What is Ketamine?
Ketamine, a synthetic pharmaceutical compound, is a widely used dissociative anesthetic listed on the World Health Organization's Essential Medicines. FDA approved in 1970, it's valued in medical settings for its rapid onset, safety, and short duration. Commonly employed in surgical procedures, especially in pediatric surgery, its excellent safety profile extends to breathing/airway management. Additionally, ketamine effectively manages acute and chronic pain due to its analgesic properties.
Recently, ketamine has found clinical application at subanesthetic doses for various mental health conditions, such as depression, alcoholism, substance dependencies, post-traumatic stress disorder, anxiety disorders, and other psychiatric diagnoses.
“Therapeutic ketamine” refers to ketamine that is administered to a patient primarily for a psychiatric indication, psychospiritual exploration, and/or psychological work. Therapeutic ketamine does not include ketamine that is administered primarily for anesthesia or pain management, which are considered separate fields (specialties) from therapeutic ketamine.” Ethical Guidelines were published (with additional commentary) in the Journal of Psychedelic Psychiatry (Vol 2, Issue 4, Dec 2020, pgs 19-23).
How Ketamine Works
Ketamine is a dissociative anesthetic, causing a sense of detachment from one's body and surroundings. It acts as an NMDA antagonist in the glutamate neurotransmitter system and an opioid receptor agonist. In depression, ketamine may stimulate neural growth, potentially offering relief from habitual thought patterns underlying mood and behavior. The exact mode of action is not fully understood, and research continues to explore additional mechanisms.
Dosing Strategies and Route of Administration
Ketamine can be administered through various methods, such as intravenous infusion, intramuscular injection, subcutaneous injection, intranasally, or sublingually/orally. At Widening Circles, we utilize intramuscular injection for its rapid onset and high bioavailability.
Research shows that low doses of ketamine, which are minimally psychoactive or sub-psychedelic, have demonstrated an antidepressant response. However, this effect usually accumulates with repeated administrations over short periods. Some practitioners believe that the psychedelic and dissociative experiences at higher doses offer a more robust and enduring outcome. Generally, lower doses are associated with empathogen-like (heart opening) responses, while higher doses lead to dissociative, psychedelic, out-of-body, and ego-dissolving peak experiences, though individual experiences vary.
The Ketamine Experience
The ketamine experience involves a relaxation of ordinary concerns and mindset, disrupting negative feelings. At lower doses, you may encounter mild anesthetic, anxiolytic, antidepressant, and psychoactive effects. Increased sensitivity to light and sound, altered time perception, and empathogenic effects may occur, enhancing participation in psychotherapy.
Higher doses are more likely to induce internal, dissociative, and psychedelic states, diminishing body sensations. These journeys can robustly address existential concerns, accelerate psychological and possibly spiritual growth, and foster a transformative response.
Sensory effects may include distorted visualization, feeling suspended or floating, out-of-body sensations, vivid imagery, and changes in visual, tactile, and auditory processing. Synesthesia may occur.
While some describe psychic experiences as bizarre or frightening, others find them pleasurable. Even challenging experiences can be valuable, and our team provides stability and psychotherapeutic support to navigate them for your recovery process.
Why Ketamine Assisted Psychotherapy (KAP)?
Being in a different state with ketamine can make you feel more open. Therapy sessions aim to build a connection and trust between you and your providers.
It's helpful to have a goal for the experience, like changing habits or exploring spiritual ideas. Our team will help you set these goals, but it's important to be open to the experience as trying to control it can cause anxiety.
Your sessions will be unique and each journey is unpredictable. Afterward, you may feel better emotionally and notice a reduction in symptoms like depression or anxiety. Your experience may shift your thinking, offering new perspectives and behaviors. Any temporary challenges will be understood in the context of your healing process, as our goal is to help you change patterns that cause difficulty and distress.
When Will I See Positive Effects, and How Long Will They Last?
Ketamine treatment has been shown to offer rapid relief of depressive symptoms. Studies report a 70% initial response rate and a 40-50% remission rate for treatment-resistant depression. Durable improvement usually requires multiple administrations as part of a comprehensive treatment program. It may not permanently relieve your condition, and combining it with other medications and psychotherapy is common to reduce the risk of relapse. Additional ketamine boosters or alternative therapies may be needed over time.
If you don't respond initially, repeated treatments are offered. However, if there's no response after multiple doses, additional ketamine won't be provided. The treatment team will discuss alternative options. While a course of ketamine treatment typically offers a few months of benefit, repeated treatments can have a cumulative effect. Ongoing research explores optimal dosing schedules and integrating psychotherapy to sustain these benefits.
Medical and Psychiatric Eligibility for KAP
Before participating, you will be carefully interviewed to determine if you are a good candidate for ketamine treatment. This will include discussing your medical and psychiatric history, and review of your medical and psychiatric records if necessary.
You are required to be under the care of a primary care physician to evaluate your overall health, and in particular your respiratory and cardiovascular status. You are also required to be under the care of a mental health provider, either a current therapist, or someone you begin treatment with at the start of your ketamine treatment and will continue your care thereafter.
