Ketamine assisted psychotherapy

What to expect

Why Ketamine Assisted Psychotherapy

The most effective use of Ketamine for depression is a combination of medical and psychological interventions. Medically, Ketamine has restorative but often short-acting benefits. The current medicalized ketamine clinic model represents an opportunity for symptom relief, but also often requires ongoing use of the medication to maintain benefits. This model’s focus on managing symptoms is similar to daily antidepressant use. However, combining medication and psychotherapy can facilitate the deep healing required for long-term relief as it engages the client as a participant in a counselor-supported and individualized healing process.

Biologically, Ketamine activates the neurotransmitter glutamate and promotes structural and functional neuroplasticity in the prefrontal cortex. Through chronic stress, adversity, and depression, individuals can experience atrophy of neurons in this area including retraction of neurites, loss of dendric spines, and elimination of synapses. This pathophysiology is indicated in major depressive disorder. You could think of these synapses as trees whose roots and branches have atrophied or disappeared. Ketamine, via glutamate, is like fertilizer that promotes new growth, restoring the tree to health. It is hypothesized that this process of synaptic repair is the primary mechanism of action in clients who have not responded to serotonin-based interventions like antidepressants

A stressed neuron (above) vs. a neuron responding to Ketamine (below).

Psychologically, a key feature of psychedelic medicine is its ability to temporarily shut down the Default Mode Network (your ego) so that you can experience reality without your typical filter. (Carhart-Harris et al., 2017) What we think we understand is that the story you manufacture about who you are and how you relate to the world can become too rigid in treatment-resistant depression and may color your reality in negative ways. Ketamine has the potential to help you step outside of beliefs that no longer serve you. It’s a big shift and one that has the potential to help you change your perceptions and thus change your reality.

This sounds wonderful, and it can be. In a recent clinical trial with cancer patients, using a similar medication, greater than 80% of participants reported “moderately or greater increased well-being/life satisfaction.” (Griffiths, et al., 2016) This study was the beginning of the current research renaissance into psychedelics and the data continues to confirm benefits. It’s important to note is that these outcomes are the result of a combination of medication and psychotherapy. Though the medicine itself can have restorative impacts on the brain, the ego-based narratives that a Ketamine treatment may expose often require psychotherapy to fully resolve.

Many clients have felt trapped for years or even a lifetime by negative beliefs such as “I’m unlovable, a disappointment, a failure, it’s hopeless, or the world is a bad place.” Many report that Ketamine is able to essentially dissolve these stories for a time, but they may have a tendency to return depending on multiple biological, social, and psychological variables. That’s why it’s important to support this Ketamine-produced window of insight with cognitive and behavioral change in order to truly integrate the experience into your psyche.

In addition, Ketamine is a non-specific amplifier of internal experiences, be they cognitive, emotional, or somatic. The client does not get to choose what gets amplified and what doesn’t. Those who have a strong resistance to internal experiences may try to fight the medicine in order to retain a sense of control resulting in a difficult session. Opening the door on repressed feelings can be uncomfortable, and a trained counselor’s job is to make the process much less challenging.

At Athens Psychedelic Therapy, we offer preparation sessions (before) and integration sessions (after) ketamine infusions. We want to ensure that your journey is transformational, long-term, and that you get the opportunity to heal that you’ve been waiting for. We are specifically trained in this type of therapy and have the necessary experience to support you. Feel free to reach out to us so that we can schedule a free virtual consultation.

Ketamine benefits

 

NMDA Receptor

Ketamine works on a different receptor than antidepressants and modulates glutamate instead of seretonin..

 

Anti-suicidal properties

It’s common for clients to experience diminishing or disappearance of suicidal thoughts which can be life saving.

Fast acting

Some patients will improve after the first treatment and many significantly respond within 3-4 treatments.

 

minimal side effects

Most side effects occur during treatment but not in between sessions.

TReatment Resistance

Individuals who have not achieved benefits from other treatments are more likely to respond.

