IS KETAMINE TREATMENT RIGHT FOR ME?
If you hadn’t noticed yet, we are in the midst of a shift in how we talk about and treat mental health concerns. Up to 33% of people with depression don’t respond to multiple kinds of conventional antidepressants. The story that people with depression or anxiety have a chemical imbalance and need to be on daily medication for the rest of their life (the serotonin hypothesis) has been debunked and more and more folks are now looking to other ways of healing. It has become clear that the body has a much more complex process than the “chemical imbalance” theory suggests as there are multiple elements involved in mood and recovery.
Over the last several years there has been greater awareness of other elements involved in mood including GABA and glutamate and the process of neuroplasticity. Where it was once thought that the adult brain was static, stops growing or changing, we now see a rich and resilient neuroanatomy interacting with the nervous system and the entire body and being. In the book Neuroplasticity, Moheb Costandi defines neuroplasticity as “the ability of neural networks in the brain to change through growth and reorganization”. We now see a brain that rewires and is capable of change, undergoing “synaptic pruning”, responding to our behavior and experiences.
So, if we now know the adult brain can change and we can experience an improved mood and outlook because of it, how can we activate the process? One of the forerunners in the birth of this new treatment approach is Ketamine but, how is Ketamine different from SSRIs and other medication commonly prescribed for depression? Let’s explore this a bit further.
Many medications have an effect on the body but have very limited impact once the medication is out of the system but with Ketamine there appears to be changes in neuroplasticity, (changes in neurological pathways) which appear to have important effects even after the drug is out of the body. As John Crystal MD says “With most medications, like valium, the anti-anxiety effect you get only lasts when it is in your system. When the valium goes away, you can get rebound anxiety. When you take Ketamine, it triggers reactions in your cortex that enable brain connections to regrow. It’s the reaction to Ketamine, not the presence of Ketamine in the body that constitutes its effects.”
Over the past two decades, researchers have been studying Ketamine and learned that it activates glutamate production which creates rapid results and is an element to activating neuroplasticity. Studies have found Ketamine and psilocybin both have immediate and rapid effects of improved mood and a decline in depression, these effects continue even after the drug is out of the body. (More on psilocybin in a future article). Where most SSRIs and medications can take 4-6 weeks to kick in, Ketamine can offer immediate results.
If Ketamine is so promising for depression, how do I know if it’s for me?
This may seem like an easy question to answer but one of the most confusing parts of Ketamine treatment is deciding how to take it.
Ketamine comes in FOUR different routes of administration; 4 different ways to take it into the body and each of these options requires different levels of participation from the you. Deciding if Ketamine is right for you means knowing about the different options available and what is required of you (time, money and effort). I’ll make it easier for you by breaking these four routes down, so you have a better understanding of your options.
As a reminder, Ketamine is available legally through prescription only and consulting with an MD or ARNP is required to receive the prescription. Be sure to consult with your doctor for more information about risks/benefits. Be sure to stick with Ketamine from a pharmacy and avoid any substances from other (non-pharmacy) sources.
Another thing to keep in mind is that Ketamine should be considered as one part of a larger treatment strategy with a clear goal and intention about how the Ketamine experience will help in your healing journey. Working with a therapist to properly prepare and integrate the information is an essential element of maximizing the benefits of medicines like Ketamine that offer non ordinary states of consciousness.
Ketamine Treatment is given 1-2 times a week for 3+ weeks, depending on the route of administration. The commute time, preparation and integration will mean devoting several hours a week to the treatment. The session itself can last about 2-3 hours so consider this as well.
Ketamine’s entrance into the mental health field is quite interesting. It was introduced in the 1960s as an anesthetic for surgeries because it induces dissociative anesthesia; a trance-like state providing pain relief, sedation, and amnesia – just the thing for surgery, no pain and no memory of it! Since it’s been used since the 60s, there’s many decades worth of data on its safety and risks. (Ketamine is regarded as a generally safe drug when used in accordance with medical guidelines.) In fact, it’s been so effective, it’s on the WHO’s list of essential medicines.
Over time, doctors started noticing patients reporting interesting, mystical and life-changing experiences that occurred while they were under general anesthesia with Ketamine. Many folks reported their depression was no longer an issue after their Ketamine experience. In 2000 researchers at Yale published a very exciting paper in which depression symptoms in subjects declined substantially in less than 24 hours after Ketamine treatment.
The effects of Ketamine will vary depending on route of administration and dose.
So, the first option to consider is Ketamine infusion therapy. Ketamine infusion is offered in Ketamine clinics, many of these clinics have opened across the country and are quite easy to access if you live near an urban area. Once you find a clinic to work with, they will offer a screening and appointment with a provider to see if Ketamine infusions are right for you. It should be noted that most of the current research has been conducted with Ketamine infusions – IV Ketamine at a lower dose than for anesthesia provided in a safe clinical setting.
