What is Ketamine Treatment?

Ketamine is a relatively new and innovative psychiatric/psychological treatment approach, involving ketamine administration in a safe and supportive setting.

The exact nature of the treatment process varies depending on the particular problems being treated and the specific individual’s needs and goals. Initial sessions will involve an evaluation of a patient’s: current problems, concerns, and needs; prior history and review of current or ongoing treatment; overall health/medical condition; and an assessment of the potential suitability and viability of this type of treatment for that patient. By the end of the evaluation period, we will offer our clinical impressions and a recommended approach to treatment. These goals will be reviewed during the course of the treatment in order to assess and/or modify them according to changing needs, perspectives, and progress.

Why ketamine?

Current treatments for depression including medication usually have a 40% success rate. To make matters worse these medications do not reduce suicidal thoughts. They must be taken daily, and cause unwanted weight gain and other ongoing side effects. This is a time consuming and frustrating process for depressed patients. By contrast, ketamine treatment can reduce or eliminate suicidal thoughts, often immediately. It treats depression rapidly, with no ongoing side effects.

With ketamine, the effects are more robust than with medications. Ketamine is about 70% effective, it also helps patients with more than just their mood and depression, it seems to help them start over, and reconnect with who they are.

What does science say is happening to my brain?

The neuroscience on ketamine is fascinating. Unlike most antidepressants, it does not appear to work by serotonin or dopamine. Its mechanism is through a different neurotransmitter called glutamate.

Glutamate is everywhere in our brain and it handles learning, attention, and novelty seeking. The novelty seeking part is the most important. Ketamine seems to help our brain rid itself of old patterns, and try new ones. This appears to be essential to having a good mood. People with good moods are usually trying new things, whether recipes, books, parks, hobbies, or making new friends. Depressed people usually lose these abilities. After ketamine infusions, people often break old patterns and try new ones, which is amazing to see.

What does ketamine feel like?

Ketamine, in low doses, reduces the amount of control we have over the direction of our own thoughts.

Think of your mind as a river. Every day we are met by a fresh supply of tastes, sounds, smells, and interactions with people, and we react to this supply with fresh perceptions, thoughts, and decisions of our own. Each day, the water in a river is different water, even though the shape of the river does not change much.

Now, imagine a pond, or a backwater, unreached by any fresh current. The water is always the same, and it becomes stagnant. Like a swamp. In depression, having a bad mood is a lot like that. People with depression have a mind that doesn’t change much from day to day. It becomes stuck on a few stagnant negative thoughts and emotions. Like an eddy in a river, where the water beings to swirl around, without moving downstream, depression leaves people stuck in a whirlpool of repetition and negativity. To heal, they must let go, surrender and release repetitive thoughts, and allow into their minds a fresh stream of experience. Ketamine works by taking away the degree of control you have over your thoughts.

Many people report being swept away by water during their ketamine treatment. Emotions that are stuck, will be released, and you may rediscover within yourself a new valuable perspective on life.

When we are depressed, we control our mental contents, but we cannot control our mood. Our mood is like the smell of stagnant water in a pond. We cannot keep it fresh.

Whereas, when we are floating downstream, say, on an inner tube, we cannot grab onto anything. We cannot control what scenes pass by on the riverbank. But we are detached enough to control our perspective towards what we see. This is the reason ketamine will allow you to rediscover a healthy perspective on your life, and in turn, will elevate your mood.

Does ketamine cause hallucinations?

Most people undergoing ketamine infusions do not report hallucinations. However many people report distortions in the size and shape of their body. For example, some feel as if their hands, or lips, have increased in size. Some also experience synesthesia, which is the unique experience of seeing a sound, or hearing a color. Many also report that time does not seem to pass normally. It will dilate, or contract, such that the entire hour may seem like ten minutes, and vice versa.

During your ketamine treatment, if you close your eyes, you may experience a variety of visions, memories, emotions, and thoughts that you can’t control, and these are usually pleasant. However these visions are not hallucinations. We encourage patients to ‘go inside’ during their infusion, and to try to keep their eyes closed, since, if the eyes are opened, the experience may be suddenly interrupted.

What happens the day of?

