Depression & teenagers- is ketamine something to consider? with Psychiatrist, Erin Amato MD

Ask Dr Jessica Episode 65 discussing the use of ketamine for treatment of depression, under the care of a psychiatrist.  In recent years, there has been an increase in the number of teenagers who are experiencing major depression.  Randomized trials have demonstrated that  ketamine (given through the IV) and  esketamine (the nasal form) can rapidly improve treatment-resistant depression, including suicidal ideation.   I think it is important to stay up to date on available therapy, because with this knowledge, you never know whose life you may impact for the better.

Dr Erin Amato is a practicing psychiatrist in Montana, and she has double board certification in general psychiatry and child  & adolescent psychiatry.  Passionate about holistic and integrative ways to treat mental health disorders,  she is  a fellow of the integrative psychiatry institute, and she has spoken on many media platforms, including many morning television shows.  She has been providing IV ketamine therapy for treatment of depression since 2016.  To learn more about Dr Amato, please look at her website or follow her on Instagram @erinamatomd.

Also, to find a nearby  doctor who incorporates use of ketamine into their practice check out:  www.ASKP.org

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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Transcript

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Hi everybody welcome to ask Dr. Jessica the podcast where my goal is to keep you informed with quality medical information and to help you worry less along your parenting journey. I'm your host and paediatrician Dr. Jessica Hochman. Today's guest is Dr. Aaron Amato. Dr Amato is a psychiatrist double boarded in both general psychiatry and Child and Adolescent Psychiatry. In recent years, there has been an increase in the number of teenagers who are experiencing depression. I was really interested to talk to Dr. Amato, as she has been treating depression with a medication called ketamine. While ketamine has been around for decades, there's only been in recent years that psychiatrists are using ketamine to treat depression. That is not improving with traditional medications. I think Dr. Amato for helping to spread awareness about this medication. You never know whose life may be impacted for the better. Also, if you are enjoying this podcast, I would be so thankful if you would leave a five star review and share it along with a friend. Hi, Aaron, thank you so much for coming on to talk about ketamine. I'm so excited to talk to you. Yeah, thanks for having me. So I'm so curious, because I know you're a psychiatrist and have to say that in medical school, thinking about ketamine as a means to treat depression was not something that we learned about so I'm so curious, how did you come into this field? How did how did you learn about ketamine? Yes, well, it is still a young field in terms of psychiatry, and I first learned about it. In 2014, I lost a patient to suicide. And that put me on the path of just trying to figure out what else is out there to help people because I had been in practice for about six years at that point. And I felt like I was doing everything I could for some of these patients in terms of using various medications and talk therapy, and there were a lot of people who still weren't getting well. And so I had heard mention of ketamine and some of the journals. And I had a conversation with my father who's an oral surgeon, so he does a lot of wisdom teeth and other dental procedures. He had also heard about ketamine for depression, and we struck up a conversation and he said, You should think about using it because ketamine, it's really easy to use. It's been around forever. So that's kind of what got me my confidence initially to go out and try this. So initially, you were practising psychiatrist. Yes, yeah, very traditional psychiatrist, lots of use of medications, and then talk therapy. So how did you get into this field of psychedelic treatments? Didn't have you always been interested in alternative sources of medicine? You know, I have and it always bothered me in my psychiatric training, that we didn't talk a lot about prevention, we didn't talk a lot about lifestyle, and other things that people could do beyond just medications for helping with their mental health. So I've always had a curiosity about it. And so it just seemed like a very natural pathway. As I got interested in ketamine and also TMS as an alternative treatment for depression. And then just looking at more holistic and integrative approaches to mental health as well. I agree with you, I think the criticism that a lot of doctors get from the public is that when patients come with their symptoms of depression, we're so quick to prescribe a medication, we don't think about the root cause. Right? Yeah, I mean, that's often an afterthought. And sometimes I think we we use medications and other means because the the patients that are coming to us are very ill, they need something to get them back on track to where they can actually have the the ability to think through or plan or, or find the energy to engage in lifestyle changes that may help more with those root causes. So let's talk about ketamine. When I first heard about it from a patient, it sort of took me off guard because I thought, Wait, this is not something I ever learned about how can this really be a true treatment? Who should be using ketamine and where have you seen it work successfully? Well, I think it's a really good consideration for anyone who's had particularly depression, but also PTSD, it can be very helpful with that. And in cases where people have tried a few medications, and they've found that they either don't tolerate them because of side effects, or that they're just not getting better. Ketamine would be