What is ketamine?
Ketamine is a legal medication, originally used in Western Medicine for anesthesia. It was developed in the 1960s and was used a lot in the Vietnam war because it easy to use in the field. It proved to be safe and effective. Ketamine does not suppress the respiratory drive or paralyze muscles the way other anesthetics do, and its dissociative properties provide for rapid pain relief. Ketamine has been used in the mental health space for at least 20 years and in medicine for 60 years and as a result we know that the medicine itself is extremely safe for most individuals.
Ketamine is FDA approved for anesthesia and is used as an off-label medication for pain and mental health conditions. Recently, the FDA approved a specific form of ketamine to be used for Treatment Resistant Depression (TRD). TRD does not have an agreed upon definition but typically refers to people who have had an inadequate response from at least one antidepressant medication. TRD is relatively common with 50% or more of patients not achieving an adequate response following antidepressant therapy. This specific form of ketamine is patented by a drug company and very expensive and as a result not used by many providers practicing ketamine treatment. In addition, other routes of administration may be more effective. The hope is that this approval will lead to approval of ketamine as a treatment for depression and other mental health conditions and be covered by insurance.
What is ketamine
Ketamine is an NMDA receptor antagonist (the site of physiologic function in the brain) and it is believed that through this mechanism the brain signals different pathways to promote the building of new cells and new connections between these cells in the brain, referred to as neuroplasticity. For a long time we believed that the brain did not change once it was fully formed, but we have learned that this is not true. The brain is capable of changing, (neuroplasticity), and creating new connections and pathways through a variety of different methods. Some of those methods are meditation and exercise. Another is psychedelic medicine. It is believed that this is the mechanism through which ketamine has healing effects on depression and other mental health conditions.
The dissociative effect of ketamine means that it creates a separation of mind and body, or an “out of body” experience. While ketamine is not a true psychedelic because it does not predominantly work on the serotonin receptors (5-HT2A), it does have psychedelic properties and creates a “non-ordinary” state of consciousness (also referred to as altered state of conscious) allowing the mind to be outside of its normal waking status, and in this state, the mind can access subconscious information.
Ketamine is a powerful disruptor of limiting beliefs around ourselves and our world, allowing one to see themselves truly without all the labels and limitations. It often creates a euphoric feeling for people and many report having a sense of oneness and connectedness to others and to something bigger than themselves. Ketamine can also allow people to revisit times or memories of trauma and reconsolidate the memories around those events in a less painful, fearful, or traumatic way.
Research has shown that ketamine does do work itself. The medicine has a physiologic and psychologic effect, but that this can be short lived. Ketamine is a tool to support healing and helps to access, open up, and direct us to where the healing needs to happen. Ketamine treatment still requires that the person has a desire to heal and wants to do the work to get the results. A major component of ketamine treatment is integration. Integration involves the process of taking the insights, lessons, visions, experiences, and feelings that occur during a ketamine experience and determining the meaning of these for you in your life. The next step is creating tangible ways for you to make changes in daily life and to anchor these concepts, insights, and new ideals into how you view yourself and interact with the world. Psychotherapy can be very supportive for integration. Having psychotherapists trained specifically in psychedelic integration working with you while undergoing ketamine treatment substantially improves the longevity and sustainability of the positive effects experienced from the medicine experience itself. In addition, we know that having an induction period of a number of ketamine treatments close together also creates more lasting results. This induction period is usually 4-6 ketamine sessions, doing 1-2 a week and supported with integration and/or psychotherapy.
How does ketamine work?
How is ketamine administered?
Ketamine is a liquid and can be prepared and delivered by a variety of routes. Ketamine can be made into a syrup and taken orally or into lozenges that are meant to dissolve under the tongue (sublingual). Ketamine can also be used as an intranasal spray. Ketamine can also be injected into the muscle(intramuscular) or infused into the veins(intravenous). The way in which ketamine is administered determines how much of the drug is readily available for the body to use (bioavailability). Intravenous infusion provides 100% bioavailability and also creates the most rapid onset of effect. Intravenous infusions require having an IV in place and medical monitoring throughout the infusion, which may to some degree inhibit the setting for a psychedelic experience. However, this option may be safer for some people who are high risk or have relative contraindications for ketamine treatment. Oral lozenges have the lowest bioavailability and have a slower onset of effect, which can be supportive for people who have some anxiety and nervousness around the experience.
The intramuscular injection has a bioavailability of 93% with an onset of effects in 3-5 minutes. This method allows for administration in an office setting that can be less traumatic, does not require an IV or a monitor, but still creates a meaningful response at lower doses than the lozenges.
What happens during a ketamine experience?
Ketamine is similar to other psychedelic medicines regarding the need to paying close attention to (mind)set and setting. Working with people to prepare them for the experience is crucial. This includes a number of different steps. Starting with the the initial medical evaluation, which serves a number of different functions. It primarily allows the physician to create a medically safe environment for you and also identify any potential reasons that ketamine therapy may not be appropriate for you. The physician inquires into your psychological history to evaluate for concerning mental health conditions. We begin to establish a safe therapeutic relationship, and to be aware of anything that may come to the surface during a ketamine experience so we can best support you. Some people also prefer to have 1-3 psychotherapy talk sessions prior to beginning treatment with ketamine. These can be invaluable to building a trusting relationship with the practitioner. During these initial meetings there is also preparation for the experience. Preparation includes explaining what will happen around the medicine session itself, who will be present during the session, what the physical setting is like, what needs to be done prior to the treatment, describing what they may feel or experience, and reassuring them that safety is a primary focus. This preparation stage is especially important for those who have never experienced a non-ordinary state of consciousness or used psychedelics. Another aspect of these initial meetings is working on intentions for the experience. Thinking and/or journaling about why you want to do ketamine, what you are looking to get out of the experience, and questions or problems you want to solve are a good starting point. We usually ask you to develop 1-3 intentions. It is important to have an intentional mindset going into the experience, but it is also important not be attached to these intentions and being okay with the fact that the journey may or may not address these intentions. The ketamine journey will give you exactly what you need. Please know and accept that there is an inner healing intelligence within each of us, and that inner intelligence has knowledge about what we need to heal.
The setting of the experience is intentionally made to feel calm and relaxing and less medical. The patient is in a reclined position with access to pillows and blankets as needed. The person has an eye mask on during the experience and will have on headphones that play specifically curated music to support the experience. The person is never left alone, the physician and possibly the psychotherapist are present throughout the entire experience. The medicine’s effect is about 45-60 minutes and after 60 minutes we start doing some initial integration. During this critical period people are very open and have the highest amount of recall from the experience and we believe it is important to have support during this time. The experience is approximately 2-3 hours and it is required that the person have a friend or family member pick them up from the session. A subsequent integration or psychotherapy session will be scheduled in a short period of time after the session(s) to continue integration and healing.