Ketamine and Esketamine (Spravato) for Generalized Anxiety Disorder and Social Anxiety Disorder - COPE

Ketamine and Esketamine (Spravato) for Generalized Anxiety Disorder and Social Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry about real or imagined issues in everyday life. The anxiety is present on most days and is hard to control. Affected persons commonly feel irritable and restless; their concentration is poor and they are easily tired; they may suffer aches and pains in muscles, and frequent headaches; and they may have poor sleep. These symptoms impair activities and efficiency in everyday life. GAD is often present along with one or more other psychiatric disorders, most commonly depression or panic disorder.   Social anxiety disorder (SAD) is characterized by an excessive, irrational fear of being embarrassed or humiliated in small or large gatherings. Affected persons may avoid parties, find it difficult to speak when in groups, and underperform in social contexts. Such social situations almost always trigger anxiety. There is no anxiety or impairment when there is no social demand. The condition is also called social phobia.   How common are these disorders? GAD affects about 2-5% of the population and is severe in 1%. SAD affects about 7% of the population and is severe in about 2%.   Treatment of GAD and SAD Most drugs used in the treatment of depression are also effective in the treatment of GAD. Examples include antidepressant drugs like Celexa, Prozac, Paxil, Zoloft, etc. Antianxiety drugs such as Buspar and Seroquel are less effective treatments, as are antihistaminics. Finally, different kinds of psychotherapy, relaxation therapies, biofeedback interventions, yoga, meditation, and even aerobic exercise can benefit patients with GAD. SAD is treated with drugs belonging to the antidepressant class like the SSRI’s; a benzodiazepine, like Xanax, can provide emergency relief in specific situations. Behavioral and psychotherapeutic interventions are also important treatment strategies for SAD.   Unmet needs A small percentage of patients with GAD may remain severely impaired by anxiety despite trials of different treatments for the condition. Many patients with SAD may require emergency relief for workplace or community events that demand social engagement and performance.   Ketamine for GAD and SAD Individual patients with GAD and other accompanying anxiety disorders have been reported to experience substantial benefits with a single infusion of low dose ketamine.   One recent study administered ketamine to 12 patients with difficult to treat GAD and/or SAD. Ketamine treatment was associated with dramatic benefit, beginning within an hour of injection. The benefits lasted for up to seven days. Higher doses of ketamine were associated with greater and longer-lasting benefits. There were no serious side effects. In this study, no patient had concurrent depression, and so the recovery from anxiety was not due to the known antidepressant effect of ketamine.   Another recent study examined 18 patients with social anxiety disorder. In these patients, ketamine infusion, as compared with dummy (placebo) infusion, was associated with greater 2-week improvements in self-reported anxiety as well as clinician-rated social anxiety. The response rate was 33% with ketamine vs 0% with placebo, and 89% with ketamine vs 53% with placebo, on clinician- and self-assessment, respectively.   Take home message Low dose ketamine infusion may be a useful treatment for patients with GAD or SAD that do not respond to usual treatments. An advantage of ketamine is that it is quickly evident whether or not the patient will benefit from treatment, and so there is no need for protracted medication trials. Another advantage is that the benefits emerge within hours of treatment, and so it can be used for emergency treatment in patients who need rapid benefits to tackle looming life situations.   Learn More If you or someone you love is suffering from GAD or SAD, we encourage you to reach out to COPE to learn more about our innovative, effective, evidence-based treatments. Please call our office at COPE to schedule an appointment.