a good consideration at that point. Okay, so in summary, anybody who's tried medications, tried talk therapy, not seeing success, still feeling really depressed as someone who should think about ketamine. Yes, and there are certain medical conditions that we have to be mindful of where someone may not be a good candidate for ketamine. We see this I think more in the adult population where if it's someone who has a history of high blood pressure, that's not well controlled. That would, that would be a situation where I would be reluctant to treat someone. Also, if someone is pregnant, that would be an exclusion. If anyone has had ketamine in the past And they've had an allergic reaction to it. And then in cases where people have had the type of stroke where there's bleeding within the brain, or if they have certain vascular problems within the brain or in other parts of the body, that would be a reason to pause and consider whether that person really is a candidate. And what does the treatment using ketamine look like? Is it something where patients come in once a week? Do they come in for years, what is the expected treatment course look like? So if we're talking about IV ketamine, within my practice, our initial protocol is kind of an initial or an induction series, where we have people come in two times a week for three weeks, so a total of six treatments. Now, that's not a hard number. Sometimes we're flexible with that, if we've needed to start at a lower dose and take more time, we'll extend that initial series, but two times a week. And then for those who have shown a favourable response to ketamine, there is a need usually to return periodically for some maintenance treatments. And that looks very different for everyone. For some of my patients that are more fragile, have really difficult to treat depression or suicidal thoughts. Maybe they're coming in once a week still or every other week. Whereas other people, it's the average is, I would say monthly, that people are coming in for those maintenance treatments, and then I have a few who are able to go even two to three months in between their treatments. And do you notice that your patients feel noticeably better right away? Or does it take time, it can take time. And that's something that I have conversations on the front end with people about managing expectations and not giving up hope or being frustrated, if they don't see that quick turnaround after one treatment, I would say it's kind of a bell curve. Most people by treatment three or four, they are noticing some sort of shift starting to happen. But there are those who notice a difference within hours of the first treatment, there are some people where we get to treatment six, and it's a little bit iffy. And that's a situation where maybe I would extend and do a couple more treatments to see if we see more movement. And walk me through what it looks like for the patient when they are getting the IV treatment. Do they have you by their side during the treatment? Are you are you are you talking to them afterwards? Do you prepare them before? What is the actual experience look like? Will I or one of my other medical providers pas within my practice will go in and meet with a patient initially just to do a general assessment to see how they're doing mood wise also to assess for suicidality. That's an important thing to do, each time someone has a treatment and assessing different medical factors and then make a determination on dosing. And at that point, we have some nurses and paramedics within our practice who administer the actual treatment. And so the infusion itself, it's an infusion over 40 minutes. And then there's usually about 30 minutes of recovery time after the medicine is done running during the infusion, so I'm not with them the entire time. And there are different practice models where there's a model of delivering ketamine called ketamine assisted psychotherapy or cap in in that case, the medical provider may have just a very limited role. But there may be a therapist who is sitting with someone the duration of their treatment, and even in the time after their treatment and doing some therapy. So there are a lot of different ways that this can be administered and still see benefit for the patient. In the end, what can patients expect to feel during this experience? You know, some of it depends on the dosing level. And every, every person is different in terms of their sensitivity to different doses. So it's fairly, it's fairly standard to start with a dose that's based on the patient's weight and then to graduate that a little bit over time. But at the lower end of the dosing, a lot of people report things like they feel kind of a floating sensation, like a dreamlike state. Some people see colours, usually sounds are enhanced, and we do have our patients wear an eye shade, that helps to block out external distractions and helps them to go internally more with the treatment, which is an important part of the therapeutic process. And we have them use some over the ear headphones with some playlists of music that we've curated. We've been very intentional about the type of music that we have on these playlists, because the music for some people really becomes an important part of the ketamine experience and the therapeutic effect of it. For most people, they report it as a very pleasant, relaxing experience. There are a few people that may experience some anxiety or have some darker content that comes up for them. But I explained to people on the front end that sometimes if there's darker content coming up, that's something that needs to be dealt with and processed and rather than Pulling back and getting anxious. It's something to acknowledge and push through with the treatment. It's so fascinating. Do we know why ketamine works? Do you know what is actually happening in the brain? There's a fairly long list of ideas