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Who Is Not a Good Candidate for Ketamine Therapy?

Ketamine-assisted psychotherapy (KAP), or ketamine-assisted therapy, has seen an explosion of growth over the last several years in the United States but the practice of using subanesthetic doses of ketamine to facilitate the therapeutic process was first studied by two Iranian psychiatrists, Khorramzadeh and Lotify, who published their findings in 1973.  The following year, Fontana published a report indicating that ketamine could be an effective adjunct to psychotherapy treatment of depression.  From the late 1980s into the early 2000s, Russian psychiatrist Evgeny Krupitsky used “psychedelic” doses of ketamine to treat alcoholism and opiate addiction with much-improved abstinence rates compared to conventional treatment.  Krupitsky noted the importance of including a supportive therapy component if one was to maximize the potential for ketamine to induce behavior change and this is why ketamine-assisted therapy has evolved into a popular intervention for depression, anxiety, PTSD, and chronic pain.  


What is ketamine?

Prior to the mid-1960s, a widespread general anesthetic was phencyclidine (PCP) but this compound was problematic in that some patients would come out of surgery in a psychotic state that could be aggressive and prolonged.  The pharmaceutical company, Parke-Davis, had commissioned some chemists to find an alternative general anesthetic that was safer and did not produce such unwanted side effects. In 1962, Calvin Stevens was an organic chemistry professor at Wayne State University in Detroit, MI and he was the first to synthesize ketamine which was patented by Parke-Davis in 1966.  Ketamine was used extensively on the battlefields of the Vietnam War because it did not cause cardiac or respiratory depression and in 1970, the FDA approved ketamine for human consumption.  It was eventually discovered that lower, sub-anesthetic doses of ketamine could produce profound mind-altering effects of a psychedelic nature in addition to providing the patient with a burst of activity in the glutamate system of the brain which is believed to be responsible for the rapid anti-depressant effects and reduction of acute suicidality.  There are also downstream effects of ketamine which can mimic the actions of prescription anti-depressants. 

 

What is ketamine-assisted therapy?

Ketamine therapy would essentially be the purely medical model of ketamine treatment in that the therapeutic component is not thought to be necessary and the benefits are solely derived from the administration of ketamine.  While this can many times produce a reduction of symptoms, sometimes drastically, patients of this type of therapy will likely return to baseline symptomology within 4-8 weeks without further administrations of ketamine.  Ketamine-assisted therapy, on the other hand, views ketamine as a potentially powerful catalyst for change by embedding ketamine treatments within a protocol of psychotherapy.  At the Pearl Psychedelic Institute, we spend time getting to know a patient and their struggles and a thorough history-taking assessment allows our clinicians to understand the roots of these struggles as well as context for understanding how these struggles have maintained and impacted their lives.  After passing a medical screen to confirm the patient's suitability for ketamine administration, attention is spent on the preparation phase of the ketamine-assisted therapy.  In these preparation sessions, the patient is educated about what the ketamine experience may be like for them, given instructions on how to surrender to the experience non-judgmentally, and ways in which to facilitate work with the medicine.  Identifying and articulating intentions is a critical step in the preparation phase for any kind of psychedelic-assisted therapy and our Pearl clinicians assist our patients in formulating 1-3 clear intentions for each ketamine-assisted therapy session.  The Pearl typically favors the intramuscular (IM) route of administration with the goal of facilitating a psychedelic experience and the patient is supported by the presence of the clinician throughout the session.  Our ketamine sessions are scheduled for 3 hours (unlike many other providers) because the hour or so after the patient emerges from their ketamine experience is “The Golden Hour” where the first integration work takes place.  After spending some time recollecting the ketamine experience, the clinician and patient then explore the potential meanings behind the imagery, insights, and memories that often surface.  The human psyche inherently wants to move towards balance and wholeness.  Therefore, the information gleaned from a psychedelic (mind-manifesting) experience intends to show the patient possibly new, healthier ways to view their struggles, themselves, and the world.  These potential shifts in perspective are only possibilities unless the patient is empowered to bring this information into their daily lives which is why integration work is so important.  


