Blog - Western State Hospital Internship Program

Skills System Training!

Posted on October 30, 2015 by Susan Vaught

What do you do when you have patients who could really benefit from Dialectical Behavioral Therapy, but they can’t read, or have much lower intellectual capacity and can’t learn some of the bigger words and concepts, or have interference and challenges like active psychosis?

You call Dr. Julie Brown and learn about The Skills System—-“an emotion regulation system for ALL learning abilities!

We can attest that the principles are simple, straightforward, easy to learn, and applicable even for people with moderate intellectual disability. Dr. Brown was kind enough to pay Western State Hospital and WKPIC a visit, and to train psychology, social work, therapeutic recreation, Recovery Services, and all levels of nursing staff for an entire day.

We hope to use The Skills System to benefit patients with multiple hospitalizations due to emotional regulation issues related to chronic mental illness.

Posted in Blog, Continuing Education, General Information, Resources for Interns | Tagged DBT, Dr. Julie Brown, emotional dysregulation, intellectual disability, severe mental illness, The Skills System | Leave a comment

Friday Factoids: Challenges in Serving Rural Areas

Posted on October 9, 2015 by Susan Vaught

Mental health disorders cause more disability and suffering in rural areas of our country. The presence of high rates of depression, domestic violence and child abuse creates increased risk for behavioral health issues. In addition, rural areas have higher rates of abuse of alcohol, tobacco, opiates, meth, inhalants, marijuana and cocaine. Suicide attempts and deaths by suicide occur more often in rural settings, with the rate of deaths by suicide running as much as 300% higher than an equivalent urban sample in some areas. Reasons for these disparities are certainly complex, but can be summarized under three primary categories: accessibility of mental health treatment, availability of services, and the acceptability of receiving services in rural culture.

Accessibility to services is a complex problem that rural health providers are attempting to address. Rural residents are likely to live further apart from one another, further away from services, and have less access to transportation. Telehealth is one recent technique being used to address some of these issues but it must be considered that due to the higher poverty levels in rural areas, some people may not have access to the technology required to receive telehealth in their home. The prevalent rates of domestic violence could provide a significant barrier for the use of telehealth in such situations. Many community mental health agencies provide i- school services in order to overcome some accessibility problems. Additionally, some rural mental health centers are creating “hubs” for telehealth services, but continue to struggle with transportation to get patients in need to these hubs for sessions.

The availability of services is limited in rural areas. A major problem in service provision is a relatively low number of doctoral level psychologists, coupled with high turn-over rates for any degreed professional attempting to practice in rural areas. Structured treatment locations are even more limited. Treatment centers for substance abuse or inpatient mental health can frequently be 1-4 hour commutes each way, and the lack of the availability of services closer to home may create an unbearable financial hardship due to time away from work, transportation costs, and childcare. Additionally, rural residents may have been aware of their behavioral health difficulties but unable or unwilling to access far away services until a crisis has occurred. This same pattern exists in accessing medical services as well, but less stigma is present in seeking medical versus psychological help. As such, treatment facilities that have a rural catchment area tend to have higher levels of acuity than urban centers, and thus face working with more urgent and challenging patients and conditions with minimal resources.

Finally, as mentioned, there is a lower rate of acceptability of mental health services by many rural people. While there have been recent gains made in decreasing mental health stigma, rural areas lag behind urban environments in understanding and accepting mental health issues.

A potential solution to some of these troubling difficulties may be integrated health clinics. Since medical services are more socially acceptable to rural residents, why not address accessibility and stigma by providing medical and mental health services under one roof? This lessens the patient’s anxiety about being identified by others within their community as receiving mental health services. Also, since medical and mental health issues interact and tend to exacerbate one another, approaching patients more holistically may serve to decrease both mental health and medical crises, and reduce overall acuity levels.

An additional hurdle is that many clinicians lack training in rural cultural competencies. Creative ways of working in rural communities are needed at graduate, practicum, and internship levels—and solutions may vary from community to community, needing specific approaches. Community mental health models that work well in urban environments may not be feasible in rural areas, so clinicians need to take a “troubleshooting” approach in the rural area they wish to serve.

Solutions to the barriers to mental health care in rural areas can be identified and developed. Most importantly, all mental health services need to be tailored to the culture and way of life of the rural area being served.