of what may be happening, but we know that it enhances neuroplasticity that they're there that there's a window of probably 24 to 48 hours where there's some enhanced neuroplasticity. So that's a window where the brain may be able to process material or learn material in a different way than it has been previously. It also increases levels of BDNF. It's a long term brain derived neurotrophic factor, but I like to think of it as Miracle Gro for the brain. And there's something pretty fascinating that happens with ketamine where they've even looked at pictures of neurons are dendrites underneath a microscope. This is usually with animal studies, like looking at mouse dendrites, but they've looked at those neurons in cases where the mice have been stressed and there's been damage to the neurons and then they've looked at them after treatment with ketamine and they're actually seeing sprouting and new growth of the neurons. Another way to it works on different neurotransmitters than we typically think of traditional antidepressants working with so you know, with antidepressants, we talk a lot about serotonin, dopamine, norepinephrine, with ketamine, we're talking more about glutamate and GABA. So it really is working differently than those traditional antidepressants. It's so interesting, because I know the brain becomes more rigid and less plastic as time goes on. So the idea that we can regrow, reshape, that's so fascinating. Yeah, yeah, it really is. Now, I know the FDA recently approved nasal ketamine for treatment of refractory depression. Can you comment on on nasal ketamine Is that Is that an option for patients and when to use nasal ketamine versus IV ketamine? A? Sure. So there are several different routes of administration for ketamine. A common form is the IV infusion. It can also be given as an injection usually in the arm. It can be given orally, where it's compounded into little dissolvable lozenges. Often when it's being used orally like that, it may be combined with the type of therapy that I was describing earlier. And then it can be compounded into an intra nasal spray. One difficulty with that, though, is that you don't necessarily get consistent dosing with that. And so, so a drug company did develop a form of ketamine called S ketamine, or it's known as the brand name spravato. And that was approved by the FDA in 2019, for treatment of major depressive disorder, and it uses a little special cartridge that is a very controlled dosing of it. So it's different than what you would think of like an aspirin type nasal spray, very controlled dosing of that. And we do administer that in my clinic as well. It's different from the IV form, because s ketamine only comes in two different forms, two different doses. And it's also restricted to use, at least at this point for people over the age of 18, that FDA approval was just for more of the adult population. And there are some strict monitoring requirements that come with it as well, people who do the intranasal esketamine, it has to be done in a medical office. There are some parameters about how blood pressure has to be monitored. And from the time of when the patients get the medicine, they have to stay within the Office for monitoring for at least 120 minutes after getting that medicine. So a solid two hours. And I mean, we do similar things with the IV ketamine as well, but it doesn't have the same requirements around it in terms of that monitoring programme. And what is the age limit for IV ketamine? Well, really any of the other forms of ketamine that I described, other than s ketamine or spravato are considered off label. So there are no specific parameters about what age limit there is. In terms of my personal comfort level, I feel more comfortable treating older adolescents. There was a Yale study that was published last year where the subjects they studied even went down to age 13. They were looking at kids ages 13 to 17, and saw really good safety and tolerability. And that study showed very promising results to in terms of the antidepressant effect. So I would be open to going down to age 13, but just would be more mindful about probably providing extra support, starting with lower dosing, and just monitoring really closely. That's a really helpful answer for me just as a PT Nutrition, I see a lot of teenagers who have tried a lot of options, and they're still feeling, unfortunately, some severe depression. So it's really nice to know, and to spread awareness that there is this option out there. Yeah, and I'm hoping that the awareness grows. It's disappointing. I think sometimes when I often get patients who just find us through googling about ketamine, they're not hearing about it from their psychiatrists. And so I'm hoping that there is continued spreading of awareness. So people know that they don't have to suffer for so long going on with medication after medication that's not working. There are other alternatives, and especially thinking about adolescence in that critical window of development. And what I see often when, when I'm seeing a youth who has been on a lot of medications is and isn't doing well. It's impacting their social functioning, it's impacting their school attendance, and it can set them back so far in terms of their life trajectory. So if this ends up being a treatment, that, that we study more that we see more benefit for the paediatric population, and that we start using it. I just think there's amazing potential to get kids back on track when they've been suffering, I find that a lot of youth, especially the teenagers, they if they don't get the relief that they can for their symptoms from their doctors from from, like, from their therapist, I worry that they look to self medicate. And I know that, you know, I feel like street drugs are not are not a safe way to go. And so I liked that there's another option to help people it is monitored by a