Ketamine-Assisted Psychotherapy for Depression: What You Need To Know

As a stand-alone medicine, ketamine, the only currently legal psychedelic therapy, demonstrates effectiveness treating for unipolar and bipolar depression.  This has led therapists to develop ketamine-assisted psychotherapy for depression, a growing area of interest within the psychotherapy field, specifically for use in cases of treatment-resistant depression (TRD). Its legal status has earned high-level acceptance and recognition among medical professionals and the general public in a growing number of countries.   Read on to learn what you need to know in order to talk with your health care provider about ketamine-assisted psychotherapy for depression.

What is Ketamine-Assisted Psychotherapy for Depression?

Ketamine Assisted Psychotherapy (KAP) serves as an enhancement to traditional psychotherapy, as patients are dosed with ketamine alongside their standard treatments. During a KAP session, this low dose of ketamine is applied to enhance and deepen the session.

Why Ketamine-Assisted Psychotherapy?

While ketamine itself produces positive mental health effects, pairing it with psychotherapy produces much more satisfying and long-lasting results. Several studies have shown that ketamine contains certain properties that can help alleviate symptoms of depression, including drug-resistant cases. While these studies agreed that more research is required to establish these effects on patients, with the available evidence both from anecdotal reports and scientific works, a growing body of research clearly shows that, in addition to common mental health disorders including anxiety, panic disorder, chronic pain and trauma,  depression, in particular, can be safely and effectively treated using KAP.
The following are some of the available findings on ketamine effects on depression, anxiety and other mood disorders:

Rapid and Sustainable Effects

In a 2014 review published by Current Neuropharmacology, researchers found that ketamine showed a rapid and sustained antidepressant effect in cases of treatment-resistant depression (TRD). In other words, patients who had tried other available treatments and found them ineffective saw benefits in the administered ketamine therapy. The study further found that ketamine offered rapid and sustainable effects, showing that the benefits are often noticeable within hours, and for up to 3 days after the initial application. More conventional treatments, such as antidepressant medicines, transcranial magnetic stimulation, electroconvulsive therapy, and talk therapies, may take weeks or months to produce results. But when administered alongside ketamine, results may occur within hours.

Effective against Suicidal Thoughts and Acts

A 2019 publication in Harvard Health found that, in addition to reducing depressive thoughts, ketamine had a positive effect in minimizing physical manifestations of these thoughts, as patients showed a reduced likelihood of experiencing life-threatening thoughts and acts.

Ketamine-Assisted Psychotherapy Results

Researchers from Yale compared ketamine effects with antidepressants and other conventional treatments for depression. According to their work, ketamine produces positive effects that had not been seen before in other treatments. Firstly, it appeared that ketamine triggers the creation of glutamate, which prompts the brain to develop new neural connections. This effect makes the brain become more adaptable and able to create new pathways, thereby helping the patient develop more positive thoughts and acts more quickly. They based their investigations on patients who felt no meaningful improvement using other antidepressant medications. The results from those studies were “dramatic”, as more than half of the participants demonstrated a significant, rapid decrease in depression symptoms after just 24 hours. Further, with the help of brain imaging techniques, medical experts have been able to see direct changes in the brain which signal improvement after a person has undergone a ketamine-assisted psychotherapy session.

What Happens During a Ketamine-Assisted Psychotherapy Session?

Since the mid-2000s, American psychiatrists, in collaboration with therapists, have been administering ketamine intravenously. By 2015, more clarity had emerged regarding other possible administration routes, as medical professionals began using the intranasal (inhaled) or sublingual (under the tongue and dissolved) route. These methods of administration have gradually become common, as they are less invasive and more efficient ways to administer the treatment. A 2019 publication in the Journal of Psychoactive Drugs revealed that these other methods allow the entire therapeutic dosing spectrum to take place when ketamine is given “in a non-medicalized office setting with full psychotherapeutic support.” Patients should expect ketamine to be administered sublingually or intranasally during their KAP session.
Once administered, the psychedelic effect of the drug is leveraged to bring the subconscious to the surface. Memories, sensations, feelings, and life experiences, including overwhelming and painful ones, are made accessible by the conscious mind – enabling the patient to identify the underlying sources of their depression, trauma, and anxiety. When ketamine is offered independently from other treatments, many patients cannot recall with vividness what their experience during the therapy was like once they are out of the session. But in a guided KAP session, patients report this recall to be substantially greater. Further, a guided session tends to keep new patients much more calm through the session (as many are apprehensive about the effects). With this calmness and awareness, a patient can fully engage with their subconscious memories, and actually prime their brain to be more receptive to new learning.

