Phases of care with Ember Health
Our objective is to help each patient craft individualized care plans that map to their unique needs. This requires setting expectations about what care looks like over time to achieve treatment goals.
We deliver care across four distinct phases, outlined in greater detail below.
Intake
Most of our patients (60%) learn about Ember Health through a trusted mental health practitioner. Another 20% hear about us from a friend or loved one, and another 20% of patients find us through independent research.
The first step for any of these individuals is a 20 minute intake call with one of our doctors which they can easily schedule via our online booking link. In an effort to reduce barriers to care, we do not charge for that call. This conversation serves two purposes: the patient shares more about their situation so that we can assess whether we believe treatment with Ember is the right clinical fit; we share more about how we understand ketamine to work in addressing depression, and the model of care we’ve established at Ember.
If the patient has a clear diagnosis of depression as affirmed by a licensed mental health professional, and is interested to move forward with care, we send them information to book and request connection to their mental health team. We will only start working with patients for whom we have an established connection with at least one mental health provider who can confirm their depression of diagnosis, and who agrees to collaborate with us in our shared patient’s care.
If the patient is working with a mental health team or provider, but is unclear whether they have a diagnosis of depression, we reach out to their providers to better understand their background, and assess together whether they are an appropriate candidate for treatment with us.
If the patient is not working with a mental health provider, but would like to move forward with care at Ember, we may recommend a set of trusted provider partners who they may consider working with. We will only work with these individuals pending the establishment of a mental health team who has outlined a clear diagnosis of depression.
All patients who are clear to book and move forward with our care select one of our clinical locations for their foundational series.
Foundation
The foundational course of care at Ember includes a thirty-minute in-office orientation conversation with a Clinical Director, followed by four infusions over two weeks in the same location. We instruct patients to schedule at least 1 calendar day between each of their four infusions.
The orientation visit offers patients the opportunity to meet our team, see our space, and better understand what they can anticipate in their upcoming care. We introduce the concept of intention setting and ritual creation which will be a core part of each infusion experience. We describe the themes we often hear patients discuss in relation to the altered state of consciousness. We address any outstanding questions or concerns. We provide the patient with a packet of resources to help them get the most from their care.
With rare exceptions, the Clinical Director on site (MD) runs the first foundational infusion. This is a standard 90-minute appointment, and can often be among the most psychologically intense. See here a more in-depth description of the in-office patient experience. At the conclusion of the fourth infusion, we set clear expectations about what comes next, and schedule an evaluation check in call two weeks later with the Clinical Director and patient to assess results.
We capture PHQ-9 data multiple times throughout the foundation of care so that we can have an objective measure of how well treatment worked for each patient. We solicit qualitative input from each patient and their provider team. There are a few ways we may collectively recognize that ketamine is working. Specifically, patients:
Feel motivated to do small tasks they may have put off for weeks (e.g. respond to emails or clean out their closet)
Are open to the kinds of activities and engagements that have felt overwhelming (e.g. attending a party, catching up with a friend)
Aren’t feeling weighed down by the normal negative thinking cycles
Are better able to manage external stressors and obstacles that once felt paralyzing
Aren’t expending energy trying to block out certain memories or traumas - they don’t feel terrifying anymore
Feel more present in relationships (e.g. while caring for a loved one)
Are finally “getting” what their mental health team may have been telling them for years
Following foundational treatments, 90% of the patients we have worked with have experienced noticeable relief of their depressive symptoms. See here a more in-depth write up of our assessment process, including the critical role our provider input plays. Every patient who realizes treatment success after the foundation enters into what we refer to as the “Learning” Phase.
Learning
We expect that patients will need to come back at increments over time for what we call “booster infusions” to maintain their improved mood established in the Foundation. This is because exposure to stress and trauma over time will prune back the neural growth stimulated by ketamine treatments (see here as reference our article on how ketamine works for depression). While depressive symptoms begin to return an average of six weeks following foundational care, some patients experience the return of symptoms as soon as two weeks, and others can go several weeks or even months feeling depression free.