References
Smalley, K. B., Rainer, J., & Warren, J. (2012). Rural Mental Health : Issues, Policies, and Best Practices. New York: Springer Publishing Company

Rain Blohm, MS
WKPIC Doctoral Intern

Posted in Blog, Continuing Education, Current Interns, Friday Factoids, Resources for Interns | Tagged acuity in rural areas, psychiatric services in rural areas, treating illness in rural areas | Leave a comment

Friday Factoids: Hoarding Disorder

Posted on October 2, 2015 by Danielle McNeill

Hoarding Disorder (HD) has been in the media spotlight. HD is a new psychiatric diagnosis added to DSM-5 in 2013. I have heard others ask in casual conversation “why would someone do that?” While this may sound like an answerable question to some, research has just begun to touch on the complexities of this disorder.

The DSM-5 describes HD as a “persistent difficulty discarding or parting with possessions, regardless of their actual value.” Patients suffering from HD often have co-morbid psychological conditions such as depression, substance abuse, Attention-Deficit/Hyperactivity Disorder (ADHD), obsessive-compulsive personality disorder, and schizophrenia. While middle aged and elderly people are more likely to be diagnosed with HD, many patients report their symptoms began in late childhood or adolescence. Trauma and other significant stress may not be a cause of HD but can significantly exacerbate it. Hoarding seems to follow a pattern of slow and insidious symptoms starting in late childhood, and then accelerating after age 40. Every patient with HD is unique but categories of some items seem to occur more frequently. Paper items such as newspapers, magazines, books and junk mail are frequently stacked in the home. Various types of containers such as food containers, boxes and bins may be present. “Freebie” items are sometimes sought after and stored in excess. Food, clothing and kitchen items are a prevalant category of items. Broken items that a patient with HD feels may be repaired “someday” may be difficult for the patient to part with. Some items pose a higher sanitation and health risk. Rotting food, urine, feces, or used toilet paper may be a primary issue for the patient. Subsets of patients with HD keep large numbers of animals as pets. The patient may feel they are providing adequate care to their pets despite the presence of feces, urine and a large number of animals in poor condition present in the home.

While a higher number of patients with HD are identified in urban areas, those in rural environments are more likely to die from problems in their environment. One theory about this disparity is that HD is identified more quickly in urban areas due to the complaints of neighbors regarding sanitation problems. Patients who are residing in a more isolated environment may not come to the attention of authorities until there is EMS contact for fire, injuries from falling items, the patient falling, or other medical crises. Patients with HD report a higher number of chronic medical conditions with less medical care contacts than those of the same age. There seems to be a cluster of medical illnesses occurring at higher rates and younger than average age. Obesity, hypertension (HTN), diabetes, lung disease, and obstructive sleep apnea (OSA) are a cluster of problems that seem to be more prevalant for these patients. Neurological problems such as stroke, dementia, seizure disorder and traumatic brain injury are reported more often by patients with HD. More systemic disease processes such as Systemic Lupus Erythematosus (SLE), and Fibromyalgia seem to be somewhat more prevalant. Researchers have begun to examine the genetics of HD. The presence of HD and Obsessive-Compulsive Disorder (OCD) seem to be more prominent in some families.

Treatment of HD has proven difficult for mental health professionals. Research in this area is urgently needed. HD accelerates with age so mental health professionals are likely to see more cases of this disorder as the number of older adults increases. Some patients have poor insight and can seem oblivious to their plight. Many describe themselves as “thrifty” or “saving things” for others should a need arise. Drastic interventions, like a forced clean-up of the home, have been shown to significantly increase the risk of suicide. Questions linger over what point hoarding behavior may constitute a danger to self, requiring involuntary hospitalization. HD seems to have a very high relapse rate with current treatments of SSRI medications and Cognitive Behavioral Therapy. Case management with routine home visits proved to be of benefit but legal and ethical dilemmas are present in this form of treatment. HD seems to be a condition of equifinality, meaning there are many paths involved in the earlier question of “why someone would do that.”

References

Ayers, C. R., Iqbal, Y., & Strickland, K. (2014). Medical conditions in geriatric hoarding disorder patients. Aging & Mental Health, 18(2), 148-151. doi:10.1080/13607863.2013.814105

Bratiotis, C., Steketee, G., & Schmalisch, C. S. (2011). The Hoarding Handbook: A Guide for Human Service Professionals. Oxford: Oxford University Press.