 

high response rate

70-80% response rates are typical compared to 40-60% for antidepressants. Ketamine is often helpful for clients who have not responded to antidepressant medications.

contraindications for ketamine Assisted Psychotherapy

These conditions are not a good fit for Ketamine therapy due to the medicine’s potential to trigger or exacerbate psychotic episodes, increase blood pressure, or interact with other substances eg. substances of abuse or substances that block glutamate release. Ketamine has not been studied in pregnant mothers. Caution is used with clients who have close relatives with psychotic or delusional disorders like schizophrenia, as Ketamine may trigger a first episode of psychosis in clients with an underlying biological vulnerability.

 

  • Active Mania

  • Psychosis

  • Uncontrolled Hypertension

  • Clinically Significant Substance Use

  • Pregnancy

  • Glaucoma or recent ocular surgery

  • Intracranial Pathology

  • Acute Alcoholism

  • Patients taking high-dose benzodiazepines, pregabalin, gabapentin, Lamotragine, and possibly Opioid Agonists (see new research).

Ketamine research

 

  • Abstract: At least 10-20% of the patients suffering from depression meet criteria for treatment-resistant depression (TRD). In the last decades, an important role of glutamate in mood modulation has been hypothesized and ketamine, a non noncompetitive antagonist of the N-methyl-D-aspartate (NMDA) receptors, has been demonstrated to be effective in both MDD and TRD.

    Methods: aiming to systematically review the current literature focusing on the main pharmacological properties and impact of ketamine in TRD, a detailed literature search in PubMed/Medline and ScienceDirect databases was conducted. Twenty-four manuscripts including a total of 416 patients fulfilled inclusion criteria.

    Results: Most studies demonstrated that the NMDA antagonist ketamine has rapid antidepressant effects in TRD patients, confirming the active role of glutamate in the pathophysiology of this complex condition. Ketamine has been demonstrated to be rapidly effective and was associated with a significant clinical improvement in depressive symptoms within hours after administration. Also, ketamine was also found to be effective in reducing suicidality in TRD samples. Read full article here. https://www.ingentaconnect.com/content/ben/cn/2014/00000012/00000005/art00006

  • Objective: To test the efficacy and safety of a single intravenous subanesthetic dose of ketamine for the treatment of PTSD and associated depressive symptoms in patients with chronic PTSD.

    Results: Ketamine infusion was associated with significant and rapid reduction in PTSD symptom severity, compared with midazolam, when assessed 24 hours after infusion (mean difference in Impact of Event Scale–Revised score, 12.7 [95% CI, 2.5-22.8]; P = .02). Greater reduction of PTSD symptoms following treatment with ketamine was evident in both crossover and first-period analyses, and remained significant after adjusting for baseline and 24-hour depressive symptom severity. Ketamine was also associated with reduction in comorbid depressive symptoms and with improvement in overall clinical presentation. Ketamine was generally well tolerated without clinically significant persistent dissociative symptoms.

    Conclusions and Relevance: This study provides the first evidence for rapid reduction in symptom severity following ketamine infusion in patients with chronic PTSD. If replicated, these findings may lead to novel approaches to the pharmacologic treatment of patients with this disabling condition.

    Read full article here: https://jamanetwork.com/journals/jamapsychiatry/article-abstract/1860851

  • Abstract: Ketamine can be used in the treatment of opioid withdrawal symptoms. Here are two case discussions of treatment of withdrawal symptoms in opioid dependent patients undergoing detoxification. Our case reports endorse the hypothesis that N-methyl D-aspartate (NMDA) antagonists may selectively inhibit the expression of opiate withdrawal. The use of intravenous ketamine can be considered as a bridge to successful initiation of buprenorphine to wean the patient off from high opioid doses while providing adequate analgesia during the transition period. Read full article here. https://benthamopen.com/contents/pdf/TOPAINJ/TOPAINJ-4-1.pdf

