus patients and staff. { ex. at least eight patient recliners, eight potable cardiac monitors, eight IV poles with pumps, at least two nurse's desks with chairs and includes a closing door for patient privacy during treatment}. Including access to a patient waiting room with non-rolling chairs and a table or desk {that displays education items etc.} and access to a consult office with a computer, a chair, a desk and two patient non-rolling chairs {privacy for the patient/family members and physiatrist}. |
| Clinical Pharmacy and Pharmacy Tech time availability | Recommend that facility allocate up to 0.125 FTE, 5hrs per week, to review Ketamine list, check and verify doses, review inventory, etc. Also to include Pharmacy Technician up to 0.375 FTE, 15hrs per week, for compounding Ketamine. (All depending on scale of clinic size of 8 patients per day) |
| Volume of appropriate Veterans | Ketamine therapy is optimal for facilities in reducing ideation or behavior and preventing suicide among the Veteran population. |
Contact
Comment
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About
Origin story
Dr. John Spollen was the lead psychiatrist at the VA Medical Center in Little Rock, AR. He noticed that Veterans were experiencing increased thoughts of self-harm, hopelessness, and depression due to their undertreated depression. Veterans' PHQ9 scores and suicide scores at his center surged for over a year, so he followed his clinical intuition by advocatin
...
Dr. John Spollen was the lead psychiatrist at the VA Medical Center in Little Rock, AR. He noticed that Veterans were experiencing increased thoughts of self-harm, hopelessness, and depression due to their undertreated depression. Veterans' PHQ9 scores and suicide scores at his center surged for over a year, so he followed his clinical intuition by advocating to pilot a new state-of-the-art treatment, Ketamine therapy, for Treatment-Resistant Depression. In December 2019, Dr. Spollen and his team were the first Mental Health Ketamine Clinic pilot program for his facility, within VISN 16, with only 19 patients. Since implementing the Mental Health Ketamine Clinic, therapies offered within the clinic have improved Veterans’ depression score rates by 85%, as evidenced by the PHQ-9, the national depression measurement tool.
Original team
Kristen Kemp, BSN
Registered Nurse
Cortney Threat, MSN
Registered Nurse
Kelly Hair, MD
Psychiatrist
Douglas Provaznik, MD
Psychiatrist
Kelley Burrow, MD
Psychiatrist
John Spollen, MD
Psychiatrist
Dustin Thompson, Pharm D, BCPS
Inpatient Pharmacy Supervisor
Sherika Davis, CPHT
Controlled Substance Technician
Darla Pettis, MSN, VHA-CM
Deputy ACOS/Nurse Executive Mental Health
Hi. Great work. I have data from San Diego. We started our clinic in January 2020 ,first with Esketamine, now Esketamine, and IM and IV Ketamine. If you are interested let me know.
For Veterans wanting to start Ketamine Therapy, please contact your local VAMC Primary Mental Health Provider to discuss if this is an option.