Ember Health offers IV ketamine infusions for mental health conditions. We interviewed Dr. Nico Grundmann to learn how more about therapeutic applications of ketamine. Read his responses or watch the video below.
Getting to Know Dr. Nico Grundmann
Dr. Nico Grundmann is a founder and the Chief Medical Officer of Ember Health, which provides intravenous (IV) infusions of ketamine in a safe, medically monitored setting to people seeking relief from depression. Ember Health works in partnership with mental health providers in New York City to offer this service in conjunction with, and as a complement to, the kinds of services that more traditional mental health providers use with their clients.
Dr. Grundmann is an Emergency Medicine Physician by training, devoted to improving how healthcare systems operate for those who need it the most. Working in emergency rooms from suburban California, to inner-city New York, to rural West Virginia, Nico grew frustrated by how frequently he was treating acute symptoms of mental health without helping his clients with more sustained, long term solutions. Many years of working with ketamine as a safe medicine for sedation prompted continuous research of the drug’s efficacy for other conditions, including depression. Nico co-founded Ember Health as a way to help individuals take control of their lives, and contribute to shaping the field in line with his values. Dr. Grundmann pursued his residency training at Kings County Hospital / SUNY Downstate in Brooklyn, NY, and received his Medical Degree and Masters in Business Administration from Stanford University. He lives in Brooklyn with his wife and family.
IV Ketamine – From Acute Symptoms to Long-Term Solutions
Dr. Grundmann spent almost a decade as an Emergency Medicine physician, and was used to seeing clients with depression come into the emergency room (ER). “A third of all visits to the ER are from people who suffer from depression, whereas depression affects 10% of the general population. People with depression are three times more likely to show up to the ER when they have chest pain than the general population… In other words, people with depression are over-represented among patients who come to the emergency department.”
Emergency medicine also allowed Dr. Grundmann to regularly see the benefits of ketamine in a variety of applications on a daily basis. “I’m not exaggerating when I say that we use ketamine multiple times a day and in doses close to a hundred fold higher than the doses now used in mental health for conscious sedation and anesthesia. I was also being exposed to an abundance of research that was showing how deeply effective ketamine was for people with depression. In Emergency Medicine, that first started coming up with acute suicidality, and there have been a handful of papers showing that ketamine causes a rapid reduction in suicidal thinking.”
Increasing Accessibility through Ember Health
“The more I looked into the literature, the more I saw that this was a real thing, not just a theory… We felt like there was an opportunity to provide access to this care without some of the significant logistical hurdles that people otherwise faced in receiving it.” Ember Health now operates two IV ketamine clinics in New York City, with a third launching this fall (2021). “We’ve run a couple thousand infusions for people over these last couple of years, because it works.”
Treating Depression with IV Ketamine: Three Layers of Impact
Medical, clinical trials for IV ketamine treatment of depression have seen more research papers published in the last three years than in the preceding twenty. While IV ketamine has been widely shown to be effective for depression, there is little consensus on how it works. “What we’ve learned from those papers, and from our clients, is that ketamine actually has three distinct benefits. If you have a practice that focuses on all three of these things, you actually see markedly better outcomes.”
“The first effect is biological. If you give the drug to the right person in the right route of delivery over the right period of time at the right frequency at the right dose (a lot of clinical aspects need to be done correctly) then three out of four of people will experience a reset of their emotional reward system… When this treatment works, people don’t necessarily feel happy, that’s not the goal. People feel neutral. Then from neutral, they’re able to experience emotions that are appropriate to what’s actually going on around them. So, they do something that should objectively make them feel happy or good, and they get to feel that, often for the first time in years. Similarly, this doesn’t prevent negative emotions… If something sad happens, they feel sad, and that’s an appropriate response at times. Treatment helps them prevent spiraling from a single negative event in the future.”
“There are now half a dozen clinical papers that have shown that the experience changes the outcome of care. The sessions often provide psychological content that people can talk about… These include insights, changes in perspective, a reframing of some of the trauma or issues that they’ve been through… We talk with every client after every session quite extensively… No two people have described their sessions in the same way. We can do things to positively influence the experiential side of treatment. We create spaces that are comforting. Our providers are with our patients at all times for support and to ensure their emotional as well as physical safety. We provide therapy and music therapy. We help our patients with intention setting. All of this makes it more likely that a person will have psychologically fruitful content come up.”
“The final effect of IV ketamine is that for a couple of weeks after treatment, a person’s brain becomes more neuroplastic – it is quite literally a time that they can change their thinking. They can grow new neural connections more easily. This is where the title of Michael Pollan’s book [How to Change Your Mind] comes from. There are windows after each infusion where a person is better able to break habits and form new ones. In this time, people can more easily develop supportive habits. Psychotherapy becomes more effective. Yale published a recent study showing that cognitive behavioral therapy (CBT) is specifically adaptive. Many “adaptive learning” techniques have shown benefit post- IV ketamine treatment because the ketamine makes those techniques ‘stickier’.”
