faq

Ketamine is a synthetic pharmaceutical compound, classified as a dissociative anesthetic. It is one of the most widely used drugs in modern medicine, and is on the World Health Organization’s List of Essential Medicines. It was developed in 1963, FDA approved in 1970, and adopted by many hospitals and medical offices because of its rapid onset, proven safety, and short duration of action.

Ketamine is most commonly used in surgical settings, including pediatric surgery, due to its excellent safety profile, particularly around breathing/airway management. It has also been utilized successfully in managing acute and chronic pain conditions due to its analgesic properties.

In the last two decades, ketamine has been increasingly clinically applied at subanesthetic doses as an off-label treatment for various chronic treatment-resistant mental health conditions, such as depression, alcoholism, substance dependencies, post-traumatic stress disorder, obsessive compulsive disorder, and other psychiatric diagnoses.

Non-medical and recreational use of ketamine began in the late 1970s, leading to its cultural reputation as a club/party drug; it was also enthusiastically adopted by the psychedelic community and others who value exploration of altered states.

Depression is a common, severe, and potentially life-threatening syndrome. Several preclinical and clinical studies suggest that the glutamatergic system is involved in the mechanism of action of antidepressants. The non-competitive NMDA antagonist ketamine has been shown to have a rapid (hours) therapeutic effect in unipolar depression, treatment-resistant depression, and bipolar depression. Intravenous (IV), intramuscular, sublingual, or oral administration of subanesthetic doses of ketamine results in rapid, robust and relatively sustained antidepressant effects including the rapid resolution of suicide ideation (1-16). The following clinical algorithm was developed to implement and ensure the safe use of ketamine for the treatment of moderate to severe, treatment resistant depressive symptoms including suicidal ideation (SI). This guideline is based on an extensive review of the literature as well as the combined collaborative experience of physicians and psychiatric nurse practitioners using ketamine for the treatment of depression. Given the safety, high degree of flexibility in the administration route of subanesthetic doses of ketamine (1-16), this guideline provides a set of broad and flexible recommendations that can be implemented as recommended by the psychiatrist working in collaboration with psychotherapist to best fit specific cases. Patients may experience Conscious Sedation is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually not impaired.

In our practice, a medical doctor or a nurse practitioner administers ketamine for the treatment-resistant depression after the failure of other treatments. Ketamine is not a first line treatment for depression and it is “off-label” at this time and not FDA approved for depression treatment.

As mentioned, ketamine is classified as a dissociative anesthetic, where “dissociation” means a sense of disconnection between mind and body, and from one’s ordinary reality and usual sense of self.

The present understanding of ketamine’s mode of action is as an NMDA antagonist working through the glutamate neurotransmitter system. (This is a different pathway than that of other psychiatric drugs such as the SSRIs, SNRIs, lamotrigine, antipsychotics, benzodiazepines, etc.)

In depression, the spindly receptors on neurons that facilitate signal transmission may recede, and the amygdala and hippocampus (both which help govern mood) may shrink. Animal research has shown that ketamine can stimulate neural growth within days (and sometimes hours). One hypothesis is that there is similar action in humans.

Another hypothesis is that ketamine affords a reprieve from habitual patterns of thought that underlie mood and behavior, thereby creating an opportunity for learning new and healthier patterns of thought. There is no current consensus on mode of action, and other mechanisms may be found central to ketamine’s effects.

In the days leading up to your first ketamine administration session, it is beneficial to take some time to self reflect and set goals for your journey. Many have found it beneficial to set an intention for the experience. Engage in relaxing activities to encourage a sound mind and body.

On the day of your KAP appointment you will first meet with your provider. Together you will take some time to build a sense of connection between you and your providers, as we believe that the efficacy of this medication is tremendously enhanced by safe settings in the context of trusting relationships. This can be done by determining an invocation, or a phrase or feeling recited to draw focus. Music can also be used to provide a welcome and relaxing environment. Your level of participation is entirely up to you. You have the control to stop or change the session at any time.

Your overall session will last for 2 to 3 hours. At the end of this time, you will be assessed to determine if your mental awareness is at a stable state.

Ketamine treatment can result in a number of benefits, and there are now many studies demonstrating its efficacy; however, it is still a relatively new and experimental psychiatric intervention, and there are no guarantees of your outcome.

Ketamine is distinguished from other psychotropic medications by its rapid onset, often producing relief in as soon as a few hours. The literature indicates a 70% initial response rate to ketamine, as well as a remission rate (return of symptoms) for people with treatment-resistant depression of 40-50%.

Durable improvement generally occurs with more than one administration, and is most robust when part of an overall treatment program. It may not permanently relieve your condition. If your symptoms respond to ketamine, you may still elect to be treated with other medications and ongoing psychotherapy to reduce the possibility of relapse. Over time, you may also need additional ketamine booster administrations or other therapies to maintain your remission.

If you do not respond to ketamine after the first administration, repeated treatment will be offered. If you do not respond after a series of 8 doses, additional ketamine will not be offered. Studies have shown it is not effective to keep repeating ketamine in those who do not respond to the first doses. The treatment team will discuss with you other available options at that time.

Although a course of ketamine treatment typically provides only a few months of benefit, repeated treatments have been shown to have a cumulative effect, prolonging mood improvements, and current research is focused on how to sustain these benefits with an optimal dosing schedule and integration of psychotherapy.

This is an effective medicine, and it is even more so when you work with it to create positive changes in your life that can sustain your recovery.

Your responsiveness to the treatment will be tracked in our electronic survey program. The survey program will apply a scale to your mood/pain/cravings, and allow you and your provider team to discuss what may have been brought forth for you.

Throughout your KAP journey you are encouraged to participate in the surveys and in personal journaling. These results and any personal notes that you would like to share can be discussed with your provider team. We have found that these objective measures provide valuable perspective about the progress made in our work together.