IV ketamine offers the highest bioavailability rate at near 99% so the body can absorb the Ketamine easily and you get maximum exposure to the medicine. Another benefit with IV is the dosage can be increased, decreased or stopped during a treatment. Many folks find comfort in receiving IV Ketamine treatment since most of the research has been with IV Ketamine and so if evidence based medicine is a priority, IV is the best route. Having medical staff available and being able to control the dosage may also provide comfort to some folks. This tends to be the most costly form of Ketamine treatment since there are multiple licensed providers involved in the care.
The second option is IM or intramuscular Ketamine injections. Here, Ketamine is injected and has similar, rapid results with a similar amount of bioavailability of IV form at about 95%. IM Ketamine is usually offered in a clinical setting and can be given in a private room or in a group. Some providers may even offer at home injections, bring the IM to your home for a private experience. This flexibility offers variable costs and ease of access for many people. A group setting environment will be a lower cost than say a private, at home injection. Once the Ketamine is injected, a person will need to wait for the duration of the process, unlike IV, there is no turning down or reducing the flow of Ketamine so, you’re along for the ride once the injection has occurred.
In 2019, the Food and Drug Administration (FDA) approved the third Ketamine option, a nasal spray called esketamine (brand named SPRAVATO) which is derived from Ketamine. This FDA approval was significant since it had been decades since the FDA approved a new drug for depression.
This form of Ketamine is available in a clinic setting and since it’s approved by the FDA, many insurance programs may cover it. To access this medication, a person must be referred by a provider to a SPRAVATO certified program. To be eligible, a person needs to have been diagnosed with Treatment Resistant Depression and have tried at least 2 anti-depressant medications. Once at the clinic, the client is given the nasal spray container, (much like a nasal allergy spray bottle) and they give themselves the spray. The client remains at the clinic under the supervision of a clinician and then returns home after a couple of hours. The bioavailability changes quite abit in this form to about 48%.
The fourth option is Ketamine Lozenges or Troches. These Lozenges are Rapid Dissolving Lozenges that look similar to a sugar cube (although they taste horrible, nothing like a sugar cube!) and once placed under the tongue, they dissolve quickly. The person swishes their mouth with the dissolved material and then may swallow it. The benefits of the Rapid Dissolving Lozenge is it can be mailed to one’s home and taken in the privacy of their home. This option became very popular during the pandemic as people were unable to go to a local clinic so having the option for taking the lozenge at home gave many people access to this care who otherwise would not have been able to get the treatment. Many companies have opened in the past year that offer telemedicine based, At Home Ketamine Lozenge Therapy like Mindbloom and Nue.Life. A person does need to have a “sitter”, this can be a partner, friend or other who is in the room and watches over the client during the process. The Lozenge is a wonderful way for many to access Ketamine as there is no need to travel to a clinic, the medical appointments are online and the Ketamine Rapid Dissolving Lozenge is mailed to the person’s home (their signature is required). This is one of the lower cost options. However, the bioavailability of the lozenge is the least here at about 37%.
Ketamine Treatment is given 1-2 times a week for 3+ weeks, depending on the route of administration. The commute time, preparation and integration can mean devoting several hours a week to the treatment. The session itself can last about 2-3 hours so consider this as well.
While Ketamine is considered generally safe, there are some risks to consider:
Ketamine Bladder Syndrome (excessive use increases risk of bladder damage). Be sure to research this more if you have any bladder concerns.
Cardiovascular Risk - Folks with High Blood Pressure, Heart Disease and other Cardiovascular conditions (Hypertension) could be at risk for heart attack or stroke, a blood pressure monitor should be used and clearance from your doctor.
Thyroid Disease – Folks with thyroid problems (particularly hyperthyroidism) could be at risk due to the activation of the sympathetic nervous system and should consult with their doctor.
Substance Abuse Issues – Ketamine can be helpful in treating certain substance use concerns and yet it can also be a risk for folks currently using. Consider a detox protocol or consult with your doctor before Ketamine treatment.
Active Hallucination, mania or acute mental health problems – folks with acute mental health problems should be cautious and avoid Ketamine treatment until after they have stabilized their mental health.
Cognitive Impairment – Long term Ketamine use may lead to Cognitive Impairment
The question of Is Ketamine Right For Me might be a bit more complex than you originally thought. To determine if it’s right for you, consider the goals you have or outcome that you want to get from the treatment then consider the cost, the time you can give and whether or not you prefer needles, lozenge or nasal spray.
https://www.frontiersin.org/research-topics/24059/the-glutamate-hypothesis-of-mood-disorders-neuroplasticity-processes-clinical-features-treatment-per https://psychedelicreview.com/same-but-different-antidepressant-mechanisms-of-psilocybin-and-ketamine/