Ziv Ezra Cohen, M.D.

Copyright Principium Psychiatry, PLLC. All rights reserved. 

Manhattan TMS 

Estelle Autissier, RN

Is the treatment FDA approved?

Estelle Autissier, RN

Can I continue my current medications?

Ketamine: Although this varies by patient, we usually start seeing the effects of Ketamine on mood after 2 or 3 infusions. However, for a longer lasting effect, patients usually need at least 6 infusions. The response rate for Ketamine is quite high, with 70% of patients showing improvement in depressive symptoms.


TMS: On average, patients report improvement in mood, concentration, and energy levels at around 2-4 weeks of treatment. Timeline of improvement varies from patient to patient, with some noticing changes in mood as early as the 15th session, while others may not notice improvement until closer to the end of the treatment course. Based on scientific literature and data from our practice, about 70% of patients respond to the treatment.

Ketamine: The number of infusions needed vary by patient and by depression severity. We recommend an initial treatment with 6-10 infusions over the span of 2-4 weeks. Then, a maintenance phase is recommended with booster infusions every 2-4 weeks to maintain a continued effect on mood.


TMS: The standard TMS treatment course for major depression is 36 sessions, conducted daily on weekdays. Depending on individual patients, additional 10-15 sessions may be recommended to reach full therapeutic effect. Patients have the option to return for maintenance sessions 6-8 weeks following completion of full treatment course on a need basis. 

Ketamine For Anxiety

Estelle Autissier, RN

How will I feel during the session?

@ Principium Psychiatry

Ketamine: The Ketamine dose, calculated for each individual based on his or her weight, is given over 60-75 minutes in one-fourth increments. We encourage patients to stay in our office for an additional 10-15 minutes after the infusion is completed to ensure there are no lingering side effects.


TMS: Each TMS session lasts 25 to 50 minutes depending on the protocol being used. Patients may be prescribed modified treatment protocols depending on individual symptoms. 

IV vs. Oral vs. Intramuscular vs. Intranasal Ketamine: Why Route Matters

Does insurance cover this treatment?

Ketamine: Most patients find Ketamine infusions to be very relaxing and enjoyable. The most common perceivable effects during infusions are: sleepiness/drowsiness, feelings of relaxation and euphoria, heightened perceptions (colors and sounds are more intense), feeling of mild intoxication, and feelings of  “a weight being lifted” or “being reset”. Please see our blog post about this topic: [add hyperlink]. 


TMS: Patients sit in a comfortable reclining chair. The patient’s head is secured with light padding and the magnetic coil is placed against the head. The coil then will deliver the treatment pulses twice per minute for the duration of treatment. During TMS sessions, patients are awake and alert, able to carry conversations, watch television, listen to music, or read. No medication is used, and patients are able to drive afterwards. 

How long is each session?

Estelle Autissier, RN

The use of ketamine for treating depression has been regarded as “the biggest thing to happen to psychiatry in 50 years”. We know it works – studies have shown that ketamine infusions are successful in reducing depressive symptoms in 70% of patients with severe, treatment-resistant depression. But why does it work? What is it about this anesthesia drug that makes it one of the most successful agents in treating depression?


Ketamine blocks the action of NMDA, or glutamate, a neurotransmitter in the brain. Glutamate is associated with brain plasticity, or creating new connections within the brain. A 2010 study found that ketamine acts as a facilitator to create these new connections, called synapses, and therefore improving nerve signals in parts of your brain. Traditional antidepressants, such as SSRIs, work by increasing the amount of serotonin, a neurotransmitter that is depleted in depression. However, traditional antidepressants can take weeks to work effectively, leaving patients who are actively having thoughts of harming themselves very vulnerable. Ketamine starts having antidepressant effects within 24 hours of the first infusion, and although researchers and doctors aren’t quite sure why, keeps working for weeks afterward so that patients don’t have to have daily infusions to keep seeing positive effects.


Another theory as to why ketamine works so well for treating depression was explained in a 2017 study by neuroscientist Yan Yang. The study hypothesizes that ketamine may work in the lateral habenula, a brain region that acts as the opposite of the brain’s reward center. If the lateral habenula is overactive, it suppresses the feelings of pleasure one normally gets from pleasurable activity, leading to apathy and hopelessness. One theory is that ketamine blocks the hyperactive lateral habenula directly, leading to quick relief of depressive symptoms.


