Why did it get weird? Is that an indisputable element of IV ketamine treatment for depression? We respond with a resounding NO!
(article from The New York Times, 12/26/2022)
In the New York Times article, “I Took Ketamine for Depression. Things Got Pretty Weird”, writer Vanessa Barbara describes her experience with IV ketamine treatment for her depression, which she received in Juiz de Fora, Brazil.
A splashy title like that draws a lot of attention — from those who are familiar with ketamine treatment, people who are just curious about it (because it’s all over the news), from doctors, medical experts, business people…. Just about everyone’s been hearing about and reading about the renaissance of psychedelic research exploding in the US and around the world for the treatment of depression, anxiety, trauma, and substance abuse.
Many people reading first-person accounts of ketamine treatment for depression haven’t received it themselves. So they’re interested in learning all they can.
The fact is that there’s such a wide variety of patient experiences when ketamine is used in treating psychiatric conditions because there are so many different settings in which it is currently offered, such varied approaches to it in terms of patients and the symptoms they hope it will help, so many ways to prepare for and integrate the treatment experience…. and such a wide range of administration.
And a negative experience can have to do with the rate of the infusion, the size of the dose, the consistency of flow, the comfort or discomfort of the setting, and even your mindset as the infusion begins…
There is so much more to the the treatment–and to the experience and your response to it–than just getting the medicine from an IV bag into your body.
(More on that later because we don’t even use IV bags.)
Ketamine is recognized as extraordinarily effective for severe depression that hasn’t responded to other treatments or medicines. But the way you might feel during the treatment itself can be hard to predict.
Since Ms. Barbara’s description pertained to her experience with IV ketamine treatment, let’s focus on ketamine administered intravenously.
Not all IV experiences with ketamine are equal. For example, just to start with mechanics, if the rate of the infusion is controlled by a precise intravenous pump, ketamine reaches the brain at an even, controlled rate. But if the infusion is monitored and controlled by hand, adjusting a wheel located on the tubing from a hanging bag, the flow of medicine may speed up too fast. And that can result in too much medicine too fast, yielding an upsetting acceleration of ketamine’s effects.
When the rate is determined by the thumb on a wheel, a patient can be overwrought. (….or if the cannula inside the vein changes position, the flow can slow.) A precision pump can ensure a smooth, consistent flow of medicine, and enhance the experience. That’s good, right?
But the ”right rate” for one person may be too fast for another.
Or the starting dose for one person may be too much for someone else.
And — so importantly — there are many ways your own mindset can influence your experience during ketamine treatments and during other psychedelic treatments coming down the road. The dissociation during an infusion can sometimes feel overwhelming because you’re anxious, sensitive, or afraid to experience a non-ordinary state of consciousness. Because it’s not going the way you expected or the way you’ve read about.
Sometimes the dissociation you feel during an infusion is a little nebulous. Not clear. There’s not a story line. There’s no colors. Things feel strange and unreal but without a clear meaning that you can piece together. You feel gypped–how come everybody else gets blissed out and you don’t? Maybe you’re stuck obsessing and the one thing you need to get out of your life and away from is right there, front and center, during your infusion. (That can be so maddening.) Maybe you’re riled because you had a fight on the way in. (Which is so bad for you, by the way–try to avoid that!) Or maybe, the whole experience is just so strange that it seems like you don’t have any thoughts…. You might feel so out of your body that you’re not sure you’re even a person.
And this is supposed to HELP you? Really??
Really.
Even someone who’s had a negative or challenging ketamine experience can get better and go into full remission. But they’re going to need a little help making sense of how and why it happened…. discerning the meaning and the message…. and integrating that experience so that they can come out on the other side of it and move forward.
Positively, Creatively. With a new narrative.
Then consider the problem Ms. Barbara experienced when her partner joked with her and she suddenly thought her daughter was 15 and not 3.
Words spoken to you when you are deeply dissociated during a ketamine infusion may sound intense, or far away, or frightening because they interrupt you and pull you back into the room, and the dissonance can be…. jarring.
Before and during your infusion, your mindset and the treatment setting itself help shape the experience.
Ours is pretty gorgeous, by the way.
We value the importance of set and setting. Preparing yourself emotionally for your treatment is critically important (and we’ll help you with that!). And making sure that the setting is private, soothing, safe, and that you feel like you have the time you need to come back into your body, and ground yourself at the end. We keep things safe, quiet, meticulously clean…. and soft, warm and inviting.
During ketamine treatment, you are open and vulnerable.
It’s easy to misinterpret a kind word or light humor…to think your 3 year old is suddenly 15 and you’ve missed her life.
We don’t want anything to intrude that triggers stress for you — from disruptive conversation, to joking, to cell phone calls —because it can undermine what can be an extraordinary experience.
Ms. Barbara spoke of pleasant music. And she was on to something important. We encourage you to bring in instrumental music to listen to during your treatment — music without words reaches you without engaging you cognitively to think about the words in the lyrics. The rhythm and flow of music that you find beautiful can help shape your experience. And we work with ketamine integration therapists who can provide special music tracks specifically for each infusion.
And a final point. Ms. Barbara signed up for 6 infusions. But experience has taught us that 6 infusions sometimes aren’t enough. In others, it may take a few more. To make this decision requires evaluation of the whole patient and their response to treatment.