Drury, H., Ajmi, S., Fernandez de la Cruz, L., Nordsletten, A. E., & Mataix-Cols, D. (2014). Caregiver burden, family accommodation, health, and well-being in relatives of individuals with hoarding disorder. Journal of Affective Disorders, 159, 7-14. doi:http://dx.doi.org/10.1016/j.jad.2014.01.023

Saxena, S. (2007). Is compulsive hoarding a genetically and neurobiologically discrete syndrome? Implications for diagnostic classification. The American Journal of Psychiatry, 164(3), 380-384. doi:http://dx.doi.org/10.1176/appi.ajp.164.3.380

Rain Blohm, MS

WKPIC Doctoral Intern

Posted in Blog, Current Interns, Friday Factoids | Leave a comment

Friday Factoids: The Search for Causation of Autism Spectrum Disorder

Posted on September 25, 2015 by Susan Vaught

With the diagnosis of Autism Spectrum Disorder (ASD) on the rise, professionals and parents from all walks of life have been increasingly steadfast and diligent in their research and support for families and people contending with these issues. One of their goals is to find a suitable treatment for the millions who currently experience difficulties, that would greatly reduce or permanently eliminate symptoms of the often debilitating disorder. Another main focus for many is the development of preventative guidelines or an inoculation that would drastically reduce the number of sufferers who develop ASD.

To achieve any of these goals, it is imperative that we understand the root cause(s) of ASD. Scientist and medical professionals have been testing hypothesis after hypothesis but have yet to discover the origin of the disorder. Medical Science and families were hopeful when the announcement was made that the prevalence of ASD in the Amish Community was 0%. Unfortunately, we now know this information is inaccurate, but not all hope has been lost. Research data obtained from 1899 Amish children ages 3-21 years was collected. The results proved that the disease does in fact exist in the Amish population at the rate of approximately 1 in 271 children. This is a significantly reduced rate when associated with the national average of 1 in 68 children today in the U.S. It’s a comparison of .0037% to .0147% but what does that mean for explorations of causation?

Research into how Amish Communities differ from everyday society is currently being conducted. The lack of radiation, radio waves, and gamma waves is being considered, as well as a comparison of the amount of artificial ingredients, preservatives and hormones added to the processed, manufactured foods ingested by most Americans. Another area being looked at is the number of chemicals we are subjected to through use of common household products including shampoos, household cleaners and pesticides. Since the Amish have no religious objections to vaccines, with many getting them as recommended by the CDC guidelines, inoculations can be ruled out. Future research should test for ASD in remote populations. A comparison can then be made with the percentage of incidence with the data obtained from the Amish Community in hopes of finding a correlation or pattern.

Reference
Reynolds, A. (n.d.). Combating Autism from Within: Guess what? The Amish vaccinate! Retrieved September 20, 2015, from http://combatingautismfromwithin.blogspot.com/2008/01/guess-what-amish-vaccinate.html

Robinson, J., Nations, L., Suslowitz, N., Curraco, M., Haines, J., & Vance, M. (2010, May 22). Prevalence Rates of Autism Spectrum Disorders Among the Old Order Amish. Lecture presented at International Meeting for Autism Reseach in Franklin Hall B Level 4 (Philadelphia Marriott Downtown, Philadelphia, PA.

Crystal K. Bray, BS
WKPIC Doctoral Intern

Posted in Blog, Continuing Education, Current Interns, Friday Factoids, Resources for Interns | Tagged Amish, Autism Spectrum Disorder, Causes of Autism | Leave a comment

What is being in “Recovery”?

Posted on September 23, 2015 by Susan Vaught

I talk a lot about “recovery” as a Peer Support Specialist, as do many in our place of work. We have a “Recovery Mall,” but defining recovery is difficult. It means so many different things to different people. Each individual has his or her own goals. My recovery may seem too simplistic or too grandiose. It also depends on from what we are recovering. What does that even mean?

The working definition from the Substance Abuse and Mental Health Services (SAMHSA) is at the bottom of my email messages: “Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” No matter what organization, governmental or grassroots, the definition has similarities. The running theme is that the person is able to control his or her own life. He or she takes charge of their own wellness and reaches toward goals. It is a process though, not a clear destination that can just end. It’s also definitely not a straight line from point a to b. To borrow from the Beatles, “It’s a long and winding road.”

