Whether you’re just starting treatment or have been going for a long time, there are some reasons why you may not be seeing the efficacy you expect from treatment.
When treatment used to work
When interventional treatment used to be effective for reducing symptoms, but isn’t anymore, there are several factors we look at to help patients see benefit again.
Time Since Last Treatment
Treatment works best with maintenance. Typically, the best results for TMS maintenance is within about a month since the last treatment. The best results for ketamine maintenance are typically around 3 to 5 weeks since the last treatment.
If you feel like your mental health symptoms are returning, it can be helpful to check when you last had treatment. If it’s been longer than a month or 3 to 5 weeks, it may just be time for another maintenance treatment. If it’s been longer than about six months, it may be helpful to start with a few treatments close together before spacing out to monthly maintenance again.
Alcohol, Marijuana, and Benzodiazepines
Alcohol, marijuana, and benzodiazepine use each decrease the effectiveness of treatment and shorten the amount of time that ketamine or TMS is effective. Rather than needing maintenance every 3 to 5 weeks, patients may need to come in for treatment more frequently, even every week or 2 weeks, until they are able to decrease their use of these depressant medications.
Medication Changes
Medication changes can influence the benefit patients see from treatment.
If a patient has stopped taking a medication, treatment may not be effective because they are going through withdrawal.
If a patient has added a medication, it may be flattening their mood and make them feel unmotivated or sedated throughout the day. This does not need to be a psychiatric medication. Beta blockers, for example, are a form of heart medication but can cause a flattening effect or depression.
Subtle Changes
Patients may feel worse because they’ve stopped exercising. They may have gone away on vacation, or gotten sick, or busy at work and fallen out of the routine.
Sometimes it’s vitamins. Patients may have stopped taking their vitamins and now they’re vitamin D deficient again, or they’re anemic again.
It may be a hormone changes. Patients may be going through perimenopause and their estrogen is lower, or their testosterone levels may have decreased with age.
Life Events
Events outside of our control can have a great impact on mood and make it feel like treatment isn’t working anymore. Maybe your boss is changing at work, or you lost your job, or your pet died, or your parent is sick — and that weighs on you. Increasingly, we have seen patients struggling with the news or with politics creating a lot of anxiety and negativity in their life.
Each of these factors can have a big impact on mental health. It may not be that your treatment isn’t working anymore, but that there are other outside factors that are influencing your mood.
Ketamine efficacy over time
Some medications build up tolerance very quickly. Many patients on SSRIs may notice that their first six months on the medication are blissful, but after that period, the medication stops working as well. They may need to change their dose, or to rotate medications. This is very typical of SSRIs, SNRIs, and benzodiazepines, but it is not typical of ketamine.
There is not evidence that ketamine will stop working over time when administered in clinical doses with clinical spacing between treatments.
For patients taking ketamine at home in frequent or daily doses — often in the form of lozenges or troches — they may begin to build a tolerance to ketamine. This can be especially unfortunate for patients for whom ketamine has been a kind of last resort, and one of the only things that has been helpful for them. For this reason and others, we highly discourage at-home ketamine use.
With a typical treatment schedule, which involves 6 initial treatments over the course of 2-3 weeks and as maintenance treatment every 3-5 weeks, we do not see a tolerance to ketamine develop over time.
When you’re starting treatment
For patients beginning ketamine treatment who have gotten to the third or fourth infusion without seeing any benefit, we look to the same factors as above that may be influencing treatment.
We review what medications you’re on, substances like alcohol, marijuana or benzodiazepines, as well as your diagnosis. For some patients, there may be elements of a personality disorder that could be influencing the effectiveness of treatment.
The support of family and loved ones to pursue treatment can also affect the efficacy of treatment. Sometimes, even with the best of intentions, families may try to keep a family member in a box because they are wary that the quality or status of their relationship may change. Buy-in from your family can be an important factor in how much benefit you are able to see from treatment.
Lastly, there is a percentage of patients for whom treatment does not work. Ketamine has great statistics — for treatment-resistant depression, 70-80% of patients see a 50% reduction of their symptoms by the second or third infusion. However, this still leaves a percentage of patients who do not see benefit, and we’re still trying to piece together why.
Maybe it’s a receptor defect in the NMDA receptor, or a receptor defect for [x] or [x]. Maybe it’s some biological downstream metabolite pathway we don’t know about yet. As research on ketamine treatment continues, we hope to learn more about why it does not appear to be effective for all patients.
About Us
Wells Medicine is a Houston-based practice designed to provide meaningful care for mental health. Providing targeted interventional treatments for Depression, Anxiety, OCD, PTSD and other conditions, with Ketamine Treatments, Stellate Ganglion Blocks, TMS, and Nitrous-Oxide Treatments. Focused on comprehensive care and integration with Psychiatry, Psychology, and Support Services. We are evidence-based, patient-focused and mission-driven.
The content here is for informational purposes and should not be relied upon for medical decisions. For the details of your specific medical conditions and treatments consult your doctors or other qualified healthcare professionals.
