Moving Along

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A KETAMINE JOURNAL

Everyone who comes to me for ketamine is struggling. Some patients feel quite depressed, others have had a good response to medications but still they feel stuck, with residual symptoms and an inability to move forward. Everyone has tried a variety of medications—I have set that as a condition of treatment—but everyone does not struggle in the same way.

I had tried ketamine-assisted psychotherapy (KAP) with a single patient, followed by a ‘mini-group’ of 2 patients. These were individuals I had treated for years. The time came to try KAP with a group that included patients who were referred by other psychiatrists. Two of the 3 patients in this next group came specifically for KAP.

Ms D was my long-standing patient. She had responded to traditional medications, but still had residual symptoms and wanted to see if ketamine would help. Ms E came just for KAP. She had a psychiatric history that spanned decades and included psychoanalysis, medications from every class (including MAO inhibitors), electroconvulsive therapy, intravenous ketamine, and a visit to a psilocybin retreat. The third patient for this group, Ms F, had contacted me because she felt “stuck.” She had stopped working a few years ago and thought she should return to work. She had tried career-focused resources, psychotherapy, and has been on 5 different antidepressants. Ms E felt the current medication was helpful, but still, she was struggling to take action and her self-esteem was remarkably low.

Ms D was taking a standing benzodiazepine for a seizure disorder, and benzodiazepines can interfere with ketamine’s efficacy. Rather than stop the seizure medication, I started with a slightly higher dose of ketamine. I ask the patients to hold the lozenges in their mouths for 15 minutes and spit it out at the end. Ms D inadvertently swallowed the sublingual medication, thereby getting both sublingual and gastric absorption and a deeper and longer dissociative experience. When we spoke the next day, she was still feeling woozy and had not gone to work. She was struggling with a great deal of sadness over distressing events that were going on in her life. I hoped this would propel her to address issues that needed her attention.

Ms E wanted to start with a higher dose because she had not had a psychedelic experience with psilocybin. I pointed out that ketamine and psilocybin are not chemically related and she started with the usual dose. She emerged from the first dissociative experience with an immediate improvement in her mood.

I assumed that it would be easy to induce a psychedelic experience for Ms F, as she had no previous exposure to psychedelics. I was wrong—she felt nothing from the medication during the first 2 sessions.

What I did not anticipate was how I would be impacted by the disappointment of a patient’s lack of response. And in a group, when some people get better and others do not, the disappointment is compounded. Patients come to KAP with both high expectations and optimism.

So how did it go? Ms D reported that she felt about 25% better with regard to all of her issues. Her Beck Depression Inventory (BDI-2) Score started at 32 (severe depression) and ended at 9 (mild symptoms).

Ms E felt remarkably better. Her pretreatment BDI-2 score was 29 and her post-treatment scores was 1. She commented that ketamine assisted psychotherapy with sublingual administration was more helpful than intravenous ketamine treatments had been.

Ms F had a bit of a dissociative experience during the third ketamine session with a higher dose. She did not think so, but I have not heard anyone say they had the sense the world is "melting" in usual states of consciousness! Ms F was not clinically depressed when we started or finished, and she felt disappointed in the ketamine experience; however, she was able to put together a resume during this time. I asked her to return for an individual meeting after the group ended. She was getting ready to start a new job and was now “unstuck,” but she did not attribute her progress to the work we had done in the KAP group. As with any improvement that occurs after an intervention, I was left to hope it had made a difference.

You may wonder how long the effects of KAP lasted for the 6 patients I have written about in these last 3 articles. I will point out that when psychotropic medications are tested, results are often reported after 8 to 12 weeks of treatment, we do not know how the patients fare over time. Nor do we know exactly how long any medication needs to be continued in any given patient. What we do know is that some patients will relapse if they go off the medications, and some will relapse even if they continue the treatment.

Mr A, the first patient I treated with KAP, found it to be helpful. Soon after, his mood was impacted by grief and loss. What changed immediately, and has held a year later, is that he focuses more on current-day problems and less on regrets from decades past. A year later, he tried KAP again in a group and used ketamine 3 more times. This time, his journey did not mimic my vacation.

Ms B, my longtime patient who was looking for a miracle, felt much better for several months. With stressors, she suffered a relapse of depression, a second round of ketamine did not help, and she started on dextromethorphan-bupropion (Auvelity), a rapid-acting anti-depressant that targets NMDA receptors. Her mood continues to vary with significant stressors in her life and ketamine did not change this in a permanent way.

Ms C, the patient who had been hospitalized for a suicide attempt, has remained well for the past year. Her mood is good, and she has been more resilient. She comes to see me less frequently and says that ketamine was life changing.

Ms D continues to sort through family stresses. In the months after KAP, she made progress addressing stressful issues in her life and her mood has been notably better.

Ms E has not relapsed into her dark depression. Months later, she returned to participate in another KAP group in anticipation of seasonal mood changes. She also is doing well.

I have not heard from Ms F since we last met.

In the next article, I will wrap up “A Ketamine Journal” with my own thoughts and observations about ketamine assisted psychotherapy.

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.