Clients with depression, especially TRD (Treatment Resistant Depression), Depression of Bipolar Affective Disorder, Generalized Anxiety Disorder, PTSD, OCD, Asperger's (no studies for the last one, just in my experience), chronic pain (e.g. migraines, trigeminal neuralgia, other chronic pain syndromes). If you're curious if ketamine is right for your client, ask me (email/phone).
Every client will need an initial evaluation before starting ketamine treatment. If the schedule permits and the client is willing, they could receive their first ketamine treatment on the same day as the evaluation. As the schedule fills up, I anticipate that there may be a delay between the evaluation and the first treatment. I generally recommend 8 weekly treatments.
The medical Assistant and provider will check in the client, discuss their symptoms and progress, decide on the dose. The Medical Assistant will give them the im injection and the client stays in the darkened room for about 30min. We will check on them during this 30min frequently. They can have a friend or loved one in the room with them. After the experience is over I meet with them again for 15min to debrief, discuss what came up, etc
We give ketamine im (intramuscular). It's basically the same (same bioavailability) as iv (intravenous) which is the most common form in studies and ketamine clinics. But intramuscular is much more convenient (an injection that lasts 1-2 seconds vs an iv drip in a vein for 40min) and the duration is very reliably 30min in most cases. I think the experience is equivalent to iv if not better. I am not a fan of intranasal or sublingual ketamine because those routes are very unreliable, with unpredictable effects (even at the same dose) and unpredictable duration. im & iv are best.
I generally suggest once a week treatment. The benefits of each dose manifest over 2-3 days after, so once a week treatment allows one to see the benefits of each dose fully before getting the next dose. For most clients I recommend 8 treatments, which appears to have become the standard. About 85% of clients have lasting benefits after 8 treatments. Some clients feel partial benefit after 8 treatments and we can offer ongoing treatment beyond 8. Some clients feel they need a booster a few months after they've had 8 treatments and we can do that. Sometimes clients reach full benefit before 8 treatments. 8 treatments is NOT the maximum number of treatments
: I recommend eating a small snack 2-3 hours before treatment. That seems to minimize the incidence of nausea. If a client forgets to eat during that time frame, they should not eat for 2h before ketamine. Water is ok.
: Because many clients feel a bit out of it/groggy after treatment, I would request that at least for the first few treatments, clients arrange a ride home. Integration: It would be great if every client who gets ketamine can see a therapist (ideally a therapist they're already established with) to help integrate the insights from the treatments. I understand that this may not be easy or possible. I will provide as much integration as possible at the end of each session and at the beginning of subsequent sessions.
Ketamine can make the eyes sensitive to light, so we will darken the room as much as possible and offer the clients eye masks.
Ketamine can heighten the sense of hearing, so we will try to get noise generators to cover up distracting noises. I encourage clients to bring a music player/headphones to listen to music if they want. Alternatively clients could bring ear plugs to minimize distraction from noises. Some people report feeling chilly during ketamine treatment, some report getting warm. If a client is worried about getting cold,perhaps they could bring a blanket or similar.
Medical contraindications: Uncontrolled hypertension, since ketamine can elevate blood pressure. History of seizures. Active bipolar mania. If you're not sure, contact me. In my opinion a history of psychosis is not a contraindication to receiving ketamine, but the client should not be actively psychotic. You can contact me to discuss.
A history of dissociative abuse (PCP, street ketamine) is not an absolute contraindication, but we may have to consider drug testing and making sure the client is committed to sobriety and we don't trigger a relapse.
Benzodiazepines: There's an 'urban legend' that benzos are contraindicated. This is a misunderstanding. There's at least one study to suggest that benzos can dull the effects of ketamine in a dose-dependent relationship, i.e. if a client is on large doses of benzos, this may significantly dull the benefits of ketamine. At lower doses it's less clear, i.e. there can be benefits. If a client is interested in ketamine and is on large doses of benzos, a ketamine treatment can be given and if there's limited benefit, strategies for tapering or skipping benzos in a safe way can be explored.
Lamotrigine: appears to dull the benefits of ketamine. Not a contraindication but if a client is on lamotrigine, they may need to skip the AM dose to get benefit from ketamine.
Naltrexone: not a contraindication. There's conflicting evidence whether naltrexone dulls or amplifies the effects of ketamine. If a client is on ntx we can try a ketamine treatment and if there's suboptimal response discuss skipping ntx.
Levothyroxine, NP Thyroid, Armor Thyroid: These can amplify the blood pressure elevating effects of ketamine. My plan is to monitor BP before and after treatment, and if BP gets significantly elevated instruct the client to skip thyroid meds before treatment.