  • Abstract: Ketamine is a prescription drug used for general anesthesia. In subanesthetic doses, it induces profound psychedelic experiences and hallucinations. The subanesthetic effect of ketamine was the hypothesized therapeutic mechanism in the authors' use of ketamine-assisted psychotherapy for alcoholism. The results of a controlled clinical trial demonstrated a considerable increase in efficacy of the authors' standard alcoholism treatment when supplemented by ketamine psychedelic therapy (KPT). Total abstinence for more than one year was observed in 73 out of Ill (65.8%) alcoholic patients in the KPT group, compared to 24% (24 out of 100 patients) of the conventional treatment control group (p<0.01). The authors' studies of the underlying psychological mechanisms of KPT have indicated that ketamine-assisted psychedelic therapy of alcoholic patients induces a harmonization of the Minnesota Multiphasic Personality Inventory (MMPI) personality profile, positive transformation of nonverbalized (mostly unconscious) self-concept and emotional attitudes to various aspects of self and other people, positive changes in life values and purposes. important insights into the meaning of life and anincrease in the level of spiritual development. Most importantly, these psychological changes were shown to favor a sober lifestyle. The data from biochemical investigations showed that the phannacological action of KPT affects both monoaminergic and opioidergic neurotransmitter metabolism, i.e., those neurochemical systems which are involved in the pathogenesis of alcohol dependence. The data from EEG computer-assisted analysis demonstrated that ketamine increases theta activity in cerebrocortical regions of alcoholic patients. This is evidence of the reinforcement of limbic cortex interaction during the KPT session. Read full article here. https://www.tandfonline.com/doi/abs/10.1080/02791072.1997.10400185

  • Abstract: Current research suggests that ketamine-assisted psychotherapy has benefit for the treatment of mental disorders. We report on the results of ketamine-assisted intensive outpatient psychotherapeutic treatment of a client with treatment-resistant, posttraumatic stress disorder (PTSD) as a result of experiences of racism and childhood sexual abuse. The client’s presenting symptoms included hypervigilance, social avoidance, feelings of hopelessness, and intense recollections. These symptoms impacted all areas of daily functioning. Psychoeducation was provided on how untreated intergenerational trauma, compounded by additional traumatic experiences, potentiated the client’s experience of PTSD and subsequent maladaptive coping mechanisms. Ketamine was administered four times over a 13-day span as an off-label, adjunct to psychotherapy. Therapeutic interventions and orientations utilized were mindfulness-based cognitive therapy (MBCT) and functional analytic psychotherapy (FAP). New skills were obtained in helping the client respond effectively to negative self-talk, catastrophic thinking, and feelings of helplessness. Treatment led to a significant reduction in symptoms after completion of the program, with gains maintained 4 months post-treatment. This case study demonstrates the effective use of ketamine as an adjunct to psychotherapy in treatment-resistant PTSD. Read full article here. https://journals.sagepub.com/doi/full/10.1177/1534650121990894

  • Conclusion: The results of this double-blind randomized clinical trial of KPT for heroin addiction showed that highdose (2.0 mg/kg) ketamine psychedelic psychotherapy (KPT) elicits a profound, full psychedelic experience in heroin addicts. On the other hand, low-dose KPT (0.20 mg/kg) elicits "sub-psychedelic" experiences that are very similar to ketamine-facilitated guided imagery. Highdose KPT produced a significantly greater rate of abstinence in heroin addicts within the first six months of follow-up than did low-dose KPT. High-dose KPT brought about a greater and longer-lasting reduction in craving for heroin, as well as greater positive change in nonverbal unconscious emotional attitudes.