doctor. It's just nice to hear about an alternative. Yes, and there is abuse potential with ketamine. It's known in the club scene or the rave scene as Special K. But when administered in an office setting like this, where it's very controlled, the doses we're using are much lower than what's being used in a more of an abuse context. It can actually help with treatment of addiction. There have been some studies that have come out showing that when ketamine is used for treating alcohol use disorder, that it can help decrease cravings, it can help people maintain sobriety. So it is so important though to have it administered under medical supervision and monitoring. Now, can you give advice to patients on how to find a quality location where they can get this kind of treatment? That is a very good question. I think a great resource to start with is the website for the American Society of ketamine physicians, psychotherapists and practitioners. And that's a s k p.org. And on that website, they have a lot of great resources, and they have a locator map where you can, I think you can type in your zip code or your state or you can hover over the map and find a practice or a physician who is associated with that organisation. And so that's one level of screening to say, who's out there who is tied to a reputable organisation that's probably involved in doing some continuing education. So that's a really good starting point. I also think it's important to look for medical settings where there is some involvement with a mental health professional. Ketamine has been administered and administered well by anesthesiologist ER doctors, other other specialties. But I think it's important to know do they collaborate with psychiatric professionals to make sure that the diagnosis is right to make sure that there's monitoring for suicidality, and that there's some sort of a continuing plan because ketamine is not the be all end all. It's just one slice of the treatment pie. And when someone is done with that, say, initial series of six treatments, you got to know what is the plan for that ongoing treatment and monitoring, whether it's treatment with medications or talk therapy, or looking at lifestyle factors like nutrition and sleep? You've got to make sure that you're working with someone who understands the importance of being plugged into a team and making sure that you have a mental health professional as part of that. I'm so glad you mentioned that because I agree wholeheartedly, you really have to think of these medications as a piece of the pie. But it can't be the entire focus of treatment. Right. Especially for lasting effects. Right. Exactly. Because we know with ketamine, like I was mentioning before there is this need for ongoing booster or maintenance treatments. So and most of the patients that come to us, yes, they may be on medications that don't feel like they're working. But once they've done the ketamine if they've seen benefit, then it's time to continue working. Usually with some degree of medicines. It may mean taking some away that aren't working any longer. Maybe it means retrying something. There is some anecdotal talk about whether people actually may respond better to medications after they've gone through successful treatment with ketamine. I don't have any evidence to back that up. But those of us that have been doing this for a long time there is that question about well, maybe trying medicine again, maybe it will work better this time. So just remembering that I mean, these are complex patients. So you have to have a very intentional, well thought out, all encompassing treatment plan where it's not just the ketamine, yes. No. What about what about patients that are moderately depressed? Would you ever recommend ketamine in that setting? I would, yeah. Because I mean, we see plenty of people who they're doing medication, they're doing talk, talk therapy, they may be even doing the lifestyle changes, and it's helped to some degree, but they feel like they're stuck. They're not making progress still. And in cases to where people have some sort of trauma that has gone on, whether it's early childhood, or somewhere in their adult life, that's another area where sometimes people are functioning. Maybe they're moderately depressed, but they're feeling stuck, like they can't move on. And the ketamine often helps people move forward in the progress with that. So yes, with moderate depression, I would still consider a treatment with with ketamine. Can you speak to any studies? Is there are there any evidence based studies out there that that show benefit from ketamine? Or is this still sort of a grey zone? Well, like I mentioned, ketamine is still a young treatment. Some of the early studies that came out were in the early 2000s, showing that there was potential benefit and an antidepressant effect. But in the last, I would say, I mean, I've been doing this regularly since 2016. And the research just continues to explode and continues to escalate. And which is so exciting, because for those of us that were early to get into the field, we were often calling each other sharing data, just trying to put together protocols that were consistent and evidence based. So yes, the research continues to grow. And I mentioned depression and PTSD as as main targets for ketamine. But there have been case studies showing some benefit in eating disorders patients. There have been some smaller studies showing benefit for OCD. So I hope we continue to see further research in those psychiatric conditions that we still see that treatment resistance where people aren't responding to meds or therapy, and they need help, and potentially ketamine may be useful. Also, the whole field of just psychedelic medicine and psychedelic psychiatry that's on the horizon is exciting, too. In terms of research that's emerging, any specific psychedelic medication that you see coming