Ketamine Overview

Ketamine is a synthetic/man-made pharmaceutical compound,  approved for use as an anesthetic agent for surgery and procedures requiring sedation and pain relief.   Ketamine has been in regular use for over 50 years, with an excellent safety profile, particularly around breathing/airway management. It is routinely used with pediatric patient.

Ketamine has been proven to benefit depression and anxiety conditions, including Post Traumatic Stress Disorder, at the dosing that is significantly lower than needed for surgical sedation.  The benefits have been realized in cases that were considered treatment refractory – not responding to other interventions. The response to ketamine has been notable for rapid onset, which distinguishes ketamine from other psychotropic medications that often have a lag time of several weeks. Ongoing research is focused on how to sustain the benefit of treatment with an optimal dosing schedule and integration of psychotherapy.

Based on the research and my experience working with patients, the response to ketamine is realized across the following pathways and processes.

  • Mood and outlook – increased sense of possibility and awareness that change is possible, with improved interest in activities, desire to engage, and capacity to take pleasure in the experiences that unfold.   From this point, behavioral and cognitive interventions can take hold more readily
  • Pattern of thought – clearing away of destructive and cycling thought loops and the development of alternative capacity to work with the mind, what emerges and what else can exist.   From this point, mindfulness training with and without ketamine can be employed to build on this new capacity.
  • Sense of safety – connection with restorative states of being, that enhances the window of tolerance to engage with difficult psychological material that may have been avoided.   This aspect of integration supports the recovery from trauma, and aligns with somatic psychotherapy to recognize the role of the body in storing and releasing emotions.

In my practice, I provide ketamine in conjunction with psychotherapy based on the research evidence that indicates benefit for:

  • Treatment refractory major or bipolar depression
  • Anxiety Conditions
    • Post Traumatic Stress Disorder
    • Obsessive Compulsive Disorder
  • Addiction and behavioral/impulse control disorders

Criteria for treatment include:

  • Severity of condition / level of functional impairment – based on screening tools and subjective assessment
  • Non-response to alternative treatment – ie.  medications and psychotherapy.

I do not provide ketamine for primary pain management, and defer to pain management providers or IV infusion clinics with this focus.  That noted, I am willing to treat patients with chronic pain who have a pain management treatment team in place when the targets are psychological factors that exacerbate pain (anticipation, fixation, rumination), and a typically depressive disorder.

In my practice, ketamine is administered by either:

  • Intramuscular injection (IM) – in the shoulder / deltoid
  • Oral Dissolving Tablet (ODT) – under the tongue.

These routes optimize the ease of administration and comfort to support the psychotherapy process .

  • Intramuscular injection (IM) delivers a highly bio-available dose of medication that onsets quickly to achieve a peak experience that can be titrated to achieve the dissociative states that are correlated with treatment response and psychological growth.
  • Oral Dissolving Tablet (ODT)  is provided to those who are hesitant to receive an injection, to work with lower peak effect, and for take home doses – in certain instances.

Alternative routes of administration include intravenous (IV), sub-cutaenous (SC) and intranasal.

Intravenous (IV) administration is typically provided by anesthesiologists/nursing staff in a medicalized setting, and affords the benefit of being able to adjust the dose in real time to sustain particular state level and stop delivery immediately, if needed.  While potentially advantageous by these technical parameters, the intrusion of an catheter can be disruptive and impose cost and staffing burden relative to the ease of intramuscular injection (IM) – which is effectively as bio-available.

Ketamine is a safe and well-tolerated medication that is routinely given in the outpatient setting and for take home use for certain pain conditions. It is a preferred anesthetic agent for its safety profile, particularly around the lack of suppression to respiratory drive, and with some increase in blood pressure, which can be beneficial in surgery.   At the lower doses used in treatment for mental health conditions, these concern are further mitigated.

Medical clearance prior to treatment is focused on cardiovascular health as there is temporary increase in blood pressure at the time of treatment.  Basic medical management with antihypertensive medication can resolve this issues. Blood pressure is checked routinely during treatment, with medication provided if needed. In some cases, a more comprehensive cardiologist clearance may be indicated.

Provision of ketamine in medical setting for mental health treatment is not associated with abuse based on research studies. In the community, ketamine can be abused by users who need increasing doses to achieve the same effects – a tolerance phenomena, that results in dependence and psychological craving.   These escalating doses and frequency of use increase the risk for cystitis – an inflammatory bladder condition.   With more frequent provision of ketamine in the medical setting, the risk of cystitis is increased, though remains low. Patient with a history of cystitis may be at increased risk for reactivation.

It is possible to have transient side effects with the medical provision of ketamine – that typically resolve within 4 hours, and may be pre/treatable with medication:

  • Dizziness
  • Blurred vision
  • Headache
  • Nausea, vomiting
  • Dry mouth
  • Restlessness
  • Impaired coordination
  • Impaired concentration

The literature around ketamine provision describes an ’emergence phenomena’, in approximately 10-20% of cases,  in which a patient may experience subjective distress with psychological or physical restlessness.   This experience has been more clearly reported when ketamine is provided for procedures, which involve disruption to body integrity and pain.  In the event of such an emergence experience,  low dose anxiolytic medication has been beneficial.

