Ketamine Therapy vs Therapeutic Ketamine Infusion

Ketamine treatment offers exciting therapy options that are legal in North America, however the terminology used can often confuse clients – are they receiving just a ketamine infusion or does it include therapy? Join Kate Kincaid, LPC, CMHC and Jennifer Fraser Montjoy, PMHNP-BC, PhD Candidate as we explore the distinction in these terms and the types of ketamine healing available.

Ketamine Treatment

Over the last decade, a growing subset of clinicians, primarily psychiatrists and psychiatric nurse practitioners in collaboration with psychologists and therapists, have taken a different approach to ketamine treatment in mental healthcare. A deviation from the medicalized intravenous ketamine infusion clinics, ketamine-assisted psychotherapy (KAP) uses ketamine as a psychotherapeutic tool during the post-administration (i.e. psychoactive) phase, the 40- to 60-minutes following ketamine administration. This approach has gained momentum in the U.S. by psychiatric providers and mental healthcare clinicians due in large part to the resurgence of psychedelic research in academic and clinical settings, specifically the psychotherapeutic research of psilocybin and 3,4-methylenedioxymethamphetamine (MDMA) in treatment-resistant depression, post-traumatic stress disorder, palliative care, and end of life care [1].

However, within the psychedelic research and clinical mental health communities, there has been confusion and misinformation proliferated about available treatment approaches and options utilizing racemic ketamine. It is our intention and hope that the following will provide clarification regarding available ketamine treatment options and some distinct differences between these approaches in mental healthcare.

Ketamine Infusion vs Ketamine-Assisted Psychotherapy

In general, there are two different approaches with which ketamine is being utilized to treat unremitting mental health conditions. One approach aligns with the traditional biomedical model and is typically offered in ketamine infusion clinics. In these settings, ketamine hydrochloride is administered intravenously (IV) over approximately 40 minutes in sub-anesthetic doses (e.g. 0.5mg/kg) [2]. Most, not all, IV ketamine infusion clinics are managed by providers certified in anesthesiology and/or pain management. At these clinics, patients are continuously monitored (e.g. blood pressure is automatically taken every 5 minutes; heart rhythm is monitored with 3- wires attached to the chest using adhesive pads).

Medical technicians, medical assistants or nurses are overseeing the medication administration, and medical equipment that remains chair-side and connected to the client. Patients are discharged approximately one-hour post-ketamine administration. Psychotherapy and psychotherapeutic support are not typically a consideration in IV ketamine infusion clinics. Researchers have reported reductions in depression severity and suicidal ideation using the medicalized approach in randomized control trials; however, the duration of these benefits remain unclear and have been reported as short-term (3-7 days) by most investigators [3].

The other approach is a more interdisciplinary, called Ketamine-assisted Psychotherapy or KAP; whereby, therapists and psychologists, in collaboration with psychiatric providers, work closely with patients during the post-administration or psychoactive phase of ketamine administration. KAP emphasizes integration (i.e. processing insights and employing these in daily life). KAP providers most commonly administer ketamine sublingually and/or intramuscularly; consequently, clients are not connected or tethered to medical equipment during their sessions. Instead, heart and respiratory rates and blood pressure are measured  pre-and post-ketamine administration. This psychotherapeutic approach seems to be growing in popularity as clinicians and patients realize the benefits with concurrent ketamine administration and psychotherapy.

Defining ‘Therapeutic’ for Ketamine Infusion vs KAP

There is confusion related to the semantics of therapeutic; to clarify, within the context of pharmacology, the term therapeutic relates to the dose or amount of a medication to be considered effective or efficacious in treating specific conditions or disease states. For example, for an antibiotic to be therapeutic, it must be administered at a specific dose for a specific duration to aid the body in combating certain microorganisms underlying infection. Lithium is another example, whereby serum lithium levels outside of the therapeutic range may be toxic or conversely subtherapeutic or ineffective. That being said, some providers, even within psychiatry, are advertising therapeutic ketamine services more aligned with the pharmacological context and are not actually providing concurrent psychotherapy. This is understandably creating confusion for both consumers of mental healthcare, other clinicians, and communities interested in psychedelics for medicinal and healing use.