more to the forefront? Well, the two that I think were closest to seeing some sort of FDA approval for our MDMA, which is not a classic psychedelic, but it sometimes gets lumped in, like ketamine gets lumped in sometimes. But the studies for PTSD with MDMA are so promising, it's really exciting, because PTSD is one of the psychiatric conditions that we just don't see a lot of benefit with medications. And then the other one is psilocybin, or sometimes people call it mushrooms, magic mushrooms. But there are over 25 academic centres that have studies dedicated to psychedelic medicines. Right now. Academic centres like Johns Hopkins, and Johns Hopkins is studying psilocybin for treatment of depression, anxiety at end of life, smoking cessation, Alzheimer's, I think they have a Lyme Disease study that's going on. So it's I can't wait to see what some of the results are. Because there's such public demand and interest in this because there are so many people suffering. And I worry that the scientific studies and also the legal regulations are not keeping up with the public demand. And so I think a lot of people are thinking of going out and trying this, or they are going out and trying it because they're hearing about the potential benefit. But I want those studies. So we know more about safety. And, and also just thinking about ethics and standards. As we have these new treatments rolling out we have to make sure we do this right. So we don't see bad outcomes, and then a a withdrawal of support of these agents. No, I really commend you because I think doctors were not typically looking outside the box. And I think the way you're approaching this with safety ethics, but you're also pushing the boundaries a little bit for the benefit of patients. That's fantastic. Thank you. And I feel like we've kind of in the public discourse, we've just skipped right over ketamine to a lot large degree. I mean, you see articles in the news just about every day about psychedelics. And so I think that's what people are hearing about right now. And a lot of people don't realise that ketamine is here. It's been well studied, it's been around for decades. So we know it has a really good safety profile when it's used in the right setting with the right monitoring. And we know that it has potential benefit. But I think people are just kind of skipping right over it because psychedelics are kind of a sexy topic, and they're hot in the news. But ketamine is legal in all 50 states, it's available, so people should really think about giving that a try before waiting around, potentially for any FDA approvals on the other psychedelics. And I'm curious as you continue to use ketamine Do you see what are you noticing? Are you seeing a lot of successful outcomes? Do you have any stories you can share? Sure, I see a lot of successful outcomes. And I have to say, I think ketamine has become just the most exciting and promising part of my career. I've been in practice since 2008. And I just, I just love what we see with ketamine, because within that period of three weeks, or someone's doing six treatments, we can see such a turnaround in that time, which is so different from waiting for medications to take weeks to months to work for someone. I also do TMS in my practice for depression, that's transcranial magnetic stimulation. We see some great outcomes with that too. But the standard protocol is a nine week protocol. So again, you don't see that faster turnaround like, like we do with ketamine. But one one standout case that I think of at least with an adolescent was a girl, about 15 years old, had been unlocked on lots of medications. She had had a couple of inpatient hospitalizations and lots of ER visits for chronic suicidality and self harming behaviours. She was not really socialising much with friends, they were having a hard time getting her to school on a consistent basis. And so we did ketamine, and there was such a turnaround for her, her suicidal thoughts stopped, there was no more self harm. She said people at work noticed that she was more cheerful when working with customers, she started attending school regularly. And the feedback that I was getting from her parents to was that she was just doing so well, compared to how she had done before that initial series, and she now she continues to come back on a monthly basis. She is on a couple of medications, but she's just doing really well. And I see stories like that also in the adult population. And I see some really great things. On the trauma side, too. I think that's been one of the most amazing things that I see is people who have had such a negative impact in their life because of trauma that maybe happened during their childhood or adolescence. And then seeing that with ketamine, they're able to process that trauma or view it from a different perspective, that just gives them a renewed outlook, and an ability to either move beyond that, or see more progress in the talk therapy that they're doing, where they just weren't seeing the progress that they needed. It's amazing, almost they can talk with less, less inhibition. Is that what Yeah, I think it's it sometimes things will come up with the ketamine related to the trauma, but it doesn't have the emotional charge. And it doesn't induce that fight or flight response that so many people get primed with chronically, when they've dealt with trauma in their past. So that that is a really amazing thing that we see. And then with that, you know, if there is a breakthrough on the trauma side, there's usually an improvement in the depression and the anxiety. Also, if people see an improvement on the depression and anxiety side, they may feel like they're able to engage in their lives more and work out regularly, socialise with people leave their houses and make a trip to Costco or WalMart where maybe that had been impossible for a while so so those are the those are