Recovery is a journey for which each of us must arrange our own transportation. We can’t have our hands held the entire way. At some point, it is a decision. Once a spark of hope is ignited, a person goes from being constantly helped, to taking charge of their life. That was my recovery point. I spent years being helped; I went to my doctors and dwelled on my illnesses. I identified so strongly with my illnesses, that my identity was lost. Once I decided to cross over from being a consumer of services, to providing services, I could say that I believed I was on the road to recovery from my mental illnesses. The road never ends though.

Igniting that spark of hope is the premise of Peer Support. That is what hundreds across the state, mostly in a volunteer role, are trying to do for others. Peer Support is now known as an essential tool in the recovery process.

Rebecca Coursey, KPS
Peer Support Specialist

“Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” SAMHSA

Posted in Information About Peer Specialists, Resources for Interns | Tagged Being in Recovery, Definition of Recovery, Recovery, SAMHSA | Leave a comment

Friday Factoids: Comparative Psychology

Posted on September 18, 2015 by Susan Vaught

According the Oxford Dictionary, psychology is “the scientific study of the human mind and its functions, especially those affecting behavior in a given context,” Many professionals in the field today would generally provide the same roundabout information if asked. However, with the inclusion of Comparative Psychology, many dictionary and professional definitions will have to be updated.

Comparative Psychology is the relatively new branch of psychology that focuses mostly on the study of purposes and perceptions of animal behavior, or non-human behavior, which is causing all sorts of controversy. Its validity is a hot button topic amongst professionals in both psychology and veterinary medicine as well as the layman dog owner. Some mental health professionals fear that acknowledging or including Comparative psychology as an accepted branch would harm the forward progress and positive public perception that they, and those before them, have fought so diligently to obtain. Others, however, argue that as with the evolution of all social and physical sciences, psychology too must grow and change when new facts come to light so as to continue to be relevant and beneficial to those it serves.

The number of practicing Comparative Psychologists in the U.S. is extremely low but each up-coming semester hosts the potential to graduate more to the field. It is growing in popularity. To date, this writer was not able to locate any state or federally mandated list of requirements for individuals practicing as Comparative Psychologists. Therefore, it is very important that consumers be aware of the actual degree held by the individual of whom they seek these services. Any degree or field of study outside of a PhD./PsyD. in Animal Behavior or Comparative Psychology would be seriously suspect and should be questioned since the field is still in its adolescent years with a limited number of qualified, practicing professional.

References

Definition of psychology in English:. (n.d.). Retrieved September 14, 2015, from http://www.oxforddictionaries.com/us/definition/american_english/psychology

Hauber, M. (n.d.). Animal Behavior and Comparative Psychology. Retrieved September 14, 2015, from http://www.gc.cuny.edu/Page-Elements/Academics-Research-Centers-Initiatives/Doctoral-Programs/Psychology/Training-Areas/Animal-Behavior-and-Comparative-Psychology

ISCP. (n.d.). Retrieved September 14, 2015, from http://comparativepsychology.org/index.html

Crystal K. Bray, B.S.
WKPIC Doctoral Intern

Posted in Blog, Current Interns, Friday Factoids, General Information, Resources for Interns | Tagged animal behavior, comparative psychology, psychology fields | Leave a comment

Article Review: Impact of Person-Centered Planning and Collaborative Documentation on Treatment Adherence (Stanhope, Ingoglia, Schmelter, & Marcus, 2013)

Posted on September 16, 2015 by Susan Vaught

Purpose
Mental health providers are faced with the challenges of completing quality documentation on time, building a therapeutic alliance, and managing a client’s treatment compliance. Stanhope, Ingoglia, Schmelter, and Marcus (2013) examined the impact of person-centered planning and collaborative documentation on service engagement and medication adherence within community mental health centers (CMHC). As part of person-centered planning, collaborative documentation is being explore as a tool that works to benefit the agencies and clients by ensuring treatment services appropriately reflect the client’s values and preferences and that documentation is completed in a timely manner.

Background
Stanhope, Ingoglia, Schmelter, and Marcus (2013) emphasized there are challenges clinicians experience with lack of engagement in mental health services among people with a mental illness. Contributing factors to disengagement from services include mistrust in the mental health system, poor alliances with providers, a perception that providers are not listening to them, and inadequate opportunities to make decisions and collaborate in treatment. Mental health agencies are starting to place an emphasis on transparency and utilizing a collaborative approach to documentation so that it represents a true reflection of the treatment session.

