What is Ketamine?
Ketamine was discovered in 1956 and approved by the FDA in 1970. It is widely used as an anesthetic in children, adults, and the elderly. Ketamine is a safe, effective anesthetic and has been listed on the World Health Organization’s Essential Medicines list since 1985. Multiple studies and trials at Mt. Sinai in New York, Yale, and other prestigious universities and hospitals since 1990 have shown that ketamine is exceptionally effective in treating treatment-resistant depression, PTSD, anxiety, suicidal ideation, neuropathic pain, and other related mood disorders. Unlike standard antidepressants like SSRIs and SNRIs, which generally take 6-8 weeks to work (if they work), ketamine is fast-acting. It can sometimes show immediate efficacy after a single intravenous dose. Because of its fast-acting nature, ketamine can be an essential tool in preventing suicide and immediately alleviating the suffering caused by major depressive disorder.
Who is a candidate for Ketamine infusions?
Ketamine is recommended for anyone with treatment-resistant depression, meaning tried and failed at two or more antidepressant therapies and those with PTSD.
What are the chances of responding to ketamine treatment?
While we cannot predict who will respond to ketamine, a meta-analysis by the American Psychiatric Association using data from multiple ketamine trials reported that over 70% of treatment-resistant patients responded positively after receiving the initial round of low-dose infusions. There’s no way to predict what someone’s response will be or at what point they will react. Some patients respond to the first infusion, while others take 4-6 infusions. The degree and duration of response are also highly dependent on the individual. Unfortunately, not everyone responds to ketamine treatment. Those who have not improved after six infusions are unlikely to benefit from further ketamine treatments.
How many treatments are needed?
An initial series of six ketamine infusions are recommended for optimal results over 2-3 weeks. After that, patients are placed on a maintenance program and are asked to return when they feel it necessary for single infusion boosters. During the maintenance period, the duration of relief varies by patient. The average time of relief between booster infusions is 4-6 weeks. There is no way to predict what your needs will be. Some patients find that the time between boosters lengthens as they go through this process, prompting them to come in every other month, every three months, or even less frequently. In our experience, patients find ketamine boosters effective for as long as needed with no long-term side effects.
Is ketamine an FDA approved medication?
Ketamine is FDA approved for use in the United States as an anesthetic during surgical procedures. Ketamine is not approved for the treatment of psychiatric conditions. Therefore, its use as a psychiatric treatment is considered “off-label.” “Off-label” does not mean it is experimental, ineffective, or illegal. Physicians routinely and legitimately prescribe many other medications for unapproved indications based on additional scientific research completed after a drug’s approval. The rationale for this- is money. It takes large sums of money for the FDA approval process, which is why the majority of drugs being used “off label” will never be approved.
Is ketamine safe?
Despite its dramatic effect, ketamine is an extraordinarily safe medication. It has been used for over 50 years as an FDA-approved general anesthetic agent. It has wide application in operation rooms, ICUs, emergency departments, pain centers, burn units, and pediatric anesthesia and is non-addictive with few significant side effects. It is also listed on the World Health Organization’s “essential medicines” list due to its efficacy and safety record.
What are the possible side effects?
Ketamine is rapidly removed from the body. Any side effects typically resolve within a short time after completion of the treatment. An altered sense of time, temporarily increased anxiety, visual abnormality, diminished ability to feel sensory input, excitability, reduced appetite, transient mental confusion, nausea/vomiting, nystagmus (rapid eye movements), restlessness, inability to speak clearly, and synesthesia (a mingling of the senses).
Ketamine infusions may cause mild increases in blood pressure and heart rate. These are monitored and resolve quickly after the treatment is stopped. The rate of treatment and dose may be adjusted if necessary.
Ketamine does not interfere with breathing or respiratory drive, especially at low doses and without other sedatives or narcotics. Allergies to ketamine are rare.
How do I prepare for a ketamine treatment?
A designated driver must accompany all patients, or treatment will not be provided. You may eat or drink without concern, but try not to eat a heavy meal directly before your infusion.
Please bring these with you if you wish to listen to music during your treatment and prefer your headphones/music.
What can I expect for my first infusion?
Ketamine experience is hugely unpredictable. Experiences vary from person to person, but also from infusion to infusion. Experiences tremendously depend on the “set and setting” of the treatment. “Set” refers to your mindset–the intention you carry going into an infusion. “Setting” is the physical environment.
When you arrive at the clinic, we will place you in a comfortable reclining chair, attach a vital machine monitor, and obtain a set of vital signs. An IV is started. As part of our “setting” we offer you use of a weighted blanket, eye mask or starry galaxy light ceiling projection, earphones and ketamine oriented soundscape. Once comfortable, we will dim the lights and begin the infusion. A trained professional (therapist, qualified guide, or medical staff) will monitor you throughout the infusion process, so rest assured that you will never be left alone.
How will I feel during my treatment?
Although the specific subjective experience you will have is impossible to predict, there are some shared experiences many patients report. The main thing to remember is that ketamine produces a disconnection from one’s ordinary reality, known as dissociation. This state frequently generates experiences that include visual, auditory, and other sensory effects, including the sensation of traveling outside oneself during an infusion. The medicine may induce or enhance feelings of empathy, creativity, purpose, perspective, and openness to new ideas. Although the sensory effects will dissipate within moments after the infusion is complete, the enhanced feelings induced will become part of a new neural network formed.
Do I need to have therapy as well?
