Ketamine Assisted Psychotherapy

The past two decades have seen a reawakening of psychedelic clinical use and research in the US, after these psychotropics were unfairly shelved in the 70s due to restrictive anti-drug legislation. 

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Ketamine has many effects in the brain, but there is now broad agreement that a key action is its noncompetitive antagonism of the N-methyl-D-aspartate (NMDA) receptor that modulates the neurotransmitter glutamate. It produces extremely effective analgesia and, for more than 30 years, has been commonly used in clinics and hospitals as an anesthetic for children, adults, and the elderly due to its rapid onset and short duration of action. Altered NMDA receptor signaling is seen in various conditions including addiction, depression, PTSD (Post-Traumatic Stress Disorder), Huntington’s disease, and Alzheimer’s disease. Through NMDA receptor antagonism, ketamine can modulate several key neural processes that are altered in depression, drug addiction and PTSD such as synaptic plasticity, neurogenesis, and neural network connectivity.

 

Ketamine use is devoid of life-threatening side-effects . In addition, there is one other advantage to ketamine over similar substances, namely its effects are of short duration and can be managed within the customary timeframe of most psychological/psychiatric sessions (i.e., in approximately one hour), so it can fit into current service delivery systems.

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Why Ketamine in Therapy?

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An evolutionary argument

The Phylogenetic story of our brain started long before we were humans -450 million years ago-, and the ability for this brain to process and be impacted by emotion started around 350 million years ago. Meanwhile, our capacity as humans to reason and have the language-based ability to frame our "story" is at most 160 thousand years old, with the explosive evolution of the mammalian prefrontal cortex. So basically, if we have been evolutionarily processing trauma for the past 350 million years, we have only been able to "talk about it" and "build a story around it" for about 0.04% of that time. Our highly evolved pre-frontal cortex allows us to frame ourselves in the world, understand a culture and its expectations of us, plan complex life projects, socialize and reflect on our lives, but does it help process trauma?

 

If the body and the non-cognitive brain have been holding on to trauma for most of our lives -and our evolution- how can we expect our intellect alone to solve the injury?

 

The argument here for working with Ketamine and other psychedelics, is their ability to transiently inhibit the way in which the prefrontal cortex in association with other areas of the brain 'keep our story in place'. This 'relaxing of the thinking mind' allows more access to underlying trauma associated content. Psychedelics allow our views of ourselves and the world to relax, our story to flexibilize and the underlying injuries to come to surface. With the right psychotherapeutic guidance, these injuries can be met with understanding, kindness and nurturing awareness, allowing the hurt to finally find a safe place to land, and a more nurturing framework of our thinking brains to naturally appear in the aftermath.  

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A clinical evidence-based argument

 

Ketamine and Depression: 
There are a number of well-established treatments for major depressive disorder (MDD), but they are only partially effective or even not effective at all in a significant number of patients. There is overwhelming evidence for ketamine therapy in depression, dating back two decades. A recent meta-analysis comprising more than 40 Randomized Controlled Trials and 3,299 participants confirms Ketamine is effective in severe and treatment resistant depression with response rates of up to 73%. Data shows that repeated doses of the agent further strengthen the medication's antidepressant properties. Also, dosage was shown to be an important factor, with higher doses associated with superior effects relative to low doses.

 

Ketamine and Substance Use Disorders: 

There are multiple trials that have studied the effects of Ketamine in Alcohol Use Disorder (alcoholism); they have shown increased abstinence, reduction in heavy drinking and improvement in comorbid conditions like depression. Studies that have used injectable Ketamine in patients with addiction to cocaine showed decrease in cocaine craving, increased abstinence rates and decreased overall cocaine consumption. 

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Ketamine and Post Traumatic Stress Disorder (PTSD):

A study done in 30 combat veterans suffering from PTSD found that repeated high-dose ketamine infusions significantly reduced both depressive and PTSD symptoms, and also reported an insignificant downward trend in substance use.

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Ketamine and Anxiety:

In a recent study using injectable Ketamine on patients with treatment resistant anxiety, the majority of patients experienced an improvement in anxiety symptoms as well as improved social functioning. Most patients that respond to Ketamine for anxiety, can remain in remission over three months. ​

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