Ketamine-Assisted Psychotherapy For Depression Treatment Guidelines

As Ketamine-Assisted Psychotherapy is still an emerging therapy, the adult patient guidelines are still evolving but are usually based on the following process (please note that this information is not a substitute for information  given directly to you by a physician and is included for general knowledge purposes only:

• Are American Society of Anesthesiologists Patent Status 1 (A normal healthy patient) or 2 (A patient with mild systemic disease) are usually considered appropriate candidates and are considered ideal candidates for ketamine administration.
• Report moderate/severe depressive symptoms who have failed to respond to at least 2 adequate treatment trials, those reporting acute suicidal ideation with a history of depression, and patients with co-morbid depressive symptoms and pain who cannot receive standard oral antidepressant therapy due to medical problems affecting their PO intake.
• Are without contraindications for ketamine treatment including active psychotic symptoms or history of a primary psychotic disorder (e.g., schizophrenia or schizoaffective disorder), manic symptoms, hypersensitivity to the drug or its components, history of severe, ongoing alcohol or substance dependence (including ketamine).

Personnel involved in the treatment should include:

• A Patient Monitor: A qualified medical provider (e.g., attending or resident physician), mid-level provider (Nurse Practitioner-NP or Physician Assistant-PA), or
  registered nurse (RN), who observes, assesses, and documents the patient’s response during ketamine administration. The Patient Monitor must have current credentials in basic life support (BLS) and be competent in the administration of medications.
• Medical Provider: A a person licensed to practice medicine in the relevant jurisdiction.  Providers in residency training must be monitored and supervised for the entire event by a faculty or fellowship-level physician with current privileges to administer moderate or deep sedation.

A patient undergoing Ketamine assisted psychotherapy must have capacity to make decisions about their medical treatment. The physician  authorized to administer ketamine will inform the patient about the risks and benefits of the treatment as well as the fact that ketamine is not approved by the FDA for the treatment of depression. Therefore, the use of this medication will be off-label. Patient understanding and agreement will be documented by signing a medication administration consent form.
Typically,  a ketamine dose of 2 mg/kg,  (based on the review of the literature and the collaborative experience of physicians using ketamine for the treatment of depression and pain) is administered by an anesthesiologist (attending or fellow) will administer ketamine to the patient following the recommendation of an authorized psychiatrist.  The is  administered in 4 or more boluses (>4 if patient weight is >100 kg) given approx. 10 min apart and the maximum bolus dose for ketamine is 50 mg

How to Know If Ketamine-Assisted Psychotherapy is Right for You?

For those patients who become aware of the potential benefits of KAP treatments, they will first want to confirm the appropriateness of this method for their particular condition; most providers will offer an initial screening to make. During the screening, they will also determine the best approach for you, whether it is ketamine alone or ketamine assisted psychotherapy. However, before your first consultation with the ketamine provider, it is always best to seek the opinion of the professional who best understands your medical history – your primary physician. Despite the increasing legitimacy that has developed over the last 20 years, ketamine is still not a first-line approach in mainstream medical practice for treating depression, as there remain practitioners who have not yet been satisfied by conclusive research. Nevertheless, the patient has the right to suggest a KAP-based treatment option and to discuss it with their doctor.

How to Talk to Your Doctor About Ketamine-Assisted Psychotherapy for Depression

Simply inquiring about the appropriateness of ketamine therapy can be a source of great anxiety for many new prospective patients. While the treatment is undoubtedly beneficial for many patients, many mainstream doctors are not yet recommending ketamine treatment, so patients are best served coming to the discussion armed with knowledge, facts, and a reasoned argument. As medical practitioners deal in evidence and fact, the patient should arm themselves with widely-recognized, evidence-based results from medical journals. With this evidence, and demonstration that you fit the criteria for treatment and are aware of the costs. Remember, KAP therapy is a relatively new field of study, and your doctor may simply not be focused on the subject (and thus knows little of the research). Of course, your doctor might be a proponent of ketamine treatments, and will recommend a provider for you.

Choose a Trusted Ketamine-Assisted Psychotherapy Provider

Choosing a provider can be a bit trickier than it would seem, as the skill of the practitioner in guiding a KAP session can be a critical factor in how successful it is. New prospective patients should seek the recommendation of a medical practitioner, or the ketamine-assisted psychotherapy for depression reviews of existing patients. Visiting nearby clinics for free consultations will provide the most direct insight into a particular provider’s philosophy, approach and support.