    Thus, it is possible that the higher rate of abstinence in the high-dose group was to some extent due to positive effects of ketamine on craving (which has been reported with other NMDA receptor ligands). It also may be due to the positive transformation of nonverbal unconscious emotional attitudes. Read full article here. https://www.researchgate.net/profile/Evgeny-Krupitsky/publication/266249375_Ketamine-Assisted_Psychotherapy_KPT_of_Heroin_Addiction_Immediate_Effects_and_Six_Months_Follow-Up/links/57cf7a8608ae057987ac0e23/Ketamine-Assisted-Psychotherapy-KPT-of-Heroin-Addiction-Immediate-Effects-and-Six-Months-Follow-Up.pdf

  • Results and conclusion: Seven completed studies were identified. Two studies focused on alcohol use disorder, two focused on cocaine use disorder, and three focused on opioid use disorder. Both cocaine studies found improvements in craving, motivation, and decreased cocaine use rates, although studies were limited by small sample sizes, a homogeneous population and short follow-up. Studies of alcohol and opioid use disorders found improvement in abstinence rates in the ketamine group, with significant between-group effects noted for up to two years following a single infusion, although these were not placebo-controlled trials. These results suggest that ketamine may facilitate abstinence across multiple substances of abuse and warrants broader investigation in addiction treatment. We conclude with an overview of the six ongoing studies of ketamine in the treatment of alcohol, cocaine, cannabis, and opioid use disorders and discuss future directions in this emerging area of research. Read full article here. https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00277/full

  • Abstract: Ketamine is a dissociative anaesthetic drug which acts on the central nervous system chiefly through antagonism of the n-methyl-d-aspartate (NMDA) receptor. Recently, ketamine has attracted attention as a rapid-acting anti-depressant but other studies have also reported its efficacy in reducing problematic alcohol and drug use. This review explores the preclinical and clinical research into ketamine's ability to treat addiction. Despite methodological limitations and the relative infancy of the field, results thus far are promising. Ketamine has been shown to effectively prolong abstinence from alcohol and heroin in detoxified alcoholics and heroin dependent individuals, respectively. Moreover, ketamine reduced craving for and self-administration of cocaine in non-treatment seeking cocaine users. However, further randomised controlled trials are urgently needed to confirm ketamine's efficacy. Possible mechanisms by which ketamine may work within addiction include: enhancement of neuroplasticity and neurogenesis, disruption of relevant functional neural networks, treating depressive symptoms, blocking reconsolidation of drug-related memories, provoking mystical experiences and enhancing psychological therapy efficacy. Identifying the mechanisms by which ketamine exerts its therapeutic effects in addiction, from the many possible candidates, is crucial for advancing this treatment and may have broader implications understanding other psychedelic therapies. In conclusion, ketamine shows great promise as a treatment for various addictions, but well-controlled research is urgently needed. Read full article here. https://www.sciencedirect.com/science/article/abs/pii/S0028390818300170

  • Abstract: The N-methyl-D-aspartate receptor antagonist ketamine has rapid onset activity in treatment-resistant depression, post-traumatic stress disorder and obsessive compulsive disorder. Due to similarities in brain network activity in depression and anxiety disorders, we hypothesized that ketamine might also be active in other refractory anxiety disorders. We evaluated the efficacy and safety of ketamine in 12 patients with refractory generalized anxiety disorder and/or social anxiety disorder who were not currently depressed, using an ascending single dose study design (0.25, 0.5, 1 mg/kg administered subcutaneously) at weekly intervals. Within 1 h of dosing, patients reported reduced anxiety, which persisted for up to seven days. A dose-response profile was noted for anxiolytic effects, dissociative side effects, and changes in blood pressure and heart rate, with minor changes at 0.25 mg/kg, and progressively greater and more durable changes at the higher doses. Ten of 12 patients were treatment responders at 0.5–1 mg/kg. Ketamine was safe and well tolerated in this population. Ketamine may be a potential therapeutic alternative for patients with refractory generalized anxiety disorder/social anxiety disorder. Along with its demonstrated effectiveness in patients with treatment-resistant depression, obsessive compulsive disorder and post-traumatic stress disorder, these data raise the intriguing possibility that ketamine may have broad efficacy in disorders characterized by negative emotional states, and that these disorders may share a common precipitating neurobiology. Read full article here. https://journals.sagepub.com/doi/abs/10.1177/0269881117705089

  • Abstract

    In summary, the dual action of Ketamine leads to a unique constellation of dopamine driven positive reinforcement, but low addiction liability.