Some people reach remission after just 4 infusions, like the lovely young woman we treated with severe anorexia. Her response was so dramatic, she made a video about it. Others need 8 or 9, and then they turn around dramatically. Imagine the disappointment she experienced when she was not better after 6 infusions if 8 might have done the job?
Sadly, there are severely depressed people in the US and around the world who received too few infusions and gave up. They believe ketamine didn’t work for them and won’t work for them in the future. And maybe it won’t. It doesn’t work for everyone.
Ms. Barbara’s experience is a good example.
It might be very different if you are given a different approach—preparation, attention, and integration of the infusion experience.
Let’s be clear. Ketamine treatment is not for everyone. It truly doesn’t help everyone who tries it. But it does help a high percentage of those who need it. Still, for some people it just takes more to achieve the relief and joy they wish for and need. And Ms. Barbara — and thousands like her — has no way of knowing if ketamine is not for her, or if another couple of infusions might have helped her achieve remission and the joy that goes with it?
There is so much more research we need.
Our goal is to get you back to your best self, to see you thrive, connect with friends, bubble over with gratitude for the gifts you have in your life.
We love that. We’ve seen it happen with people we treat. And we know to respect the medicine and the differences in individuals… to administer the medicine and titrate it to work.
This is not a one-size-fits-all medical treatment.
You can find ketamine treatment in clinics, hospitals, and private practices. My private practice is Innovative Psychiatry, and we’ve worked for decades to use innovative methods to help people get better. We never stop learning. And we back everything we do with research and evidence-based outcomes.
When I learned what ketamine could do for my patients I began offering ketamine treatment several years ago for those who were candidates. And we’ve seen exceptional results from our work.
We continue to go the extra mile, and bend over backwards, to care for our patients through the process.
If you suffer from severe depression, PTSD, social anxiety, alcohol and substance use disorders, or suicidal thoughts, call us.
Ketamine can make such a transformative difference in your life.
Give yourself the opportunity to find out what remission is like for you.
To the restoration of your best self,
will you ladies please answer a simple question for me?
is there any evidence that iv ketamine is any more effective than intranasal esketimine or don”t you know? if you do not answer, i will assume the negative.
your persistent friend! sam
It’s a lovely day to respond to a great question — because we’re in the midst of a Monday holiday and a terrible winter storm, and the office is closed! I do know the answer: intravenous ketamine appears to be more effective than intranasal esketamine. Here’s the data that supports my assertion: Bahji, Vasquez and Zarate (2020) published a systematic review and metanalysis of 24 randomized controlled trials (RCT’s) comprising 1877 participants in order to compare the efficacy and tolerability of IV ketamine to intranasal esketamine (the nasal spray marketed in the US as Spravato). RCT’s are the most rigorous level of clinical research. They compared response and remission from depression, reduction in severity of depressive symptoms, and reduction in suicidality (as well as tolerability as measured by treatment retention and drop-outs). They pooled data from 24 different trials comprising 1877 participants, summarizing the existing literature; metanalysis was the best tool to use for this kind of comparison because there were no head-to-head trials of IV ketamine vs. IN esketamine. Here is what they found: Intravenous ketamine appears to be more effective than intranasal esketamine. (They said “appears” in their paper. I would take that word out and say intravenous ketamine is more effective than intransal esketamine because that’s what the data showed.) IV ketamine produced greater response and remission, and fewer patients dropped out of treatment. Here is their data: greater overall response (IV ketamine RR = 3.01 vs. intranasal esketamine RR = 1.38); greater overall remission rates (IV ketamine RR = 3.70 vs. intranasal esketamine RR = 1.47), and lower dropouts (IV ketamine RR = 0.76 vs. intranasal esketamine RR = 1.37).
They are working on an updated metanalysis–they’re careful, brilliant, and exceedingly attentive to science. And other teams are studying this question as well, in the US and around the world, and evaluating IV, IM, IN, and oral (e.e., via troche) ketamine and its enantiomers. The research is exploding.
But while we wait for it, let’s go over a couple of things that might explain why IV ketamine is more effective than intransasal esketamine. IV ketamine administration is 100% bioavailable whereas the bioavailabiity of intranasal esketamine is only 54% — and that’s assuming it is administered under ideal conditions, with no run-off down the back of the throat and no nasal congestion interfering with absorption. This is critical if you believe that dose is important (and we do–it is for most medicines!). The dose of IV ketamine can be titrated according to body weight over a broad range, and we can adjust the rate of infusion, the duration, uses slow pushes, slow it down, stop it, etc. — and with IV, we have maximum flexibility to attend to and manage any side effects during administration, like elevated pulse or blood pressure, nausea, or fear. It give us many, many ways to optimize safety, response, remission, and patient experience in clinical practice. We can’t even come close to that with intranasal esketamine.
I had 8 treatments,every treatment gave me the same experience. Very pleasant calm,, soothing. Other than a few times the outside door was allowed to close hard or an occasional loud motor cycle leaving the stop light out front. Even these distractions left as quickly as they came. Again all 8 treatments were very pleasant whether I was administered a strong dose or lessor.