the details that we see that it's it's not just about symptoms that are listed on a rating scale, like the PHQ nine, it's what is happening in this person's life that they're able to function again and, and show up as the mom that they want to be for their kids or leave the house and engage with friends again. So we love seeing those stories. It sounds like for some people, you really are giving them their life back. It really does feel that way. And I sometimes wish that you know in psychiatry you don't think of having before and after pictures, but it's almost like we see a change and how people look physically when the light comes back to their eyes or when there's just a brightness about them again That's a really awesome thing to see, too. That that is, that is so awesome. And I'm, it's really it's so it's so nice to be educated on this subject because you're making my you're opening my mind so hopefully can help spread awareness. And lastly, just in terms of side effects, I know you mentioned who, who can't get ketamine and I know you mentioned that for some people it brings to the surface some dark thoughts, are there any other side effects that that people should be aware of when it comes to ketamine treatments? Yes, so nausea and vomiting are the most common side effect. So we do ask people to fast, usually for four hours before IV, two hours if it's before the intranasal ketamine treatments, and we do use some anti nausea medicines to support people, we try to ask on the front end if they've had nausea if they've had surgeries or anaesthesia in the past, or if they have a history of motion sickness. And so if that's the case, then we'll use some of those anti nausea medicines on the front end to try to prevent that side effect. And then it is a normal, effective ketamine to raise blood pressure during the treatment. And that's usually not a problem for people who don't have a history of high blood pressure. But for those who do, they just need to make sure that their blood pressure is well controlled, and that they're taking their medicine on days when they're having a treatment. And in terms of that psychiatric piece, and dark things coming up, I try to assess on the trauma side, if people have experienced a lot of trauma, is it something that they have worked through to some degree in therapy, if so, then we just proceed a little more carefully, I usually start off with a lower dose on the ketamine and just really make sure that they feel supported coming in. One thing I didn't really touch on too, with ketamine and other psychedelic medicines is the importance of set and setting. So set is mindset mindset coming in to the treatment is so important. And so I tell people things like make sure in the few hours before you come in for a treatment that you stay away from content that you know, tends to hijack your emotions in a negative direction. So don't take a work email or phone call right before you come in. Stay off of social media, don't be checking news headlines. So kind of create a bubble because when people come in anxious and fixated on something that has a tendency to get magnified within the treatment. And then the setting piece is what we try to create for people. So our treatment rooms have dimmed lights, Minimal Stimulation, we use that I shade the music just to try to create a setting that that sets people up for success and a really great therapeutic outcome. So sorry, if that was an old version, I would ask but I'm thinking even just taking just taking newsbreaks. And staying off of anxiety provoking thoughts is a good a good tip in general. I think so. And then I tell people afterwards, because of that window of neuroplasticity, we want to expose the brain to positive content. So one thing is that people can't drive for the rest of the day after they've had a treatment. So that is another precaution that we have in place. But I tell people use that time after a treatment to do positive things for your mental health. So go for a walk, spend time in nature. Be around positive friends or family spend time with pets, journaling, listening to music, listening to inspirational podcasts, just keeping things light and on the positive and inspirational side. I think that makes a lot of sense for that window of increased learning and neuroplasticity. Amazing and tell us where can people find you. I know you're opening up a new clinic in Bozeman, Montana. Tell us about what you're doing with with spreading awareness and getting ketamine treatments happening. Yeah, well, I'm trying to spread awareness within my community and region of Billings, Montana. We're opening a location in Bozeman and we're looking at other Montana and Wyoming locations. But people can find me on Instagram and Tiktok. It's Aaron Amato, MD, I'm trying to put some content out there so people can learn more about these treatments and other things that are on the horizon. Same thing, Facebook Erina, Moto MD. And, yeah, and in doing podcasts like this, and just public speaking, I think that's the way to get the word out. I've been doing some TV spots with some morning news shows across the country. And and I've gotten some interest lately from producers that want to take this message about ketamine to their audiences. So that's exciting. Well, congratulations and well deserved. Thank you. I appreciate it. Thank you for coming on. It was really, really, really fascinating and thank you for sharing all your knowledge. Well, I'm happy to do it and thank you for the work that you're doing with with spreading so much good content for parents and caregivers. Hey everybody. Thank you for tuning in to this week's episode of Ask Dr. Jessica. Now if you're enjoying this podcast, I would be so grateful if you would take the time to leave a five star review and share it with some friends. It all really makes a difference to help this podcast grow. See you next Monday.