At Ember Health, we aim to deliver individualized, evidence-based care, which only has patients coming in as often as they need to in order to achieve their mental health goals. The Learning Phase is therefore a critical time for us to learn each patient’s:
Depressive Signs & Symptoms: The tell-tale signs that the patient’s depression is returning, as this can look different from person to person.
Treatment Durability: The typical length of time between a session and the return of depressive symptoms for that individual.
During the Learning Phase, it’s especially important that the patient and their broader mental health team pay close attention to how the patient is feeling. Ember Health sends all patients mood PHQ-9 surveys every two weeks and closely monitors the results, which will inform our recommendations for when to come back in for boosters. Each patient’s broader mental health team also plays a critical role in identifying the return of depressive symptoms.
When the positive effects of treatment begin to wear off, the depressive symptoms that return are based on what felt difficult for each individual before treatment started. While signals will therefore be unique to each patient, some examples include:
Finding it harder to motivate around simple tasks
Not feeling as much joy from the simple pleasures
Noticing the return of the inner critic
The majority of our patients book follow up care once they start to feel depressive symptoms returning. We call this “symptom driven” care. We advise patients to receive a booster infusion within a week of the return of depressive symptoms in order to maintain the emotional baseline established in the foundation.
If patients wait too long to come in once depressive symptoms start to return, there is a chance a single infusion will not be enough to restore the baseline achieved in the foundational series. When this is the case, we recommend what we call a “rescue visit” which is a second, follow up infusion after a booster. If enough time lapses and the patient is in an especially difficult state, we might together opt to restart a “series” which is four infusions over two weeks.
To avoid such a depressive slide altogether, some patients prefer to pre-schedule follow up infusions in the Learning Phase at increments recommended by their care team at Ember, while they are learning their patterns and needs. We called this “pre-scheduled” care.
For patients who prefer the security of booking their next set of visits, we have clear, evidence-driven protocols for establishing a set cadence that will help us learn their patterns and needs.
Our shared objective for all patients is to provide as much stability of mood as possible as we learn needs and patterns, while also ensuring the least financially and logistically burdensome care plan possible. Our provider partners serve as critical collaborators in the process.
Maintenance
Patients enter into what we call the “Maintenance Phase” when we have collectively learned enough about this person and their response to ketamine over time to provide clear, actionable clinical direction for future care. The overall objective of Maintenance is to create stability of mood for patients over the long term.
For patients who never establish a clear cyclicality, visits to Ember may involve coming to Ember in a symptom driven way, now that they have learned about the warning signs that trigger the need for infusion care.
For patients who have demonstrated a clear cyclicality of symptom return, maintenance will likely entail booking infusions at a consistent cadence, just before the typical onset of depressive symptoms for that individual. For example, if a patient’s symptoms consistently return every eight weeks, we will advise scheduling treatments every seven weeks to catch them before their mood changes.
External events and circumstances (e.g. death in the family, divorce, job loss), may trigger depressive episodes early, before regularly scheduled boosters. We are always here as a resource if patients feel they need help building strength and resilience to cope with the stressors of life.
Taking advantage of improvements to make structural changes in life can increase the spans of time between patient visits. Committed to a personalized approach, we will continuously work with you and our shared patient to adjust the care plan based on bespoke needs and goals.
There is good published data showing the effect of IV ketamine treatment over the course of multiple years. See here a review of the topic from Lancet Psychiatry. We've found this to be true in our care at Ember, having treated several patients effectively for the past five years that we have been operating. We've found no change to recorded side-effects in that time. This has required patients to be in continuous care with us, coming in for treatment on a semi-regular cadence in accordance to the return of depressive symptoms. If someone stops care for a long enough period, they will be just as likely to enter a depressive episode as they were prior to starting ketamine.
Please reach out to your Ember Health clinical team if you ever have questions about how to help our shared patients gain the most from their care.