Although scientists don’t currently have all of the answers, a number of studies are currently underway to try and deepen our understanding as to how and why ketamine works in treating certain mood disorders. Through current trials and clinical observations, healthcare professionals have been able to see a huge breakthrough in patients that have exhausted all other options. One recent patient at Principium Psychiatry said the following about their ketamine infusions: “It just feels like my entire brain is being reset. It makes it so much easier to begin and maintain positive behaviors that I wouldn’t otherwise be able to do because of my depression.”    

​To see if this is the right treatment for you and learn more about Ketamine infusions at Principium Psychiatry, call us at  212-335-0236 or email us at info@manhattantms.com. We are dedicated to helping you combat your depression!     

For those seeking fast-acting relief, ketamine may be recommended over TMS. On the other hand, TMS may be more suited for those who have certain chronic symptoms of depression such as poor concentration and inability to take pleasure in daily activities.


At Principium Psychiatry, Dr. Cohen will go over both treatments with you during your initial consultation, and will make a recommendation based on his clinical expertise and knowledge of these treatments and what your personal goals are for your mood and symptoms. 

Ketamine vs. TMS: Which treatment is best for me?

At Principium Psychiatry, we offer our patients cutting-edge treatment options for their depression, and one of our main stars is IV (intravenous) ketamine. But why does it have to be IV? “I don’t like needles, why can’t I just take this as a pill or as that nasal spray everyone is talking about?” you may be thinking. IV is the best route for your brain to receive ketamine because of something called bioavailability. In addition, it is also more effective, more precise, and safer for you.


What is bioavailability? It is the amount of medication that your body and brain is actually able to use, which is sometimes different than the amount of medication that your body receives. When you take any medication, parts of the active ingredients in them don’t go to your bloodstream; they get digested, altered into an unusable form, metabolized and excreted into your body. This is particularly prevalent in oral and intranasal medications. In fact, receiving a medication intravenously is the only way to have 100% bioavailability. Let’s take a look at the different bioavailability percentages based on what route you receive ketamine:


 Intravenous: 100%

Intramuscular: 93%
Intranasal: 25-50%
Sublingual (under the tongue): 30%
Orally (by mouth): 16-24%


When we give ketamine intravenously, we know exactly where your entire dose is going: straight to your brain. The same cannot be said for other forms of ketamine. Intranasal ketamine has to bypass several layers of tissue before it can reach your brain, and too many things can happen that could cause you to lose some or most of your dose: sneezing, dripping, running down the back of your throat, etc. The same can be said for an oral pill and an intramuscular injection; these routes are just too unpredictable, and when it comes to treating your depression, we don’t want the results to be unpredictable.


When you receive IV ketamine in our office setting, it is given slowly over one hour. By doing this, we are able to monitor you closely, and if you experience any unpleasant side effects and want to stop the infusion, we are able to do that. By contrast, a dose of ketamine via intranasal spray would be done at home with no physician or nursing supervision, so side effects cannot be immediately addressed if they arise. The same is true for intramuscular or oral dosing – after you take the pill, or receive a shot of ketamine into your muscle, there is no way to stop the absorption of the medication into your bloodstream as the full dose is administered within seconds.

 IV ketamine is by far the safest and most effective approach in using ketamine to treat depression. You are in a comfortable setting with healthcare providers with you the whole time, the potential for side effects is low, and you are certain that the dose you receive is the dose that is going to your brain, maximizing the benefits of this cutting-edge treatment. 

Estelle Autissier, RN

We know that Ketamine is becoming an increasingly accepted treatment for depression in the psychiatric community, but what about other mood disorders, such as anxiety? Can a medication with such pronounced effects on depression have similar effects on anxiety? Turns out, it can! While still in the most preliminary of studies, there has been scientific evidence showing that IV infusions of Ketamine can be effective in treating generalized anxiety disorder and social anxiety disorder. This makes sense, as depression and anxiety are often intertwined with each other, feeding off one another.