There are also rare psychological and psychiatric risks associated with treatment, notable switching into mania for bipolar patients, who may not yet be diagnosed as such. While rarely described, it is possible that sustained perceptual disturbances, alternations in cognition, reality testing or subjective distress stemming from treatment may persist beyond that acute treatment.

My approach to care

Ketamine Assisted Psychotherapy is an integrated approach to your recovery that builds on the biological effects of ketamine to address the psychological and somatic factors that perpetuate conditions and their associated signs and symptoms – ie. depression, with looping thoughts, low energy and poor sleep quality.

A sustaining therapeutic relationship is valued and prioritized – with myself present throughout the treatment to hold and the organize the process.

The process involves 3 distinct aspects of treatment, each with a specific purpose:

  • ‘Preparation’ sessions – 45-60 minutes – (typically 1-3) –  better understand your psychological profile and define goals prior to dosing.
  • ‘Dosing’ sessions – 90-120 minutes – ( 1-6 – depending on initial course of care, ongoing by plan) – in which ketamine is delivered in the office to realize the biological effects and to allow for experiences that enrich psychological understanding.
  • ‘Integration’ sessions – 45-60 minutes -(typically 1 between certain dosing sessions) – to elaborate and consolidate understanding from the ketamine experience,  and evaluate the overall process – including adjustments to treatment.

Within the Dosing sessions, the timeline typically follows:

  • Check-in – 15-30 minutes – to understand your mindset in the moment, set expectations and intention for treatment
  • Dosing – 45-60 minutes – provided in the office by intramuscular (IM) or oral administration
  • Evaluation – 15-45 minutes –  to explore the direct experience of ketamine and develop insights.

The dosing sessions are designed to maximize comfort, relaxation and a sense of safety – all of which allows for deepening into the therapeutic ketamine induced state of consciousness, with separation from thought and bodily sensation correlated with better treatment response.  Patients typically rest on a couch, and are encouraged to listen to music and use eye-shades to enhance the experience and limit distraction from the therapeutic state of being

In evaluating options for ketamine treatment, it is important to properly value the role of an integrated psychotherapy process to support the psychological growth that can build on and sustain the biological effect of the treatment.

In certain instances, it may be appropriate to seek out a treatment setting where ketamine is delivered as a standalone intervention coupled to existing treatment, that may or may not include psychotherapy.  This is the case with most IV infusion centers, where the ketamine is delivered over the course of an hour and patients are sent home to recover, without providing an expanded integration after the treatment.   In the more collaborative models, there is direction to be in psychotherapy and perhaps even updates between the distributed team members;  Infusion clinic, outpatient psychiatrist and psychotherapist.

My model of care is designed to leverage the relationship and psychological openness that can arise with ketamine treatment.  I am present throughout the course of ketamine treatment and psychotherapy.  I check you in, administer the medication, and am present as you emerge to explore how you feel in relation to the ketamine experience.  This consistency and continuity supports discovery and insights that can arise in ketamine treatment, particularly in the post-dosing integration phases where I am present to help consolidate what has been experienced – whether it is a realization, a new felt body states or the absence of an intrusive thought.  I am there for you – throughout, and retain the whole picture view.  Taking the information from the dosing session, I am then able to work with full integration sessions (non-ketamine) based and collaboratively with existing therapists, to report back on the content and nature of your development.   In certain instances, I am open to give take home oral doses of ketamine to use with existing therapists.

In evaluating your needs and ways in which you are likely to best respond, it is worthwhile to consider the which approach is better suited.

The typical course of care varies based on condition and response.  The starting dose and initial number of treatment is guided by the research evidence base – which is emerging. The following are two distinct protocols within my practice, and give some sense of the clinical science and flexibility involved with this treatment.

The reference standard for treatment refractory depression is #2 treatment per week for 3 weeks (defined as an ‘index’ phase of care), and then to  evaluate spacing (a ‘maintenance’ phase) – with the goal of sustain gain to mood and function at monthly,  every 2 month, even further intervals.  In some instances, it may be possible to accelerate the maintenance phase, if the initial response is robust.  This algorithm is typically aligned with most commercial IV infusions and medically research centers.

Similarly, this protocol can be adopted for anxiety states and other conditions where symptoms are distressing, with dosing adjusted in response to gains.  My approach may include additional integration session, particularly after the initial robust response and symptom reduction, when there is less urgency and more capacity to explore content and process.

For psychological growth, addictive and behavioral disorders, there is further emphasis on the preparation stage and defining goals for change – whether in actions or pattern of thought or sensation.  The ketamine treatment itself may be a shorter course, with an initial test dose and then targeting 1-2 higher doses to allow for greater access to transformational state and/or the use of a low dose option to explore the softening of resistance.   Again, integration is emphasized.

Certain patients may find themselves in remission from acute distress as defined by the algorithm best defined for depression, and now seeking psychological exploration at the high or lower dose.   In some instances, low dose oral ketamine can be provided for take home and administration with existing psychotherapists.