Lessons Learned: A Wrap Up on Ketamine

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A KETAMINE JOURNAL

Over the course of this series, I have walked readers through the process by which I came to practice ketamine-assisted psychotherapy (KAP). I have written about how my interest developed, what I have worried about, how I have gone about learning to do KAP, my own experience with ketamine as part of a training course, and my very early experiences using ketamine with patients. Over the course of the last 14 months, I have continued to do KAP in small groups. I am still no expert in either ketamine or KAP—there are clinicians who have treated thousands of patients with ketamine.

While working on this series, ketamine got more attention. The actor Matthew Perry died after he was repeatedly injected with ketamine and left alone in a swimming pool. This gross misuse of ketamine is nothing like what happens in clinical settings, but it still shone a spotlight on the therapeutic use of ketamine. In October of 2023, just as I began to treat patients with sublingual ketamine, the US Food and Drug Administration issued a statement declaring that ketamine is not approved for any psychiatric diagnosis and that compounded medications of any type are not approved for use.¹

I started with the idea that ketamine has something new to add to the limited landscape of treatment-refractory depression and anxiety, that it works through a different mechanism and that the promise of neuroplasticity might help some of our patients who get so stuck in the maladaptive thought patterns that fuel their distress. As I wrote, others in the ketamine community commented that I was brave. The series was halted by Psychiatric Times, and then it resumed. I never intended to be brave or controversial, and this process has been both fraught and powerful.Please let me share what else I have learned.

Once I had a rhythm for doing KAP with small groups, I found it is easy to do. Most patients enjoy the brief sense of relaxation that comes with ketamine, the break from their thoughts, and the psychedelic experience. Very few have described feeling frightened or afraid. The hardest part has been the logistics of timing for a group, especially for the sessions that require patients to have a driver. COVID-19 has required some flexibility—there have been patients who want others to mask or test, and there have been patients who have missed a session (then rescheduled) because they have had COVID.

The results I wrote about with my first 6 patients have been representative of the overall results. Some individuals have had remarkable responses, some feel better, and a minority have had no response. It does seem that the psychedelic experience heralds more improvement. I have also learned that I cannot predict who will have a psychedelic response: I start with 200 mg held in the mouth for 15 minutes and then discarded. This dose may yield a dissociative state in a large man, while the same dose may have no impact on a small woman. So far, I have not found that using a higher dose reliably provides a dissociative experience if a low dose did not. For someone who has had a journey with a lower dose, a higher dose causes a more intense experience.

Some individuals have had mild side effects that have resolved within hours—blurred vision, a headache, or a sense of being woozy. No one has had any terrible or sustained adverse effects, and no one has had trouble emerging from the dissociative state, becoming fully conscious, or walking with a steady gait.

My worries about using ketamine have not changed. I monitor vital signs throughout, and I have purchased pulse oximeters that can be set to beep if heart rate or oxygen saturation are outside specific parameters. Occasionally, I have had to interrupt a patient’s journey and instruct them to take deep breaths or pump their fists—maneuvers that raise oxygenation or heart rate back to the normal range. I keep anti-hypertensive medications in the office and I periodically give someone a low dose of a beta-blocker to take before a session, but, I have never had to give one during the ketamine session. Mindbloom, a company that provides online KAP has published a study showing safety in 11,441 patients using ketamine at home,² yet I still would not be comfortable prescribing for unsupervised use, nor would I be comfortable prescribing ketamine for a patient to take in another therapist’s office.

I still do not know what to tell individuals to expect from the treatment, though I do feel comfortable saying they will likely have a pleasant experience. One patient worried he would die, I assured him that individuals do not die during supervised ketamine use (he did not die). While I anticipated being worried about the safety issues, I did not anticipate that I would feel badly when patients do not have a psychedelic experience and do not feel the anticipated improvement in symptoms. Psychiatric medications often do not work, so I was surprised that this would be troublesome for me.

I have limited the number of ketamine sessions to 3 with sublingual dosing, and I have done a second series with select patients. While my results have been very good, I do wonder if I would see even more improvement if I used intramuscular ketamine, used higher doses, or gave more treatments. My hesitation is a result of my own fears of causing harm: intramuscular ketamine is more jarring, has a higher chance of causing agitation, requires me to obtain and store a controlled substance, and may (rarely) induce apnea or muscle paralysis, situations I do not feel equipped to handle. I limit the number of sessions, in part because I want to limit the risk of addiction. Ultimately, we all do what we are comfortable with and I have chosen to be very conservative in using KAP.

Finally, I have been surprised that there have not been more referrals for group KAP. There is very little ketamine use in Baltimore and it is not a go-to option for most psychiatrists. Ketamine is seen as a last resort and something that is high risk, and now that I use it, I am not quite sure why. The patients who have come to me have requested a ketamine referral, only a few have come because the psychiatrist suggested it.

There are so many different ways to administer ketamine, and so much we still do not know. Snake oil or innovation? So far, I believe it is an under-used and powerful tool that can be helpful to many of our patients.

If you have read along as I have chronicled my experiences with KAP, thank you for traveling this road with me. It has been an unexpected and delightful detour in my career, and one that I look forward to continuing.

The views and practices expressed in these commentaries are solely those of the author and do not necessarily represent the position of Psychiatric Times or its editors.

Dr Miller is a clinical psychiatrist and writer in Baltimore. She is on the faculty at the Johns Hopkins School of Medicine.

Note: In these commentaries, Miller will discuss her experiences and thoughts as she explores issues associated with ketamine-assisted psychotherapy.

References

1. FDA warns patients and health care providers about potential risks associated with compounded ketamine products, including oral formulations, for the treatment of psychiatric disorders. FDA. October 10, 2023. Accessed December 23, 2024. https://www.fda.gov/drugs/human-drug-compounding/fda-warns-patients-and-health-care-providers-about-potential-risks-associated-compounded-ketamine

‌2. Hull TD, Malgaroli M, Gazzaley A, et al. At-home, sublingual ketamine telehealth is a safe and effective treatment for moderate to severe anxiety and depression: Findings from a large, prospective, open-label effectiveness trial. J Affect Disord. 2022;314:59-67.