What to Expect From Ketamine Therapy
*This article was originally published August 2021. It is reproduced here for valuable public education.
by DR. SCOTT ALLEN, owner of Satori Health and Wellness
In the world of ketamine treatment, a potential patient will find a vast array of treatment options. It can be confusing, especially in such a vulnerable state. Today I’ll outline the standard methods of administration and philosophies surrounding ketamine therapy.
Mindset and Treatment setting
Because of its often unpredictable psychoactive effects, the setting in which ketamine is delivered can vastly change the course of treatment. When given in a sterile, noisy, chaotic operating room, patients describe a ‘dysphoric’ and scary experience. But when presented in a calm, quiet, home-like setting, with a supportive caregiver (or guide), the experience is much more euphoric and enlightening.
Equally important is the mindset of the patient coming into therapy. Nobody seeks ketamine therapy because their inner state is a zen-like garden of order. But understanding why you’re seeking treatment, having clear goals, and a humble expectation of success is essential. Unless a patient is imminently suicidal, I encourage patients to wait several weeks before initiating therapy. Preparatory guidance about expectations, working with a patient’s therapist, and beginning a meditation practice can make or break the success of ketamine therapy.
The importance of the guide
Ketamine by itself is not a magic bullet. This is a significant point to absorb: if you get ketamine for depression, you’ll feel better for a while. But after about ten days, the depression will sink back in if you don’t pair it with some sort of integration therapy.
Like other psychedelics, ketamine can create an experience of mind expansion. Some patients report an out-of-body experience. Some say that they feel more connected to themselves and the world around them. Others, who may be struggling with traumatic pasts, can experience intense anxiety and fear. This is why it is essential to undergo ketamine therapy in a supervised setting. Many clinics will leave you alone in a room. While this will work for some patients (and be more profitable for the clinic), many patients can be re-traumatized by the medicine if they are not adequately supervised.
Inner work with a therapist, family member, or trusted friend is essential for maintaining the benefits of ketamine therapy.
High-dose vs. low-dose
Dosing is an area of divergence among ketamine practitioners. High-dose therapy (>0.5mg/kg) has the goal of inducing a dissociative state. Patients often describe being out of body, having insights, dreams, visions, or what we sometimes call a ‘mystical experience. The goal here is to separate a patient from their circular, ruminative thought patterns.
High-dose therapy depends greatly on the set and setting of treatment. The experience is often more anxiety-provoking, but the potential success may be more significant. Insights into the patient’s mental blocks and triggers are often brought to light this way. But high-dose therapy isn’t for everyone, especially for patients who are not ready to have such a massive shift in their thought processes.
Low-dose therapy (<0.5mg/kg) is probably the most practiced method. It reliably produces sedation, euphoria, and transient depression relief. The patient is awake the entire time. Visual changes may happen, but they aren’t as grandiose. Some insights may occur. Low-dose therapy is typically psycho-lytic in that some of the protective walls around the psyche may be relaxed for a brief time. This experience works well with psychotherapy simultaneously as the treatment, as the patient is aware and can work through issues with the therapist. The set and setting are important during low-dose therapy, as it can still trigger a bad experience if the patient isn’t in a supportive environment.
Routes of Administration
The most common method is intravenous, but many practitioners give ketamine intramuscularly. Intravenous administration allows greater control over the experience and potentially leads to faster remission from depression symptoms. IM injections have the advantage of being less expensive and easier to administer for non-anesthetists, but once the medication is given, it can’t be stopped. Drug absorption is similar between IM and IV, so the effects will be similar.
Intranasal Ketamine
In 2019 the FDA approved Spravato (esketamine) for use in treatment-resistant depression. It is delivered through a nasal spray. It seems to be an effective method of providing ketamine, and insurance will sometimes cover Spravato.
The nasal spray route presents some challenges. If a patient has a cold, sinusitis, or allergies, the absorption will be variable. You don’t know exactly how much the patient will get, so you have to be flexible with expectations. In studies of efficacy, Spravato works better than a placebo for depression relief.
Oral Ketamine
Oral ketamine can be delivered through a troche or lozenge. Some patients can take this at home for maintenance therapy. One strategy I find particularly effective is using oral ketamine as part of ketamine-assisted psychotherapy (KAP). A patient self-administers oral ketamine in the presence of their therapist. This method often results in rapid therapeutic breakthroughs.
Additionally, using ketamine with a therapist mitigates the addictive potential. If a patient has unrestricted access to ketamine, there’s about a 10% chance that they will become dependent on the medication, similar to alcohol and other drugs of abuse.
Treatment course
Most of the early studies reported giving ketamine six times in 2 weeks, acting as a rapid reset of neural pathways. This number was chosen more or less arbitrarily, but it has pretty good results-- often showing a 70% response rate. But, again, after about ten days, the depressive symptoms creep back in.
At our clinic, the six treatments are spread out over three months. We find this regimen to be more durable, and patients usually spend less money overall.
Whichever clinic you choose, remember that the rapport you develop with the provider will often determine the overall treatment success.
Medication vs. psychology vs. spirituality
Ketamine works via a different mechanism than other antidepressants. It blocks the NMDA receptor and its glutamate transmitting system. Most of medicine takes the view that depression is a biochemical process, and restoring favorable chemistry will improve depression. The practitioners who deliver low-dose and intranasal ketamine often take this view. Dissociation is seen as something to be avoided. Many patients have been helped in this way. I find low-dose therapy to be transient, however, and symptoms of depression and anxiety usually recur. That said, I’m open-minded about different ways to deliver ketamine. This is an area of medicine in its infancy and will surely evolve as time goes on.
I prefer to use high-dose therapy in patients that are amenable to the process. I find that having a ‘mystical experience, a session in which the patient often fails to find words that adequately describe what they’re experiencing, can be a catalyst to progress. When followed by regular psychotherapy, patients can work through the self-limiting beliefs and unproductive coping mechanisms that have been built up over the years.
Psychedelic therapy often shares similarities with spiritual experiences. Saints, prophets, mystics, and sages have– for millennia– described other-worldly, rapturous, ineffable, and visually captivating journeys. Ketamine is often described as a ‘transcending’ experience, wherein we step outside this plane of reality. We are going beyond our limited sensory experience of the world. I find it helpful for patients to gain a respect for the unknowable, as ketamine almost universally produces a journey that defies description. When we stop trying to control our inner world and surrender to the flow of time and space, we become open to the outer world. We treat life as a playground vs. a prison.