Be Open with the Provider

Your first meeting with your ketamine provider will likely be a consultation to confirm that they understand your condition, medical history, and the appropriateness of the treatment for your affliction. It is best to be open with the provider as the information you share will help schedule the right treatment course to best address your unique situation.

Preparing for your first KAP session: Pre- and Post-Treatment Guidance

There are certain things you must observe before and after the treatment. The instructions may vary between clinics, but generally, will be as follows:

Before the Therapy

• Get a good sleep the night before your ketamine therapy to avoid feeling stressed out or overtired during the treatment.
• Do not eat for 4 to 6 hours before your appointment. While some clinics also do not permit any liquids during that period, some allow clear liquids to be consumed up to 2 hours before the treatment.
• If you are taking daily medication, you will need to seek the opinions of both your ketamine therapy provider and primary physician, as there is always the potential for interactions between new and existing medications of any kind. Your doctor(s) will let you know if you should discontinue or reduce the medications prior to the treatment.
• Wear comfortable clothing, as discomfort can affect your state of mind. You might want to bring a blanket or sweater.
• If you have quiet music you would love to listen to during the session, you should be prepared to bring headphones.
• Reschedule any important engagements for the day of your treatment, and also prepare to stay in the clinic to recover for around 20 to 30 minutes before leaving.

During the Session

• You will most likely be asked to sign a consent form, indicating that you are fully aware of the therapy and its potential risks.
• If the drug is to be administered intravenously, a small needle will be placed in your vein (most likely in your forearm) while you are seated in a comfortable recliner.
• Medication will be administered slowly, over the course of around 30-60 minutes, depending on what the provider deems best for your case.
• In some clinics, treatment is carried out by a team of professionals composed of psychiatrists, psychotherapists, and anesthesiologists.
• You will be monitored throughout the treatment by a nurse or another professional with expertise in life support.  Resuscitation and monitoring equipment,  appropriately sized to the patient, will be available at the location and the recovery area.

After the Therapy

• Arrange for a driver to take you home after the session. You should not attempt to drive for the rest of that day. You should also not try to operate machinery for the next 24 hours.
• Stay away from alcohol or other recreational drugs for 24 hours.
• Do not make any important decisions for the rest of the day!

Ketamine-Assisted Psychotherapy Side Effects

Blood pressure needs to be monitored before dosing and at the close of the session. If the patient’s baseline BP is somewhat elevated, the provider in some cases may want to assess it 20-30 minutes after dosing. Blood pressure checks should be done routinely at the initiation of therapy and after dosage increases.

What are the risks? How is Ketamine impacting me?

During a KAP session, the medicine produces shifts in your consciousness. In the short-term, you will feel a sense of calmness and floating, which may detach you from reality while the effects last. Many first-time patients find that they were not prepared for such vivid feelings and report being disturbed by them.

When ketamine first became used as a treatment for resistant depression, it was only administered intravenously and without the aid of psychotherapy. While the drug showed encouraging signs of effectiveness, when used alone, these effects were short-lived. Further, when administered intravenously without psychotherapy, the drug produces “dissociative effects” (which patients characterize as feeling like an ‘out of body experience’). According to the National Institute on Drug Abuse ketamine may create short- and long-term side effects. Depending on the amount taken, ketamine without psychotherapy may cause memory loss, anxiety, impaired motor function, as well as visual and auditory distortion. Numbness, confusion, loss of coordination, disorientation, and hallucinations are some other possible experiences from the dissociative effects. While researchers have attempted to minimize the unwanted dissociative effects of ketamine therapy through alternate ingestion methods and through the support of a psychotherapist, some level of mind alteration inevitably occurs.

Some experts believe this mild mind alteration is necessary to achieve the positive therapeutic benefits of the drug. A psychotherapist can only help to prepare you for the effects that will follow, hasten your recovery from the condition, and help you to maintain the positive results long after the treatment is concluded. If you are looking to read more ketamine-assisted psychotherapy for depression articles to more about the topic, make sure to check out the rest of the Frshmind’s blog.

References

https://www.drugabuse.gov/publications/research-reports/hallucinogens-dissociative-drugs/what-are-effects-common-dissociative-drugs-brain-body
https://www.tandfonline.com/doi/full/10.1080/02791072.2019.1587556?scroll=top&needAccess=true
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6041963/
https://www.health.harvard.edu/blog/ketamine-for-major-depression-new-tool-new-questions-2019052216673
https://www.yalemedicine.org/stories/ketamine-depression/
https://www.psychiatry.org/patients-families/psychotherapy

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