Ketamine therapy facilitates new perspectives to help us better process and move on from our traumas. By temporarily silencing negative thoughts, ketamine therapy offers a window of time for relief and healing. The infusions afford a tremendous opportunity to “clean house” of negative beliefs that no longer serve us and start fresh. The role of ketamine-assisted psychotherapy (KAP), is to assist in this process. Although not required, we highly recommend that you couple the infusions with therapy, as all data show that the two combined lead to the most significant outcomes and extend the effectiveness of the medication.
What is Ketamine Assisted Psychotherapy?
The role of the therapist is paramount here
Residue can come to the surface in confusing and sometimes anxiety-inducing forms. When you are on ketamine, your ego will be resting, which can lead to a feeling of loss of control, which can be frightening. The presence of an experienced therapist can aid in patients feeling grounded and safe. Grounding reassures your mind and body that you are secure and free from harm, which allows you to dig in and tackle whatever may arise. Trusting the process and knowing that whatever needs addressing will surface is essential. After the infusion, having your therapist help you sort through your experience is highly recommended. Think of it like a friend coming over to help you spring clean. The medicine does the complicated cleaning, and the therapist helps tidy things back in an orderly fashion and aids in developing new systems to serve your future self better.
Is there anyone who should not receive ketamine treatment?
Ketamine is not used to treat schizophrenia because it may worsen the condition.
Ketamine has not been adequately studied as an initial treatment for depression or anxiety. Other treatments should almost always be tried before ketamine.
Persons abusing alcohol or other drugs are unlikely to respond to ketamine and may be at greater risk of adverse effects. These persons should seek appropriate assistance to achieve a period of abstinence before ketamine treatment.
Persons with severe and uncontrolled high blood pressure should not receive ketamine until the blood pressure is under control since ketamine can cause a very transient rise in blood pressure.
Recent evidence that the use of lamotrigine (Lamical) or benzodiazepines, such as Xanax (alprazolam), Valium (diazepam), Klonopin (clonazepam), Ativan (lorazepam), may reduce the efficacy of ketamine for depression. If you take any of these medications regularly let us know so we may optimize your treatment efficacy.
Ketamine is not recommended during pregnancy because the possible risks of harm to the fetus are unknown. Breastfeeding should be avoided for 12 hours after ketamine treatment.
Will any medications interfere with ketamine infusion effectiveness?
We recommend skipping stimulant medications on the day of your session to avoid any added blood pressure elevation since ketamine can increase blood pressure. These can be resumed the following day. We also recommend skipping benzodiazepines before your infusion if your medical provider deems this safe, as these medications can diminish your response to ketamine. Ketamine is a glutamate NMDA receptor antagonist (inhibits actions at the receptor), while benzodiazepines are GABA receptor agonists (increases actions at the receptor). Studies have shown that benzodiazepines may reduce the antidepressant properties of ketamine. These effects happen in a dose-dependent fashion. The higher doses of benzodiazepines, the less effective ketamine will be at relieving depression. However, severe risks are associated with the abrupt discontinuation of benzodiazepines, and any adjustments made should be done at the direction of a medical provider. Lamotrigine (Lamictal) in doses above 150mg/day also can block ketamine efficacy.
During our intake exam, we will discuss if and how to modify your mediation regimen to maximize ketamine’s effectiveness.
What is esketamine or Spravato?
Esketamine is the S(+) enantiomer of racemic ketamine and is already used as an anesthetic in Europe. The FDA has recently approved esketamine specifically for use in treatment-resistant depression. It is available in a nasal spray, marketed as Spravato. However, because it still has the same potential psychotropic effects and changes in blood pressure and heart rate as racemic ketamine, it is restricted for use in certified centers. We are currently not offering Spravato nasal esketamine therapy. We have seen better results with intravenous ketamine.
How long does it last?
Each person’s experience is different. Generally, patients first notice the effect onset within 5-10 minutes of starting the infusion. The peak experience will last approximately 30 minutes. Most patients return to their ordinary awareness within 1-2 hours following administration and can resume normal activities. However, we suggest you clear your day to reflect on your experience by journaling or engaging in another creative outlet to help you get the optimal effects of the medicine. Sometimes mild side effects may linger until you’ve had a good night’s rest, so we discourage operating any vehicles, returning to work, or making life-altering decisions until the following day.
For best outcomes and safety follow these treatment guidelines:
Do not operate vehicles or heavy machinery for 12 hours following treatment. Refrain from taking benzodiazepines, stimulants, or consuming alcohol for 12 hours before and after treatment. Refrain from eating within 3 hours before an infusion. Continue taking antihypertensive medication as prescribed.
The wonder of the medicine
We sometimes collect mental and emotional residue from traumatic exposure and painful experiences throughout life. We can move on and thrive in life if we are fortunate and have the tools and resources to process and adequately heal these wounds when they occur. Unfortunately, we often do not have a supportive network to provide this protection. When this happens, we are left to move forward and exist in survival mode out of necessity. We have no choice but to trudge along while attempting to maintain relationships, support loved ones, and cope with new challenges, with unresolved issues compartmentalized in the background. Our mind has a brilliant, well-intending evolutionary design known as the ego. It is essential, for we could never survive today’s challenges if we were consciously aware of all the previous residue, so it “sweeps this under the rug.” Out of sight, out of mind. It operates within the default mode network, where we typically spend all our waking hours. All goes well until we accidentally bump into one of the mounds under the carpet, evidenced by our reactivity to sometimes seemingly small triggers. Triggers are valuable because they bring awareness to past unresolved traumas. Ketamine helps address these by putting the ego to rest for a while, allowing us to remove the rug, tend to the residue our wounds left behind, and offer a clean slate to begin again.