Historically, clinicians have viewed documentation as “the enemy” because it competes with time spent with clients and many rely on “no-show” appointments to complete paperwork. Collaborative documentation can be used as a clinical tool in completing assessments, treatment plans, and progress notes together with clients during the session. This method offers clients with the opportunity to share their input and perception on services that were provided. Additionally, it allows clients and clinicians to explore important issues, clarify any misunderstandings, and focus on progress.

According to the researchers, person-centered planning is defined as “a highly individual comprehensive approach to assessment and services.” This treatment approach allows providers to collaborate with clients to develop customized treatment plans that identify life goals and potential barriers. Person-centered care is a structured way of organizing treatment that focus on making continuous use of strengths-based assessment strategies, recognizing appropriate supports, and empowering clients to be active participants. During this study, researchers looked to determine whether person-centered care planning combined with collaborative documentation improved service engagement and medication adherence among clients at ten geographically diverse community mental health centers (CMHCs).

Methodology
This study was a randomized controlled trial of person-centered care planning with collaborative documentation among clients receiving services at ten CMHCs. Five CMHCs were randomly assigned to the experimental condition, which provided training in person-centered planning and collaborative documentation to agency clinicians. The five CMHCs in the control condition provided treatment as usual. The study period was 11 months (May 2009 to March 2010).

For clients to be eligible for this study, participants were required to be aged 18 or older, have had one or more psychiatric hospitalizations or two or more psychiatric emergency room visits in the past year, have a DSM-IV axis I diagnosis, and meet at least two functional criteria of severe mental illness. Altogether, 177 clients at the CMHCs in the experimental condition and 190 clients at the CMHCs in the control condition participated.

The first aim of this study was to compare changes in the overall rate of clinician-reported medication adherence between clients in the experimental CMHCs and clients in the CMHCs in the control group. The provider who was best able to determine a client’s medication adherence rated adherence (yes or no) on a monthly basis for 11 months. For the second aim, client-level analyses were conducted separately for CMHCs in the experimental and control groups to examine whether the odds of medication adherence changed over time. Finally, logistic regression models, including a random effect for site, were run to calculate the effect of the intervention on the odds of an appointment no-show. The models used data received from each CMHC on the total number of appointment no-shows and the total number of appointments.

Conclusion
Results indicate the intervention had a positive impact on medication adherence over time. Medication adherence at CMHCs in the experimental condition increased by 2% per month over the 11-month period (B=.022, p≤.01). The control condition showed no significant change in rate of medication adherence (B=.004, p=.25), and by the end of the study, the rate of medication adherence for the control condition was lower than for the experimental condition.

In the client-level analyses, the odds of medication adherence over 11 months increased by 25% among clients in the experimental condition but by only 1% among clients in the control condition. An intervention effect generally was seen across client-level characteristics. Medication adherence over the 11-month study among clients with schizophrenia and bipolar disorders was significantly more improved at CMHCs in the experimental group.

Overall, the study found that person-centered planning and collaborative documentation were associated with greater engagement in services (a decrease in no-shows) and higher rates of medication adherence. Therefore, the study findings supported the theory that if clients have greater control over their treatment and services are genuinely oriented toward their individual goals, clients will be more engaged with services and more compliant with medication.

References
Stanhope, V., Ingoglia, C., Schmelter, B., & Marcus, S. (2013). Impact of Person-Centered Planning and Collaborative Documentation on Treatment Adherence

Psychiatric Services, 64 (1), 76–79.

Jonathan Torres, M.S.

WKPIC Doctoral Intern

Posted in Blog, Current Interns, Mental Health and Wellness, Resources for Interns | Tagged collaborative documentation, community mental health, medication adherence, recovery model | Leave a comment

Friday Factoids: Promising Long-Term Treatment for PTSD

Posted on September 11, 2015 by Susan Vaught

Post-traumatic stress disorder (PTSD) can result from being the victim or witness to a number of traumatic events including war, an automobile accident, physical abuse, assault, homicide, and other difficult or devastating experiences. It is an equal opportunity disorder and affects men, women, and people of all cultures similarly. In the United States, PTSD has been thrown into the limelight due to the number of service men and women who are returning from active duty with this condition. The current publicity around PTSD has left many in the medical and mental health fields looking to and for variations of treatment in hopes of finding more effective, longer-lasting methods to treat this illness.