Some medical and psychiatric conditions need to be treated before you can safely take ketamine. These conditions include hallucinations, untreated mania, unstable angina (chest pain/heart disease), uncontrolled hyperthyroidism, increased intracranial pressure, or evidence of liver disease. A previously demonstrated allergy to ketamine excludes one from treatment.
An EKG may be required for those with a history of arrhythmia or a history of cardiovascular issues. Untreated or uncontrolled hypertension is a contraindication to ketamine use, as the substance causes a rise in blood pressure. This increase is typically comparable to normal increases in blood pressure that occur with heavy exercise.
Pregnant women and nursing mothers are not eligible because of undetermined potential effects on the fetus or nursing child.
Those with a history of cystitis or other bladder issues may need to be cleared by urological consultation, due to the rare but potentially significant adverse effect of cystitis.
Those with a primary psychotic or dissociative disorder or who are currently in a manic or mixed episode are not eligible for treatment with ketamine. Please consult your treating clinician if you are taking Lamotrigine (Lamictal) or an anxiety medication such as benzodiazepines, pregabalin, or gabapentin as they may blunt the antidepressant effects of ketamine.
Information on ketamine’s interaction with other medicines is only partially available; any possible interactions will be assessed to help determine your eligibility for ketamine treatment.
Potential Risks of Ketamine
Ketamine has an extensive record of safety and has been used at much higher doses for surgical anesthesia without respiratory depression. As with any other medication, there are also some potential risks and side effects to be informed of and consider. The most common physical side effect is a short-term spike in blood pressure, pulse, or heart rate, which may be a risk to those with heart disease, and can be misinterpreted as a symptom of anxiety.
Other possible side effects include dizziness/lightheadedness, sedation, impaired balance and coordination, slurred speech, mental confusion, excitability, diminished ability to see things that are actually present, diminished ability to hear or to feel objects accurately including one’s own body, headache, anxiety, nausea, vomiting, and diminished awareness of physical functions such as respiration. These effects are transient and resolve as the active phase of the medication ends (generally within 4 hours). Repeated, high dose, chronic use of ketamine has caused urinary tract symptoms and even permanent bladder dysfunction or cystitis in individuals abusing the drug.
These adverse effects are much less likely in medically supervised ketamine treatment populations, but might include more frequent, painful, or difficult urination. Please inform your providers immediately if you notice any of these side effects. In terms of psychological risk, ketamine has been shown to worsen certain psychotic symptoms in people who suffer from schizophrenia or other serious mental disorders. It may also worsen underlying psychological problems in people with severe personality disorders and dissociative disorders.
Management of Adverse Effects
It is very important to abstain from eating or drinking in the 4 hours prior to your treatment so as to avoid nausea or vomiting. Additionally, due to possible blurred and altered vision, we advise keeping your eyes closed or using the eye mask provided (as long as you are comfortable doing so) until the main effects have worn off. Excessive movement can exacerbate nausea and dizziness, so it is best to lie still during the active phase while balance and coordination are impaired.
Driving an automobile or engaging in hazardous activities should not be undertaken on the day of the administration, and not until all effects have stopped. You will be assessed for safety prior to leaving the office premises, and will be required to arrange for a responsible person to drive you home from the administration.
We will check your vital signs before and after the administration, and be present throughout the session to monitor and treat any side effects. We will additionally reassure you prior to administration that the increase in heart rate is transient and due only to the effects of the medication, and not to anxiety or panic, nor any serious health condition.
We reserve the right to activate emergency response systems (such as calling 9-1-1) if it is determined by clinical judgment that your safety requires a higher level of care than can be provided in our setting.
Potential for Ketamine Abuse and Physical Dependence
Ketamine belongs to the same group of chemicals as phencyclidine (Sernyl, PCP, “angel dust”). This group of chemical compounds is known chemically as arylcyclohexylamines and are classified as hallucinogens (also known as psychedelics). Ketamine is a controlled substance and is subject to Schedule III rules under the Controlled Substance Act of 1970. Medical evidence regarding the issue of drug abuse and dependence suggests that ketamine’s abuse potential is equivalent to that of phencyclidine and other hallucinogenic substances.
Phencyclidine and other hallucinogenic compounds do not meet criteria for chemical dependence, since they do not cause tolerance and withdrawal symptoms. However, cravings have been reported by individuals with the history of heavy use of psychedelic drugs. In addition, ketamine can have effects on mood (feelings), cognition (thinking), and perception (imagery) that may make some people want to use it repeatedly. Therefore, ketamine should only be used under the direct supervision of a licensed prescriber. We have not had clients become dependent on ketamine.
Alternative Procedures and Treatments
Psychotherapy without ketamine is available and can be effective. Major Depression (MDD), PTSD and Bipolar Disorders are usually treated with antidepressant medications, tranquilizers, mood stabilizers and psychotherapy. PTSD is often also treated with Eye Movement Desensitization and Reprocessing (EMDR). Electroconvulsive therapy (ECT) and the recently introduced Transcranial Magnetic Stimulation (TMS) are also in use for treatment resistant depression.