Who Can Benefit From Ketamine-Assisted Therapy

Ketamine-assisted therapy has been demonstrated to be potentially effective for the treatment of depression, including longstanding treatment-resistant depression.  These patients have been “stuck” for many years and conventional treatments have only been minimally effective, if at all.  The burst of glutamate activity coupled with the expanded awareness of the psychedelic experience can provide patients with the insight, inspiration, and increased energy to leave the session and begin to implement the changes they need to make in their lives to be less depressed.  Ketamine-assisted therapy has also been helpful in treating various anxiety disorders, including post-traumatic stress disorder (PTSD), and it has been helpful in easing complicated bereavement as well as some chronic pain issues.  There is also evidence that ketamine-assisted therapy may be helpful in treating patients for substance use disorders but this population would likely respond best if they were truly at a point of wanting to overcome their problem and were committed to recovery.  


What Disqualifies You From Ketamine Therapy

Although ketamine has a strong safety profile, there are certain mental health and medical conditions that will preclude a patient from safely receiving ketamine-assisted therapy.  Mental health conditions such as schizophrenia and other psychotic disorders are generally not going to be amenable to ketamine-assisted therapy.  Patients suffering from these severe conditions have fragile ego strength and the potential dissociative, ego-dissolving effects of psychedelic doses of ketamine are likely not going to be helpful.  For those patients, it may be possible to safely administer ketamine intravenously (IV) so that the dose can be closely managed and psychedelic effects avoided or minimized.  There is also some controversy around treating patients with borderline personality disorder for the same ego-strength concerns but with proper careful preparation and integration, I feel like many of these patients could be treated.  There may be some risk to treating patients with bipolar disorder in that ketamine can sometimes trigger mania so treatments should only occur when these patients are in a depressive phase and they should be monitored following treatment.  On the medical side, pregnancy, uncontrolled hypertension, and acute cardiovascular disease will preclude one from ketamine therapy.  Ketamine tends to play well with other medications but benzodiazepines have consistently demonstrated reduced ketamine anti-depressant effects.  In addition, lamotrigine (Lamictal) may block the effects of ketamine but we have found that if a patient skips their dose the morning of the ketamine session, they can typically get the benefits of ketamine.


Learn More About Qualifications and If Ketamine-Assisted Therapy is Right for You

To learn more about ketamine-assisted therapy and if it is right for you, please visit our website at https://www.pearlpsychedelicinstitute.org/ check out our ketamine blogs, and consider completing a ketamine-assisted therapy referral form.  If you have questions or require some consultation, you can send an email to info@pearlpsychedelicinstitute.org and one of the Pearl clinical staff will respond.  


Ketamine-Assisted Therapy Training

The Pearl Psychedelic Institute offers an Introduction to Ketamine-Assisted Psychotherapy Experiential Weekend training for healthcare professionals who are interested in learning more about ketamine and its therapeutic uses.  This is a four-day training that begins with Day 1 providing 7 hours of CE didactic instruction that focuses on the history and research of ketamine, how ketamine-assisted therapy is safely and effectively provided to patients as well as special attention on integration, accessibility, and the need for providers to be trauma-informed.  Day 2 and Day 3 are experiential days where the 12 participants pair up and experience ketamine troche and then IM routes of administration, respectively, as both patients and sitters.  Group integration follows each morning and afternoon session on those days.  All experiential sessions take place under close medical and clinical supervision.  Day 4 is devoted to the practice of integration and closure.  There are currently no national or state certification requirements for being a ketamine-assisted therapy provider but this training will give each participant an excellent knowledge and skill base to be able to make an informed decision about whether a participant wants to provide this service.  For more information on this training, please visit our website.


KAP Training At the Psychedelic Institute
Image By: Douglas P Cooper | IG: blueridgeimages

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