Impact of Psychedelic Effects

Outside of mental healthcare (e.g. ketamine infusion clinics, hospital settings), the consensus regarding ketamine administration has been to avoid the dissociative or psychedelic effects which are achieved by slower administration (e.g. infusing the medicine IV over 40 minutes). Interestingly, a secondary analysis study [4] reported a positive association between more robust and durable depression treatment response when participants (n = 108) reported dissociation during ketamine administration.

KAP providers also use sub-anesthetic doses of racemic ketamine generally ranging from 0.4 mg up to 1.5 mg of bioavailable ketamine per kilogram; however, the routes of administration, treatment approach, and setting deviate greatly from the medicalized approach. Subjectively, and dose-dependent, clients report: a reduction in anxiety and a 40-to 60-minute non-ordinary state of consciousness (NOSC) experience ranging from trance-like to mystical or transformative [5]. Practitioners of KAP have found the NOSC to aid many clients in strengthening self-efficacy and sense of connection and to facilitate insights during and after the psychoactive phase of the ketamine administration.

In addition to utilizing dissociation and embracing the trance and/or mystical subjective experiences during KAP, providers also value the importance of the ecology of the KAP treatment approach. KAP ecology includes setting (e.g. environment/surroundings), clinicians, music, use of eye cover, and ceremony (e.g. opening and closing sessions), and maintaining a safe container are all integral components. Emphasis on the ecology is a departure from the more medicalized approach of ketamine treatment currently being offered in ketamine infusion clinics.

Clarifying KAP & Ketamine Infusion

Because the field of psychedelic-assisted psychotherapy is relatively new, it is important that we take the time to be specific and intentional about what a session is and is not. It can be easy to make assumptions without all knowledge available, and to judge that which we do not know (stigma). It is also important to note that ketamine infusion and ketamine infusion clinics differ greatly from ketamine-assisted psychotherapy, in the set, setting, administration, support, structure and integration. The more knowledge and understanding clinicians have regarding available treatment options, the more informed and empowered our clients will be when deciding which treatment options are best suited for their wellness goals.

References

1. Schenberg E. E. (2018). In Psychedelic-assisted psychotherapy: A paradigm shift in psychiatric research and development. Frontiers in pharmacology, 9, 733. doi:10.3389/fphar.2018.00733nn7.
2. Sanacora, G., Frye, M.A., McDonald, W. Mathew, S.J…Nemeroff, C.B (2017). A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders. JAMA Psychiatry. 2017;74(4):399-405. doi:10.1001/jamapsychiatry.2017.0080
3. Mathai, D.S., Meyer, M.J., Storch, E.A., & Kosten, T.R. (2020). The relationship between subjective effects induced by a single dose of ketamine and treatment response in patients with major depressive disorder: A systematic review. J Affect Disord, 264,123-129. doi: 10.1016/j.jad.2019.12.023
4. Luckenbaugh, David A, Niciu, Mark J, Ionescu, Dawn F, Nolan, Neal M, Richards, Erica M, Brutsche, Nancy E, . . . Zarate, Carlos A. (2014). Do the dissociative side effects of ketamine mediate its antidepressant effects? Journal of Affective Disorders, 159, 56-61. doi.org/10.1016/j.jad.2014.02.017
5. Dore, J., Turnipseed, B., Dwyer, S., Turnipseed, A., Andries, J., Ascani, G. . . . Wolfson, P. (2019). Ketamine assisted psychotherapy (KAP): Patient demographics, clinical data and outcomes in three large practices administering ketamine with psychotherapy. Journal of Psychoactive Drugs, 51(2), 189-198. doi.org/10.1080/02791072.2019.1587556