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What is Ketamine Assisted Therapy?




Intro


Over the past decade, the use of ketamine has been growing in utility and popularity amongst mental health clinicians and patients alike as a potential treatment option for various forms of emotional distress. Ketamine treatment, in combination with psychotherapy, which is also referred to as Ketamine Assisted Psychotherapy (KAP), can provide profound relief from depression and/or anxiety symptoms sometimes even after a single treatment. Most typically, the treatment is offered as a series of ketamine treatments alongside psychotherapy sessions to support more lasting changes in mood, anxiety, and/or substance use problems; depending on the intentions set at the beginning of treatment.



What is Ketamine?


Ketamine was first synthesized in 1956 and approved for use by the FDA as an anesthetic in the United States in 1970. It was first used in clinical practice in the 1960s as an alternative to its parent compound, phencyclidine (PCP), as an anesthetic agent during surgery. While the use of PCP has since been discontinued in the US due to undesirable side effects, ketamine continues to be a preferred anesthetic due to its highly favorable safety and tolerability profile. Initially, ketamine was classified as a “dissociative anesthetic” by the anesthesiologists, however; it has more recently gained traction in the psychiatric community as a potential treatment for a variety of psychiatric disorders. At the time of writing this (July 2022), this is the only psychedelic drug available to mental health providers for the treatment of emotional distress manifesting in a variety of psychiatric disorders. The FDA has only approved an intranasal form of ketamine called Spavato, to be used specifically for Treatment-Resistant Depression. Nonetheless, the success clinicians and patients have experienced with other forms of ketamine and for the treatment of other mental health conditions, has led to a significant rise in its clinical use. Between 2015 - 2018, the United States has seen a dramatic 500% increase in mental health offices offering ketamine treatments. Clinicians administer ketamine to patients via the intravenous route (i.v.), intramuscular injection (IM inj.), orally via absorption through mucosal membranes in the mouth, or via intranasal routes.



What is Ketamine Assisted Therapy?


Ketamine Assisted Psychotherapy (KAP) is a therapy utilizing ketamine combined with psychotherapy to treat a variety of mental health conditions. Ketamine can enhance and deepen the therapeutic process. Its treatment is usually combined with somatic and experiential-based psychotherapies such as Existential psychotherapy, Hakomi method therapy, and Internal Family Systems (IFS), in conjunction with mindfulness practices. KAP also supports and encourages the inclusion and/or development of spirituality and spiritual practices. Many practitioners believe accessing the psychospiritual aspects of the treatment process enhances the healing effects of KAP. Specific intentions are made at the onset of a KAP session reflecting the individual's aspirations for the care on an emotional or spiritual level.


In low doses, ketamine can function as a supportive adjunct to psychotherapy, because it gives a brief softening of psychological defenses, allowing for deeper self-reflection and psychotherapeutic processing. At moderate doses, ketamine has psychedelic effects, and may facilitate an out-of-body experience and near-death experiences (NDEs). Some studies of KAP have made positive correlations between NDEs and the alleviation of depressive symptoms. This suggests that experiences that include out-of-body and/or NDE may be directly associated with the therapeutic benefits of KAP treatments. Integration sessions help to provide clarity to the content brought forth during KAP treatments, allow for ongoing emotional processing, add a spiritual dimension to ongoing healing work, and/or facilitate a feeling of interconnectedness.



How does Ketamine Work?


On a neurobiological level, the effects of ketamine for the treatment of depression and/or anxiety symptoms seem to be associated with its activation of both NMDA receptors and AMPA receptors in the brain, as well as the secondary activation effects of its metabolite, norketamine, on the AMPA receptor. The downstream effects of activating these receptors are increases in glutamate release in the brain, increases in Brain-Derived Neurotrophic Factor (BDNF), and ultimately increases in the nerve cell growth. Ketamine researchers have demonstrated in animal models an increase in the number of dendritic spines on nerve cells which allows for increases in cell signal transmission. This ultimately suggests that ketamine allows for nerve cells to develop new connections and fosters cell network growth. Learn more here.



What can I expect with Ketamine?


Ketamine administration for the treatment of mental health conditions is given at much lower doses than what is used for anesthesia. With now over 60 years of demonstrated safety and tolerability, we can comfortably administer ketamine in an outpatient office setting. One can also expect to remain awake and conscious throughout a ketamine treatment experience.


Individuals report feelings of dissociation which may be described as ‘floating’, or ‘disconnected’ from the body or from parts of the body (e.g. arms or legs), or feeling disconnected from the environment. Vision is distorted while under the influence of ketamine. Colors or sounds can be altered, such as seeming to be more loud, vibrant, or intense. Sometimes people report synesthesia sensations such as tasting the music being played, or seeing the music, for example. Time perception may be altered as well.



What are the benefits of Ketamine-Assisted Psychotherapy?



There is data supporting ketamine’s ability to enhance cognitive functioning. For example, patients who were been treated with esketamine (intranasal ketamine) have shown an overall improved reaction time, improved verbal learning and memory, and improved executive functioning.



Is Ketamine legal?