One 2017 study in New Zealand found that participants with general anxiety disorder or social anxiety disorder received three ascending Ketamine doses (0.25, 0.5 and 1 mg/kg) once per week. The doses of Ketamine produced rapid anti-anxiety effects, which lasted for 3 to 7 days at higher doses. A more recent and robust study from this year using IV Ketamine and a placebo had similar findings – that those who received Ketamine infusions had a significantly higher reduction in anxiety symptoms compared to those who received the placebo, and that reduction of anxiety symptoms were sustained for the following 14 days. These studies are promising, but there is a need for larger studies to prove that Ketamine should be the standard for treatment-refractory anxiety.


From a more personal point of view, our team at Principium Psychiatry has treated many patients who, in addition to having depression, also have varying degrees of anxiety. Throughout their infusion protocols, we have found that not only do their depressive symptoms improve, but so does their anxiety. We have had patients tell us that they are now able to make plans with others and actually keep them, something that they have not been able to do in months or years. One patient happily reported that he stopped feeling the need to take his “as needed” anti-anxiety medication before meeting up with friends, as he didn’t feel overwhelmed and scared to be around others anymore. Another patient was able to reach out to old friends that she hadn’t seen in years because her depression and anxiety had been so debilitating.


With limited side effects and significant potential, intravenous infusions of low-dose ketamine have been life altering for people suffering from depression and anxiety. With its ability to improve mood, decrease suicidal thoughts, decrease anxiety and boost self-esteem, ketamine can open a door for you when you thought they were all closed and locked. To learn more about Ketamine infusions at Principium Psychiatry and to see if you are a candidate, call us at +1(212) 335-0236 or email us at info@manhattantms.com. We are dedicated to helping you combat your depression!

Ketamine: How long is a course of treatment and how do I maintain remission?

Ketamine: There are few psychiatric medications that interact with Ketamine. During your initial consultation, you will need to disclose what medications (including supplements) you regularly take to ensure there will not be any interactions during treatment.


TMS: Yes, medications are safe to use in combination with TMS. Many patients continue taking their antidepressants when beginning TMS treatment. Over the course of treatment, as the mood improves, medications can be simplified or tapered off. If you are taking benzodiazepines, such as Xanax, Klonopin, Ativan, or Valium, the dose may need to be adjusted prior to starting TMS. Your medications list would be discussed during your initial consultation. 

Friday, May 18th, 2018

Friday, May 11th, 2018

What does it feel like to get a Ketamine infusion?

Ketamine and Transcranial Magnetic Stimulation (TMS) are both cutting-edge treatments being used by psychiatrists and other mental health providers for depression and other mood disorders. At Principium Psychiatry, we are proud to have both of these treatments available to our patients. But what distinguishes these two treatments? Both treat medication-resistant depression, but what are the differences between each treatment, and how do I know which one is best for me? Below are answers to our most frequently asked questions regarding both of these novel therapies. 

How do I decide between each treatment?

Friday, April 20th, 2018

How long is the treatment course?

Ketamine: Ketamine is not currently FDA approved for the treatment of depression (although we predict it will be within the next few years). However, ketamine has been FDA approved as an anesthetic since 1970. It is a safe medication and off-label use of medications is common practice within the medical community.

TMS: Yes, TMS is an FDA-approved treatment for major depressive disorder. The Neurostar Advanced Therapy TMS device was the first to receive FDA approval in October 2008 for use in treatment-resistant depression, and most TMS treatment studies have used the Neurostar. BrainsWay, a Jerusalem-based manufacturer of TMS device, received FDA approval in 2013, and in 2015, MagVenture also received FDA approval for its MagVita TMS Therapy System. At Principium Psychiatry, we use the Neurostar Advanced Therapy device.

Estelle Autissier, RN & Yiling Wang

When choosing a method of treatment for your depression, it is important to consider timing. Antidepressants take about 4-6 weeks to work, and you usually remain on them for up to a year after your depression improves. Since antidepressant medications are usually taken daily, patients must be willing and able to be compliant to this regimen, which can be difficult. TMS, or transcranial magnetic stimulation, involves 36 daily sessions administered over 6-8 weeks. The ketamine treatment protocol is a little less time consuming, and may be a good option if you are looking for immediate relief of severe depressive symptoms. At Principium Psychiatry, all treatment methods are preceded by an initial evaluation, during which one of our providers will assess you and your symptoms to see if you are a candidate for ketamine therapy or another one of our treatment options.