Patients who have the best experience fast after midnight the night before, come in on an empty stomach, and try to arrive with a sense of peace. Patients who worry a lot about whether the treatment will work, during the infusion itself, do not get optimal effects. You should do your best in trusting the clinic, the process, and in the inevitability of getting some relief.

After arriving, you will sign in, report your symptoms on a questionnaire, sit down on a recliner, and a nurse will start a small intravenous line in your arm or hand. You will have a blood pressure cuff on your arm as well as a couple EKG leads stuck on your body, and an oxygen monitor on you forefinger. The nurse will tell you, if you need her for anything, you simply remove that thing from your forefinger and she will come in.

The ketamine will be administered and you will be closely monitored by our medical staff. You cannot drive after an infusion, and must arrange your own ride home.

What are the side effects?

The side effects that occur are during the ketamine treatment session, as there are no side effects after the fact. The drug is already being eliminated from your body.

During the ketamine treatment, by far the most common side effect is nausea and motion-sickness. Even though you will be reclined in a comfortable chair, with your eyes closed, you nevertheless may feel motion sickness.

Keep in mind that side effects vary per patient, some may experience them and some will not. However there are a few things that can be done to minimize or eliminate those side effects. The most important thing to remember is to come into the clinic on an empty stomach. Just like being on a fishing boat, or rollercoaster, eating food beforehand is not a good idea. We can give Zofran or other nausea medications if necessary before the ketamine treatment begins to make you as comfortable as possible.

In some, blood pressure increases, it will be managed, however it usually goes unnoticed by the patient.

There are reports of bladder issues in the literature, but this is almost always in people abusing ketamine daily at a high dose, and has not been observed in patients getting occasional ketamine treatments. Again, if bladder problems were a common issue with ketamine, it would not be considered the safest and one of the most utilized anesthetics in the world.

The second most important side effect, is intense anxiety from dissociation, although very rare. The vast majority do not experience this at all. In the few that do, the feeling is that ‘something isn’t right’ or that the mind is slipping away from the room or from the body. When this happens, we eliminate the feeling almost immediately, by giving a fast-acting anxiety medication and the patient is comfortable again, literally in a matter of seconds.

Despite the scare, this rare feeling of intense anxiety is subjective, and it isn’t really a danger to the patient.

Some other less common side effects of ketamine include increased cardiac output, increased intracranial pressure, tachycardia, tonic-clonic movements, vivid dreams, double vision, injection site soreness, exacerbation of current liver damage and/or liver disease, and nystagmus (blurred vision). Patients should consult with their cardiologist prior to seeking ketamine treatment if there is any history of cardiac issues.

TIPS FOR SUCCESS WITH KETAMINE TREATMENT: A HEALING MINDSET
By Thomas Cook, M.D

When you swallow a vitamin C tab, it doesn’t matter what’s on your mind. You can believe vitamin C is a waste of time, but your immune system will still benefit.

Whereas other experiences are more dependent on your state of mind.

Suppose you are trying to sit down and eat, but you’re aware your partner is upset at you. The stress may upset your stomach and cause indigestion. Italian and other cultures are wise to protect time for meals and pair them with uplifting conversation. The Italian way of turning meals into a slow ritual helps support digestion. Likewise, in some sports such as baseball or golf, players go through complex rituals before a pitch or a swing. The mindset is a necessary ingredient to success.

Finally there are some things that hinge almost entirely on one’s state of mind.

Silence is one of those things. If a friend ignores your text message for two days, what thoughts come to mind? It is like a Rorschach ink blot. How you respond to silence is colored first by what’s already in your mind. Prolonged eye contact is another example of this, and so are psychedelics.

Ketamine is so much like this, that some people report that every session is like an entirely new experience.

Excessive worry and doubt won’t ruin your ketamine experience. Most people still get tremendous benefit even in those circumstances. However, you will get the most bang for you buck if you attempt to trust, let go, and surrender. This is especially true if you are the sort of person who is prone to worrying you screw things up. I occasionally have patients who ask the staff every five minutes ,“Am I doing it right?” or who may tell us “I feel like I’m doing it all wrong.” This sort of person is full of doubt, worry, and thinks that in order to heal, they have to do something.

Instead, they should approach the experience in a passive state. Like drifting down a river on an inner tube. “Relax, kick back, and float downstream” is good advice.

If you are one of those worried people, this handout will be very helpful.