 

Ethical Guidelines for Ketamine Clinicians

At Athens Psychedelic Therapy we are dedicated to working within ethical guidelines in order to assure maximum benefit and avoid harm. Below are suggested guidelines published in the Journal of Psychedelic Psychiatry (2020) that we embrace while providing Ketamine Assisted Psychotherapy.

Ethical Guidelines for Ketamine Clinicians
Version 1.1 – Posted on 12/13/2020

The ethical ketamine clinician recognizes that therapeutic ketamine is a mental health treatment. In this document, “therapeutic ketamine” refers to ketamine that is administered to a patient primarily for a psychiatric indication, psycho-spiritual exploration, and/or psychological work. Therapeutic ketamine does not include ketamine that is administered primarily for anesthesia or pain management, which are considered separate fields (specialties) from therapeutic ketamine.

The ethical ketamine clinician recognizes that ketamine is a powerful psychoactive medicine with prominent dissociative and psychedelic properties. The ethical ketamine clinician recognizes that therapeutic ketamine patients require specialized psychological care before, during, and after receiving ketamine.

There are three roles in every therapeutic ketamine treatment: (1) a mental health professional; (2) a medical professional; and (3) the patient. In some cases, one person may be able to fulfill both professional roles, such as a psychiatrist who has substantial psychotherapy training.

  • The responsibilities of the mental health professional include: doing the clinical intake interview and assessment; doing integrative treatment planning; providing psychological preparation before the ketamine administration; providing psychological support during the ketamine administration; and providing psychological support following the ketamine administration (a/k/a “integration”); and managing any psychological or psychiatric emergencies during the course of ketamine treatment.

  • The responsibilities of the medical professional include: assessing the patient’s physical condition before ketamine treatment; attending to the physical and medical safety of the patient during ketamine treatment; and assessing and treating any adverse reactions during the course of ketamine treatment.

  • The responsibilities of the patient include: communicating clearly and honestly with the clinical team; and actively participating in the integrative treatment plan as much as possible.

The ethical ketamine clinician recognizes that there are different approaches to ketamine treatment, and that each approach has advantages and drawbacks. The ethical ketamine clinician is skillful with the specific treatment(s) that they offer. In addition, the ethical ketamine clinician is familiar with all of the major routes of administration, different dosing strategies, and different conceptual paradigms for therapeutic ketamine treatment.

The ethical ketamine clinician understands and appreciates the importance of integrative psychiatric/psychological care for therapeutic ketamine patients (i.e., using multiple strategies to get better and stay well). The ethical ketamine clinician takes the time to explain this to each patient, and helps patients to connect to these resources in their community.

The ethical ketamine clinician practices within the scope of their professional license, and they recognize their limitations with respect to their professional training and experience. They actively seek consultation as needed, and they make referrals to other professionals as needed.

The ethical ketamine clinician upholds all of the responsibilities of their professional license with respect to all aspects of their clinical practice, including informed consent, record-keeping, professional boundaries, confidentiality, and general professional conduct.

The ethical ketamine clinician aspires to be compassionate, thoughtful, honest, and forthright in all of their personal and professional communications.

The ethical ketamine clinician actively tries to make therapeutic ketamine accessible to members of the community who do not have the financial resources to pay for the treatment that they need.

The ethical ketamine clinician is honest and transparent in marketing their services. They rigorously adhere to the FDA guidelines about advertising, and their clinical and advertising claims are supported by the research literature.

The ethical ketamine clinician has received special training and/or mentorship in working with therapeutic ketamine. A comprehensive training includes substantial education in the following domains: medical, psychological, and psychedelic. Additionally, the ethical ketamine clinician regularly reads the newly published literature and participates in continuing education to stay abreast of the latest developments in this rapidly growing field.

Update on 12/30/2020: These Ethical Guidelines were published (with additional commentary) in the Journal of Psychedelic Psychiatry (Vol 2, Issue 4, Dec 2020, pgs 19-23). JPP article (PDF)