kMental Health and Teens: Why Ketamine Treatments May Be an Option

The Statistics

The numbers are staggering.

• 20% of teens age 13-18 have a mental health condition.
• 50% of cases of mental illness begin by age 14.
• 90% of those dead by suicide had an underlying mental illness.
• 8-10 years pass, on average, before treatment.

There are millions of young people who struggle with mental illness. They are at a pivotal time in their life with so many possibilities. They are our future, we owe it to them and us to focus on diagnosing and treating their mental illness.

The Research on Mental Health and Adolescents

Early intervention is key because these teens do not grow out of their mental illness. They grow up with it. A prospective study by Weissman et. al. followed teens diagnosed with major depressive disorder (MDD) over 10 years into adulthood. They found serious outcomes in youth diagnosed with MDD including a statistically significant increase in both psychiatric and medical hospital stays, social impairment with work, family and social life, and suicide attempts. 50.6% of teen onset MDD made a suicide attempt and 22% made multiple attempts, within the 10 year follow up in this study.

A larger prospective study by Pine, et al. expanded the group of disorders followed in teens to adulthood. They found teen anxiety and depression has a direct association and are a strong risk for recurrent anxiety and/or depression as an adult. They also believe the link between teen anxiety and depression with these adult disorders are likely even much higher than discovered.

Signs a Teen May Be Depressed

“As underrecognized and undertreated as depression is among adults, it is even more so among children and adolescents.” Dr. Saluja

Teens are often characterized as “moody” while they undergo puberty and discover who they are as an individual. How do you distinguish normal behavior from a red flag? Researchers Saluja et al. studied the risk factors for depressive symptoms in teens from grades 6, 8, and 10. The prevalence of risk factors increases with age and some include:

• Bullying: Strongly associated with depression for both the victim and the aggressor.
• Somatic symptoms: Absenteeism, headaches, stomach aches, feeling dizzy, etc
• Substance use: Including tobacco, alcohol, marijuana, cocaine and others. May suggest self-medication.
• Increased physical fights: Difficulty relating to peers can lead to fights.
• Unsafe sexual practices
• Increased conduct disorder

Girls are more likely to internalize depressive symptoms, leading to somatic symptoms, while boys have a greater tendency toward “acting out”. Some of these risk factors may not be an obvious sign of depression. Therefore, the authors advocate increased screening in middle school and high school for major depressive disorder. This must be recognized so these teens can receive treatment, feel better, and ultimately become more successful.

Ketamine Treatments and Adolescents – the Leading Studies

We already know ketamine treatments have rapid beneficial effects on suicidal thoughts. A large percentage of patients may experience steep reduction in suicidal thoughts immediately after an IV ketamine infusion, and continued reduction over several days with repeat infusions. This is a breakthrough for families struggling each day to keep their loved one alive. The benefits are also true for adolescents.

“There has been an explosion of ketamine clinical trials for adolescents”. These trials are exploring ketamine for suicidal thoughts, depression, anxiety and obsessive compulsive disorder. Yale child psychiatrist Dr. Michael Bloch is the principal investigator for a number of these trials. It is important to note, Dr. Bloch carefully selects patients with severe mental health problems that have not responded to other medications. Also, ketamine treatments are given under a controlled, monitored setting where side effects can be managed.

“Suicide is the second leading cause of death in adolescents. 40% of depressed adolescents don’t respond to first-line treatments. Another half of those don’t respond to multiple trials of medication paired with psychotherapy. Other than electroconvulsive therapy, which carries its own risk of memory problems, doctors have almost no other choice.” Dr. Bloch

Yale researchers are careful to point out the down side to ketamine, most likely seen with abuse and overuse. Large doses, multitudes higher than the dose used for mental health disorders, have shown complications with liver, bladder and memory problems. Addiction is also serious problem around the world with ketamine being abused as a club drug. However, when provided in a low dose, in a controlled setting for select patients, ketamine can have tremendous benefits.

Treatment resistant depression is the target for a recent clinical trial, completed March 2018, by The University of Minnesota. (LINK) Preliminary results show adolescents that respond tend to experience more sustained anti-depressant effects. The duration of these effects in adolescents was over 42 days vs about 18 days for adults. “This could be due to the versatility of the growing adolescent brain allowing ketamine to work more efficiently”. The overall response rate was a bit lower than adults, but the duration was more dramatic. We look forward to the final results of this study which will certainly help guide treatment for adolescents.

Applying the Ketamine Breakthrough – The Present and What We Know

1. Ketamine has remarkably high response rates for treatment-resistant depression and suicidal thoughts in adults and adolescents.
2. Adolescents with anxiety and depression do not outgrow their mental health diagnosis.
3. There are numerous teen risk factors that may not be obvious signs of a mental health disorder. Early screening is key.
   People are wary of ketamine. Side effects are documented, though in extreme dosing comparable to street drug abuse levels. Also, ketamine can be addicting without careful screening for abuse .

Applying the Ketamine Breakthrough – The Future and What We Need

1. Education about adolescents and mental health disorder.
2. Early screening as young as middle school age children for early intervention.
3. Consensus protocols, guidelines, and patient selection compiled from experts in the field.
4. Insurance coverage for ketamine infusions so more people can access this breakthrough treatment. Ketamine for mood disorders is an off-label use, meaning the FDA has not granted approval. For this to happen, large and expensive clinical trials must be run on this generic drug. These may indeed be the future of ketamine therapy. However, now we have the knowledge and results from ketamine. We need to increase access for struggling families.

Where to Get Help

Mental health and ketamine treatments are very broad topics, which are only touched on in this article. The internet provides a wealth of information, but is not a substitute for speaking with your primary care provider, school counselor, or mental health professional. Though ketamine can provide profound relief, it is not a first line treatment for mental health disorders in adults or adolescents. It is specifically studied for those who fail to achieve relief from traditional medication and therapies.
For anyone in distress right now, help is available:
Call 1-800-273-TALK (8255) for The National Suicide Prevention Lifeline

Text 741741 for Crisis Text Hotline

For information and help finding treatment in your area:
Call 1-800-662-HELP (4357) for SAMHSA – Substance Abuse and Mental Health Services Administration

Cindy Van Praag, MD

References

1. www.nimh.nih.gov statistics presented by www.nami.org
2. Weissman MM., Wolk S, et al. Depressed Adolescents Grow Up, JAMA. 1999;281:1707-1713 (LINK)
3. Pine DS., Cohen P. The Risk for Early-Adulthood Anxiety and Depressive Disorders in Adolescents With Anxiety and Depressive Disorders. Arch Gen Psychiatry. 1998;55:56-64 (LINK)
4. Saluja G, Iachan R, et al. Prevalence of and Risk Factors for Depressive Symptoms Among Young Adolescents. Arch Pediatr Adolesc Med. 2004;158:760-765 (LINK)
5. Price RB. Effects of Intravenous Ketamine on Explicit and Implicit Measures of Suicidality in Treatment-Resistant Depression. Biological Psychiatry. June 22, 2009, published online by the Society of Biological Psychiatry. (LINK)
6. Ballard ED, Ionescu DF, et al. Improvement in Suicidal Ideation After Ketamine Infusion: Relationship to Reductions in Depression and Anxiety. Journal of Psychiatric Research. 2014;58:161-166 (LINK)
7. Turban J. The Ketamine Breakthrough for Suicidal Children. Published online by Scientific American July 18, 2017. (LINK)
8. Wetter H. Clinical Response of Ketamine Infusions in Adolescents with Treatment-Resistant Depression. Presentation at the Department of Psychiatry. University of Minnesota