Our ketamine treatment protocol involves two phases: the loading phase and the maintenance phase. In the loading phase, patients get 2-3 infusions per week for 2-4 weeks, with the total number of infusions usually falling between 6 and 12. This loading phase is to help you achieve a significant (>50%) decrease in symptoms or even complete remission from your depression. You may start feeling an improvement after 1 or 2 infusions, but it is important to fully complete the loading phase in order to achieve optimal symptom reduction that lasts.

After completion of this phase, your treatment becomes even more personalized – we encourage patients to keep in touch with us and let us know when they feel their depression creeping back in so we can schedule another few infusions: This is known as the maintenance phase. This entails 2 infusions over the course of one week in order to maintain remission and keep your symptoms at bay.


Once a patient reaches the maintenance phase, it is quite varied how often they will need these “booster” infusions. Some patients prefer to get 1 or 2 infusions per month in order to proactively prevent the resurgence of their depression. Others come back for their booster infusions 3 or 4 months after the completion of their initial 6-12 infusions. Each person’s depression is different, therefore each ketamine treatment plan is highly personalized to optimize mood and achieve remission. 

How long does it take to work?

Friday, April 13th, 2018

Friday, May 4th, 2018

Before going to your first ketamine infusion appointment, you might feel a little nervous. You might worry about the IV needle, whether or not it will work, and how you will feel during the infusion. While there is no alternative for the needle prick, we can help you understand how you will likely feel during the infusion. The response that each person could have to a ketamine infusion can be grouped into three categories:

1. “I don’t feel any different.”
Some patients fall on the milder end of the spectrum – they do not feel anything out of the ordinary during the treatment. They may feel a sensation of wellbeing or relaxation, but no other obvious effects. It is important to know that even if you don’t feel different during the infusion, it does not mean that ketamine won’t help your depression. The “psychedelic” effects people associate with ketamine have no correlation with its effects within your brain to treat depression, so it’s perfectly okay if you don’t feel out of the ordinary during treatment. Even in those with unremarkable ketamine infusions, we still like you to stay with us for 5-10 minutes after the infusion is finished to ensure that there is no dizziness upon standing and walking.

2. “I haven’t felt this relaxed in years.”
This category encompasses the majority of the patients we see at Principium Psychiatry. A number of patients have equated their experience to drinking a few glasses of wine – they feel slightly inebriated, inhibited and relaxed. Other patients have said, “I feel like a weight has just been lifted off my shoulder.” Also in this category, usually directly after each “bolus”, or medication push, is a transient feeling of sleepiness or grogginess. While we don’t let patients fall asleep during their infusions, as we like to assess their mood and how they feel throughout the treatment, we have no problem with you closing your eyes and relaxing.

3. “This is like nothing I’ve ever experienced before.”
In the small minority of patients undergoing ketamine treatment, there is a possibility of a more intense “psychedelic” experience. This experience may include a perception of more vivid imagery when you close your eyes, or amplified background noise. You may have vivid daydreams (it is important to note that you will not hallucinate, but rather feel as though you are in a dream). A small number of patients have had mild emotional reactions to ketamine infusions; for example, they may become slightly teary or upset. All of these effects are transient, and likely will become less apparent after your first infusion.

​The effects one may experience during a ketamine infusion may vary person by person. At Principium Psychiatry, our protocol has been fine-tuned to make it as comfortable as possible. Our patients do not experience nausea or headaches, and the treatments have been very well tolerated by our patients. Overall, patients find the infusions to be enjoyable and relaxing.

Ketamine: Insurance will cover a portion of the ketamine treatment procedures but will not cover the entire infusion.


TMS: TMS is covered under all major private insurance companies including Blue Cross Blue Shield, United Healthcare, Aetna, Cigna, and Oxford. For other questions regarding costs, insurance coverage, and reimbursement, please call our office at 212-335-0236. 

Friday, April 27th, 2018

Why do Ketamine infusions work to treat depression?