We have found the following points to be most helpful:

1. Have faith in the medicine.
2. Have faith in us.
3. Have faith in yourself and your capacity to heal.
4. Let go.
5. Make your mind a sacred place.

I will discuss each of these below.

1. Have faith in the medicine.

Faith does not contradict Reason, and works with it. However, it goes beyond Reason, as it often required by necessity. To have faith in the medicine, for most people this can be accomplished by asking Dr. Cook as many questions as you like, or reading about ketamine’s effectiveness and safety profile.

There is another, more important way to having faith in this medicine. To heal from depression many of us must overcome excessive skepticism and doubt.

We can get a mild placebo (i.e. a feel-good) effect from a brand name drug, merely from its catchy and slick advertising. This is a little gullible, but very common, and it’s a form of having faith in a drug. But because of the saturated corporate advertising culture we live in, many of us swing the other direction, and we struggle with skepticism. We also have a tremendous fear of addiction in our American culture, and we are suspicious of loving a drug too much.

Skepticism can at times be rooted in trauma, and because of childhood trauma, some people cannot place much faith in any drug, because a medicine is associated with trusting a bad parental figure. Such people are prone to nocebo responses… “nocebo” is a term which means an automatic anticipation of harm. It’s important for such people to realize that in their healing journey, they are alone, and they and no one else is ultimately responsible for their healing. Solitude can, for them, help clear away unhealthy attachments and can free them up from second guessing any trust they might place in the treatment.

Do not be afraid of ketamine. I have worked with it for many years and it is among the safest psychoactive drugs. It does not lead to addiction and the side effects it produces (temporary motion sickness, dissociation) are temporary.

2. Second, have faith in us.

You are safe, and you are in good hands. We will think about your safety more than you. So you don’t have to.

We know what we are doing, otherwise we wouldn’t be doing it. We are like ground control at the airport. We take care of everything so that your mind can drift, relax, let go, and give itself permission to surrender. If you have doubt about us, or our clinic, express it. Ask us questions.

3. Have faith in yourself.

You possess an inner healing intelligence. Whatever comes up during your session is exactly what needs to come up. That is to say, you already know the changes you need to make to heal from depression. You may not be aware of this, but the healing capacity is inside you already.

It is very common for people to have epiphanies, or shining realizations, right after ketamine treatments. These epiphanies are a sort of natural wisdom. They feel like “remembering” something forgotten long ago. It feels like a lost memory because it was already in you.

Some people expect their healing to have always an upward trajectory, and when it doesn’t they lose confidence in themselves. But psychedelics have a way of removing layers and layers from the personality, and there are positive and negative layers there, and sometimes people get a worse mood after some treatments. However, what I have seen is that even though the mood may worsen, the mood tends to change (or recover) more quickly than it did before. The person becomes more flexible, expressive, less numb, and, although sad, more resilient, which is how we all were originally as children. Instead of becoming depressed, children tend to suffer, cry it out, and then adapt and recalibrate towards happiness.

This original state of mind is naturally happy, curious, and spontaneous.

For those that experienced a lot of trauma during childhood, ketamine may cause a feeling of vulnerability which is difficult to tolerate. It is helpful to re-learn to tolerate the feelings of extreme vulnerability. This, in itself, can be quite healing. We have a guide to help you through that.

If you are tortured with hopeless ideas, e.g. that you can’t do it right, that you are cursed, or that you are a hopeless case, consider the following: depressed people often feel as if their sufferings are so rare, so special, or so unique that healing is impossible. Depressed individuals will cherish these thoughts as if they are the only thing that is true. But notice that no children talk this way. This kind of unique or “I’m an extreme case” talk is a maladaptive response that comes from being wounded. No happy person thinks their happiness is unique but almost every seriously depressed person does think this… To heal, you must eventually let go of that idea. Your sufferings are not as unique as they seem. “Uniqueness” always isolates people. This is part of the isolation of depression. As you heal you must find a way to stop believing this. I cannot tell a patient when or how to stop believing this, but as soon as they do, I can tell a difference. There is less gravity to the personality, and the mood improves drastically.

“Angels fly because they can take themselves lightly.” - G.K. Chesterton

4. Let go.

The word “surrender” isn’t used today very positively.