One of the more promising treatments, currently in Phase 2 of 3 in testing, is MDMA-Assisted Psychotherapy. MDMA (3,4-methylenedioxymethamphetamine) is a psychedelic, synthetic substance noted for its capability to help patients delve into their excruciating memories. The drug reportedly facilitates trust and compassion between the patient and therapist, all the while greatly reducing the patient’s feelings of defensiveness and terror while in session. It is believed that MDMA is able to offer this therapeutic safe haven by stimulating the release of hormones (prolactin and oxytocin) linked to bonding and trust which comforts the patient and reduces symptoms of avoidance and panic.

According to the research data, an astounding 83% of participants who received the treatment no longer met the guidelines for PTSD while in Phase 2 of the study. Additionally, many of those participants reported the results lasted 3 ½ years or longer. So, why is this treatment not already approved and readily available for those who so desperately need it?

One potential answer to that question could be the stigma surrounding MDMA. Most all of you have heard it referred by it street names of “Molly” or “ecstasy.” And given so, some will not be comfortable using it as an aid during therapy even in a controlled setting providing such positive, long-term results. Secondly, the cost and time frame for each individual trial is fairly massive. The End of Stage 2 meeting is estimated to take an additional 3 years and $2.3 million before presenting results to the FDA. Afterwards, Stage 3 is speculated to have a price tag of $15.8 million and spanning 5 years until the treatment is fully available for use with the public.

References
MDMA-Assisted Psychotherapy. (n.d.). Retrieved September 9, 2015, from http://www.maps.org/research/mdma

Treating PTSD with MDMA-Assisted Psychotherapy – Home. (n.d.). Retrieved September 8, 2015, from http://www.mdmaptsd.org/index.html

Crystal K. Bray, B.S.
WKPIC Doctoral Intern

Posted in Blog, Current Interns, Friday Factoids, Mental Health and Wellness, Resources for Interns | Tagged MDMA, methylenedioxymethamphetamine), PTSD | Leave a comment

Friday Factoids (Catch-Up): Special K–Are There Any Positives?

Posted on September 11, 2015 by Susan Vaught

It was not the beginning of the zombie apocalypse that we were witnessing on the news a couple of years ago. Believe it or not, it was worse. Apparently, possible consumption of human flesh is one of the many unwanted side effects of abusing the anesthetic, Ketamine. “Special K”, as it is known on the streets, underwent a transformation into the new party drug, and it has been taking its place alongside opiates, benzodiazepines, and marijuana with teens and twenty-somethings since about 2010. Since that time, this once surgically “essential” and publically unknown drug has been drawing vast amounts of negative media, criminal and medical attention—but are there any positives associated with this drug?

Recently, scientists, mental health and medical professionals have discovered that medically controlled doses of Ketamine are very beneficial in treating Major Depressive Disorder and Bipolar Disorder. Yes, the same medication approved as an anesthetic in 1970, the same drug that has been abused to get high since the 2010’s, is providing evidence-based results that it does, in fact, reduce depression and regulate mood. Studies have shown that it produces significant results within a matter of minutes to hours instead of 2-3 weeks, which is the window within which standard pharmacological treatments for mood typically show benefits. Additionally, patients suffering from suicidal ideation who were treated with a “medically controlled dose” of Ketamine (medically controlled dose being key) reported their symptoms drastically reduced in 40 minutes, with gains lasting about 4 hours. Clinics around the U.S. are even currently treating patients suffering from depression and mood disorders using controlled amounts of Ketamine (yes, this is legal).

So Ketamine does appear to have some positives with respect to potential uses in the treatment of both unipolar and bipolar mood issues. It potentially provides treatment results, time frames and options for practitioners and patients, but the key appears to be the controlled dosing.

Reference
DiazGranados, N., Ibrahim, L., Brutsche, N., Ameli, R., Henter, I., Luckenbaugh, D., . . . Zarate, JR, C. (n.d.). Rapid Resolution of Suicidal Ideation after a Single Infusion of an NMDA Antagonist in Patients with Treatment-Resistant Major Depressive Disorder. J Clin Psychiatry., 71(12), 1605-1611. Retrieved September 7, 2015, from https://nebula.wsimg.com/5f3b6cc5e31881bab9f0fb5d070d35d2?AccessKeyId=98358B1A7BDF604FD210&disposition=0&alloworigin=1

Ketamine Facts, Effects and Treatment | Ketamine Clinics – Los Angeles, CA. (n.d.). Retrieved September 9, 2015.