The use of ketamine is regulated, which means it must be prescribed and/or administered by a clinician(s) with the authority to prescribe medications. Under these parameters, it is completely legal. Of note, ketamine is used recreationally and has incurred the street drug name of “Special K”.



Is Ketamine Addictive?


The Drug Enforcement Administration (DEA) has indexed ketamine as a Schedule III substance pursuant to the Controlled Substances Act because of concerns about its abuse potential. Schedule III drugs are considered to be less addictive than Schedule I or II pharmaceuticals, but perhaps more addictive than Schedule IV or V drugs. Interestingly, most clinicians using ketamine as a component of KAP therapy have seen minimal to no addictive behaviors associated with ketamine. And there has been no evidence of any individuals in ketamine study trials demonstrating drug-seeking behavior, ketamine cravings, or any withdrawal symptoms associated with ketamine treatment.


At this time, there have been few and only small studies of ketamine and KAP for the treatment of substance use, so there is still much to be explored and understood but ketamine and KAP are being explored in current research as a treatment for substance use disorders and/or alcohol use disorder. Anecdotally, KAP has been seen to help individuals abstain or cut down on drug and alcohol use. It may be that KAP treatment allows individuals to process potentially painful material that otherwise may be too difficult to process and thus the cycle of substance use continues to mask or numb the difficult emotions.



What are the side effects of Ketamine?


Clinical trials using intravenous (i.v.) ketamine for the treatment of Major Depressive Disorder (MDD) have shown the most common adverse effects of ketamine occur in the first four hours and include dizziness, and a sense of derealization, and drowsiness. About one-third of patients receiving ketamine will have transient and mild increases in pulse and blood pressure. On occasion nausea and/or vomiting occurs, although this can usually be avoided or mitigated by avoiding food prior to the KAP session and the use of anti-nausea medication.



Who qualifies for Ketamine Assisted Psychotherapy?


KAP is not for everyone and it is not a stand-alone treatment for mental health.

Please feel free to reach out to our team to help determine if you qualify for this treatment.






References


Abdallah, Chadi G et al. “The neurobiology of depression, ketamine and rapid-acting antidepressants: Is it glutamate inhibition or activation?.” Pharmacology & therapeutics vol. 190 (2018): 148-158. doi:10.1016/j.pharmthera.2018.05.010. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6165688/


Dore, Jennifer et al. “Ketamine Assisted Psychotherapy (KAP): Patient Demographics, Clinical Data and Outcomes in Three Large Practices Administering Ketamine with Psychotherapy.” Journal of psychoactive drugs vol. 51,2 (2019): 189-198. doi:10.1080/02791072.2019.1587556. https://pubmed.ncbi.nlm.nih.gov/30917760/


Fava, Maurizio et al. “Double-blind, placebo-controlled, dose-ranging trial of intravenous ketamine as adjunctive therapy in treatment-resistant depression (TRD).” Molecular psychiatry vol. 25,7 (2020): 1592-1603. doi:10.1038/s41380-018-0256-5. https://pubmed.ncbi.nlm.nih.gov/30283029/

Greenway KT, Garel N, Jerome L, Feduccia AA. Integrating psychotherapy and psychopharmacology: psychedelic-assisted psychotherapy and other combined treatments. Expert Rev Clin Pharmacol. 2020 Jun;13(6):655-670. doi: 10.1080/17512433.2020.1772054. Epub 2020 Jun 1. PMID: 32478631. https://pubmed.ncbi.nlm.nih.gov/32478631/


Li, Linda, and Phillip E Vlisides. “Ketamine: 50 Years of Modulating the Mind.” Frontiers in human neuroscience vol. 10 612. 29 Nov. 2016, doi:10.3389/fnhum.2016.00612. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126726/


McElvery, Raleigh. “The Past, Present and Future of Using Ketamine to Treat Depression.” 24 May 2022. Accessed 23 June 2022.


“Mindbloom: The Neuroscience of Ketamine.” Mindbloom , https://www.mindbloom.com/the-neuroscience-of-ketamine.


Minkin, Ethan, “The Ketamine Clinic Craze: Legalities and Possibilities.” Harris Bricken Sliwoski LLP, 20 June 2022, https://harrisbricken.com/cannalawblog/the-ketamine-clinic-craze-legalities-and-possibilities/.


Office of the Commissioner, and Federal Food and Drug Administration. “FDA Approves New Nasal Spray Medication for Treatment-Resistant Depression; Available Only at a Certified Doctor's Office or Clinic.” U.S. Food and Drug Administration, FDA, 5 Mar. 2019, https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified.


Shiroma, Paulo R et al. “Neurocognitive performance of repeated versus single intravenous subanesthetic ketamine in treatment resistant depression.” Journal of affective disorders vol. 277 (2020): 470-477. doi:10.1016/j.jad.2020.08.058. https://pubmed.ncbi.nlm.nih.gov/32871534/


Yavi M, Lee H, Henter ID, Park LT, Zarate CA Jr. Ketamine treatment for depression: a review. Discov Ment Health. 2022;2(1):9. doi: 10.1007/s44192-022-00012-3. Epub 2022 Apr 15. PMID: 35509843; PMCID: PMC9010394. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9010394/


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