To “lay down your guns” may be a better way of putting it. The guns are the critical and harsh negative self-talk that you may be dishing out to yourself, perhaps all day long.

Letting go of this causes an immediate improvement in mood.

Ketamine puts people into a hypnosis, or trance state, in which the mind’s control valves are released. Most people are able to let go, and do just fine at this.

This is not an achievement you must work at. In fact, the more we think of relaxation as an achievement the harder it is to relax. “Whatever you do, do not think of a pink elephant.” It is impossible… so long as it is put in those terms.

Again, you are not here to “do” anything during your treatment, but merely let go, trust, and follow the experience.

When some people try too hard to meditate, they are not actually meditating. They are only thinking about themselves meditating. This gets in the way of actual meditation. We live in a culture of hyper-reflection. It is one of the reasons we have so much depression. We have a compulsive need to think, and to think about ourselves thinking, and to think about that… and so on. Like being stuck in a hall of mirrors. When we are confronted by anything that draws us out of that hyper-reflective whirlpool, like a beautiful cathedral, or a ride at Disneyland, our first impulse is to reach for a camera, rather than to simply live in the moment. A photograph will usually diminish the experience.

Luckily, dreams cannot be photographed, and it is difficult to analyze a dream. This is perhaps one of the purposes of dreaming: to relieve prolonged sadness by leading us out of the control aspect of the wakeful conscious mind. In dreams, we relinquish control, but it is this vulnerability which makes sleep restorative. Again, to fall asleep is to let go, and ketamine is no different than that. Except that with ketamine, you are still very much awake.

5. Make your mind a sacred place.

“Sacred” is a difficult word today because our society is a religious melting pot.

But most people would agree that life is sacred, or that something about their existence is mysterious or sacred. This can be thought of as a very practical and down to earth idea.

Perhaps we can get at its meaning by saying what it is not. People would not store diamonds and pearls or other precious jewelry together in a drawer with paperclips and scotch tape. We all instinctively feel a need to set apart things of great worth, so they aren’t mixed with objects that are replaceable.

Consider that your mind and soul are things of great worth, like a priceless diamond. Yet your mind is assaulted everyday by garbage info, advertising, social media, and other worthless stuff. Sooner or later there is no room for anything else. You may begin to feel like you are the sum of that garbage, i.e., of low worth.

To restore your mind as a sacred place, consider that most thoughts are socially contagious, (just as despair and suicide can be socially contagious) but once certain thoughts are inside of us, they seem to have originated in us. They do not come from us, and they devalue us, but we grab onto them like a hoarder who lives in a mountain of garbage and never throws anything away. If we identify with every negative thought, we become like the person who feels empty after watching TV advertisements, because they agreed with every advertisement.

Your mind is like a living room, and your thoughts are like furniture. Make your mind a comfortable place to live in.

Who would put an horsehair couch, or a bed of nails, in their living room? Some thoughts are disturbing to our self esteem, but we still entertain them. Thoughts can be like rude, unwelcome visitors. For example, “I can’t make any friends” is a rude thought, like a friend who waltzes into your mind and tosses himself, all sweaty, on your favorite recliner. Later he invites the thought “it’s no use, I made a big mistake and ruined my life” to come over, who eats out of your fridge. Finally “my life is just not worthwhile” comes in, and stamps muddy shoes all over your rug.

In depressed people there is a tendency to give high value to these rude thoughts. And to be overly attached to them. Even when they harm us. That is the essence of depression. To be overly invested in, and identify with thoughts that demean ourselves.

Pardon me for saying it, but the best perspective towards most of our thoughts, is to think of them as burps or farts. Like a burp or a fart, they aren’t important, don’t need to be taken seriously, and make no sense. Like a burp or a fart many of them are useless, unwelcome, and unannounced. I have time and again seen psychedelics help depressed people get rid of the over-investment in their thoughts, to detach from thoughts, to see them as not necessarily an intrinsic part of what is YOU… and I have seen psychedelics teach people to be more playful and less serious in the way that they think.

Any perverse sense of pride and private personal attachment to our own thoughts, is often something that needs to be done away with.

I have given a lot of advice here. If it is useful, remember it. If not, forget about it.

Remember, finally, that we are there for you, and we have great confidence in your ability to heal.