Ready, Set, Go: Administering Ketamine

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A KETAMINE JOURNAL

The patient, “Mr A,” lay on the couch in my office, an eye mask blocking the ambient light, a pair of headphones emitting music that is some cross between tribal, rhythmic, and just plain weird. When the music stopped, he took off the eye mask and let himself emerge gently, as I had instructed.

“I was in the Amazon,” he said. “There were gorillas. Angry gorillas, baby gorillas, wise gorillas.”

I was caught off guard. The patient knew I had just come back from vacation, but he had not asked where I was going and this was not something I had offered.

I had this idea that I would learn to do ketamine assisted psychotherapy (KAP) and that other psychiatrists would refer patients to me for group treatment. At the Psychedelic Research and Training Institute (PRATI), my home group instructor advised me to go slowly with ketamine. Starting with 4 strangers was not a good idea, he noted, so I decided to use KAP with some of my own patients first. I started with a single patient, Mr A, whom I had known for a few years.

I had prepared for months. I thought of my patients who were stuck in spirals of negative thoughts that fueled their depression. These are individuals who have had partial responses to antidepressants but who still have the self-deprecating cognitions we see with major depressive disorder. I asked 6 patients if they might be interested in ketamine to address this and 3 said yes. All 3 are patients I have been treating for years (range of 2.5 to 16 years) with both psychotherapy and a wide variety of medications. Two had been treated with transcranial magnetic stimulation (TMS) and 1 had been hospitalized after a suicide attempt. They all feel the medicines help—just not enough.

Mr A had expressed some discomfort about being in a group, so I offered to try 3 sessions of KAP with him alone. He had considered Spravato, but the treatment schedule was incompatible with the logistics of his life. He has a specific issue he wanted to address with KAP: intrusive thoughts about past regrets (he refers to them as failures) from decades ago. Despite this preoccupation, his professional life had turned out well. He attained a professional degree and maintained an interesting and prestigious career for which he is well compensated.

KAP is not just about the administration of a chemical with the hope for a passive recovery, it is more of an active event. I have a checklist for the patients and 2 weeks before starting ketamine, I want them to alter their diets to eliminate processed foods and sugar, and to limit caffeine. They are asked to minimize or eliminate their use of substances, to exercise daily—"walking is good, walking in nature is better”—to get enough sleep, and to start a daily meditation practice. For those who are not familiar with meditation, I send them Sarah Blondin’s free course on Insight Timer, “Learn How to Meditate in Seven Days.” During this time before we begin KAP, I want my patients to focus on themselves and a healthy lifestyle to create an optimal mindset for ketamine. I am careful to tell them not to abruptly stop any substance they are physically dependent on—the idea is to be healthier, not to throw the body into a state of withdrawal and stress. Directions are given regarding medications that may mitigate the effects of ketamine, such as benzodiazepines and lamotrigine, and patients are told to fast for the hours before ketamine administration to minimize the risk of vomiting.

“In psychedelic medicine, we talk about the importance of set and setting. I will take care of the setting, you need to prepare for the optimal mindset.”

I have a checklist for myself, which includes setting up the sound system, putting out an eye mask, a blanket and pillow, an emesis basin, a blood pressure cuff and pulse oximeter for each patient, and poetry to read aloud. Before we begin, patients are asked to fill out a Beck Depression Inventory (BDI-2). They are asked to do this again before the second session, and then after the third and final session. Mr A’s initial BDI-2 score was 21, just above the cut-off for moderate depression.

Mr A had been treated for paroxysmal atrial fibrillation. While I worried about this, he did not—when he went into afib, he assured me, he noticed it, but nothing terrible happened. I contacted his cardiologist. The cardiologist said it was safe to use ketamine and expressed no concerns. After some discussion, we decided it would be a good idea for Mr A to pretreat with the beta-blocker he was already taking at night. I had him take a dose before coming to my office and he pretreated for motion sickness as well.

I closed the shades in my office, used lamps for lighting, and lit a candle to create a soft and less clinical setting. We talked about what to expect, and I asked Mr A to set an intention for the ketamine session. He said he wanted to understand why he was so dominated by anxiety. I asked him to identify things he liked about himself, and emphasized that I wanted him to focus on the good things in the 48 hours after ketamine—this period of neuroplasticity when I hoped he would be able to escape his negative, intrusive ideas. In addition, I instructed him not to work or drive for the remainder of the day, and to do quiet activities he found soothing or pleasant.

Mr A placed the dissolvable ketamine troches (200 mg) under his tongue and swished them around in his mouth for 15 minutes, then to spit out his saliva. Ketamine discussion boards are rife with talk of ‘spit vs swallow.’ Swallowing induces a longer and more intense dissociative experience and may include more adverse effects.

Mr A rested comfortably as I nervously watched him breathe. After about an hour, he told me the ‘journey’ had ended. I gave him a piece of paper and colored pencils and asked him to draw a picture of his journey. He drew colorful pictures of mountains and animals and then he talked with me about what he had experienced. He left my office feeling better, and we spoke on the phone the following day to continue integration—the process of linking his experience to his life, past and present—and reinforcing the idea that this was a time for change. The gorillas, he told me, represented his family.

I had worried that Mr A might have a bad reaction to ketamine, as he struggles with so many difficult emotions. That was not the case and while he continued to have some negative thoughts, they were easier to push aside and his mood was better.

Mr A’s Beck score remained at 21 a week later, before the second session. I found it interesting that on the first question, his response went from, “I feel sad much of the time,” to “I do not feel sad.” He did not take the motion sickness medicine for this session and noted that he felt some nausea after. Again, we spent some time talking after the ketamine wore off, and I phoned him the following day.

By the third session, neither of us was anxious. I waited until after the session to administer the Beck inventory, and his score was now 7.

Did the progress hold? It has been several months, and I have continued to see Mr A for psychotherapy and medication management. In this time, Mr A has struggled with several traumatic changes in his life, stresses that we would expect to bring sadness to anyone. His tendency to ruminate had not vanished but what has changed is that his ruminations are about his problems in the present and not concerns from decades ago.

I double checked with Mr A on the first day of ketamine administration. “Did I tell you where I was going on vacation?”

“No,” he said. “Where did you go?”

It had been a special trip to mark an anniversary, a once-in-a-lifetime adventure.

“Rwanda,” I replied.“I went gorilla trekking.”

I felt like my gorillas had showed up in Mr A’s journey, and it felt remarkable. He looked perplexed and told me he did not know what to make of it. I, too, still do not know what to make of this.

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.