Ecosystem of Care around IV Ketamine
“Our clients talk about getting unstuck as a result of care with us. Our opinion is that our practices should maximize the three benefits I’ve described. A client can benefit from all three of them, and they’re all realized when you do the treatment correctly.
Our practice at Ember Health adheres to an evidence based approach that ensures maximum biological benefit, for example in determining dosage, duration, and frequency. We also focus deeply on the experience so that it is therapeutic and beneficial. Finally, we partner with people’s mental health care providers to take a team based approach in establishing individualized care plans… We ensure that clients complement their care with us with longer term, structural changes that might help address the very reasons that they’re triggered into depression in the first place. This is what we call the ecosystem of care.”
Language becomes Access
The language used to describe treatment can shape how receptive or comfortable someone might be accessing these services. “Only about a third of our clients approach us from a psychedelic orientation. The majority come to us as the next step in trying to address their depression… We’re not oriented as a practice that provides ketamine or a practice that focuses on psychedelics. We are oriented instead on helping people who are suffering with depression through access to a tool that promises transformative relief. That means that we orient all of our language to be as neutral as possible, especially how we talk about altered states and experiences. We frame sessions in a way that does not trigger all of the associations people have with the drug war, with substances… We’ve also worked on reframing what ketamine is, because this is a common drug used more often in hospital emergency departments and operating rooms than anywhere else, by significant orders of magnitude… The stigma associated with ketamine decreases the likelihood that somebody is going to seek care for a substance that can really make a difference in their lives. We know this works, the only debates in the academic field at this point are how to optimize the treatment.”
Long-Term Care & IV Ketamine
Part of how Ember Health ensures success is by helping clients establish long-term care plans where ketamine is one in a complementary set of tools for personal wellbeing. “Ketamine does not offer a miracle where somebody gets the treatment once and never comes back… the expectation is that people will need to return on a regular basis to realize lasting benefit. Six weeks is the average duration of antidepressant effect that we’ve seen for our clients who were formerly considered “treatment-resistant.” This means that most people need to come back anywhere between two weeks to twice a year for a booster infusion, and that matches the literature on this topic.
“Ketamine is not a preventative treatment, it’s a resolution of an acute depressive episode. It stops the depression and actively puts the person back to neutral, but it doesn’t prevent them from being susceptible to becoming depressed in the future… What that means is that we establish long-term relationships with our clients. These are people we get to know really well. We are a safety net so that whenever their depression does come back, and at some point it will, we’re there.”
“When the pandemic first hit New York, we debated closing… After the first week of being closed, it became very clear from our clients that they needed this… So, I actually lived apart from my family for about a month and a half… I kept the clinic open by myself, and we made sure that we were there for the people who needed it… That also turned out to be really important for the long run. COVID has been deeply difficult for the majority of the world, and the need for options like ketamine has grown exponentially. I haven’t had an intake call in over a year where somebody hasn’t mentioned the pandemic as a stressor, as a trigger, contributing to why they’re depressed, and we’ve grown to meet the demand.”
“Ketamine abuse is a big issue over the course of the pandemic. There has been a marked increase in home-use ketamine and in prescribing ketamine for oral use in a non-supervised way. That’s something that we feel deeply against, both for medical safety reasons and for clinical efficacy reasons. Oral ketamine only works about 30% of the time as opposed to 75% of the time that IV infusions work. There are very, very complicated legal and regulatory issues with the DEA in different jurisdictions surrounding home use. A number of people who have accessed ketamine in a non-structured environment have been using it in ways that are not consistent with their mental health and wellness, and established abusive patterns at odds with addressing their depression… We often treat people who have substance abuse issues. That’s actually relatively common for us because substance users often misuse things as an attempt to escape their depression. Keeping those people away from treatment would also be a harm. We are much more careful with these clients.”
Embracing Data & Nuance in the Field
“I’m a data-driven person, and if I could flip a switch, there would be a lot more rigor in terms of practitioners following evidence-based approaches and collecting patient data, because there’s still a lot that we’re learning in this field that hasn’t been answered yet. This would ensure that people who practice this work are following what we already know to be true, like good evidence on dose, routes of administration, frequency… Developing individualized care plans is really complicated but critical. No two people have the same duration of benefit or frequency that they need to come back and see us… We believe in the need to account for and maximize the psychological side of care as well. No two people have the same experience… This already works [in the clinical trials] for three out of four people, and about 82% of our clients here at Ember. The fact that more than 8 out of 10 people can benefit from this with rigorous attention to how to maximize these treatments is really hopeful to me. It means that we actually might have a tool that just works. And so, the real question is, how do you make it work as optimally as possible?”
Connect with Ember Health
“People should know that at any point, they’re welcome to reach out. Everything with us here at Ember starts with a conversation. All clients start with a phone call with one of our doctors, usually me. The whole point of that first interaction is to learn more. We don’t assume that we know why a person’s reaching out to us. We listen to them without judgement and then share how this could be helpful for them accordingly. Not every person is appropriate for this, but we won’t know until we start with that conversation.”