I just got back from an inspiring conference in Berkeley on Ketamine for Depression. I am eager to implement some changes in how we work with people we refer or provide ketamine infusion for that may make the treatment more effective.
The conference was organized by Alison McInnes, MD, MS, who is in charge of the Kaiser, San Francisco Ketamine Treatment Program, and included expert speakers from around the world.
Dennis Hartman, founder of the the Ketamine Advocacy Network (KAN), organized an inspiring panel of ketamine patients . He also spoke of why he founded the ketamine network. He had a life changing ketamine experience at NIMH as part of a research protocol, and was then told, in essence, now forget the experience and go home… He did not do that, and instead founded KAN to advocate for making this treatment more widely available for those with treatment resistant depression.
Steve Levine, MD, who runs the largest network of ketamine infusion centers, Ketamine Treatment Centers, which has treated nearly a thousand patients, presented information about the role that spiritual experiences, and, in particular, the experience of awe, may play in the benefits of ketamine. He referred to data about the health benefits of awe, which I summarized in a post on Moodsurfing.com several months ago (Awe Reduces Inflammation). He suggested that a key change induced by experiences of awe, spirituality and dissociation may be a disruption of recursive negative thought patterns often associated with depression.
Rupert McShane, MD, from the Oxford Health Clinic in the United Kingdom described their experience and also commented on the effect ketamine has “lifting you out of a ruminative rut.” He cited sustained success rates of about 42%, but as with many of the speakers, said that about 70% experience some immediate benefit. They evaluate patients using an interstitial cystitis symptom screening questionnaire, the Massachusetts General Hospital Antidepressant Response Questionnaire and a psychiatric assessment and consent process in which they note that the data for TMS/ECT effectiveness is stronger than for ketamine.
Elias Dakwar, MD, from Columbia University gave a fascinating presentation about how he has combined ketamine infusion with intensive mindfulness training using Mindfulness Based Relapse Prevention (MBRP) to help people with cocaine addiction. Preliminary results from this treatment were remarkable. At 2 weeks, 49% of those receiving ketamine had quit, compared with only 9% of those receiving a placebo infusion. In his view, ketamine “quiets the mind” and gives you about a week’s window of opportunity to create new patterns of behavior and thought. He also indicated that the experience of mysticism (measured using Hood’s Mysticism Scale: HMS) was strongly associated with motivation for abstinence.
Angelo De Gioannis, MD, from Melbourne University described an oral dose titration approach that has the goal of finding a dose that is just below the threshold for dissociation. He titrates up to a dose that gives people the “two glasses of wine” feeling and then drops down to the previous dose. The average dose using this approach starts at 3 mg/kg and over time goes down to 2 mg/kg. He uses ketamine long term with careful controls to prevent diversion. He describes a work up that includes, in addition to a psychiatric assessment, a metabolic panel, TSH and a yearly EKG. He also combines ketamine with a simple version of biofeedback designed to enhance alpha waves.
Robert Schoevers, MD, from the University of Groningen in the Netherlands, reviewed studies on oral ketamine for pain and for depression. The most common dose used is 0.5 mg/kg, with only Dr. De Gioannis reporting using higher doses (2 – 3 mg/kg). He did a pilot study using a dose of 1.25 mg/kg daily in three divided doses. They are now starting an S-ketamine oral study.
At the end of the conference, a panel of therapists talked about how they work with patients who are receiving ketamine oral and infusion therapy. There seemed to be general agreement that ketamine created opportunities for changing long-standing patterns of thought.
This potential for change was felt to be related to the experiences of awe, spirituality, and dissociation. The period for capitalizing on this potential was felt to be anywhere from 1 day to a week after infusion.
There were two general approaches to taking advantage of this opportunity: an experiential group process emphasizing emotional awareness, and various more didactic therapies including:
- Mindfulness based therapies such as Mindfulness Based Relapse Prevention and Mindful Self Compassion.
- Emotion Modulation Therapy, which was developed by Angelo De Gioannis.
For More Information
Dakwar E, Anerella C, Hart CL, Levin FR, Mathew SJ, Nunes EV. Therapeutic infusions of ketamine: do the psychoactive effects matter? Drug Alcohol Depend. 2014 Mar 1;136:153-7. doi: 10.1016/j.drugalcdep.2013.12.019. Epub 2014 Jan 15. PubMed PMID: 24480515; PubMed Central PMCID: PMC4091719.
Dakwar E, Levin F, Foltin RW, Nunes EV, Hart CL. The effects of subanesthetic ketamine infusions on motivation to quit and cue-induced craving in cocaine-dependent research volunteers. Biol Psychiatry. 2014 Jul 1;76(1):40-6.
doi: 10.1016/j.biopsych.2013.08.009. Epub 2013 Sep 12. PubMed PMID: 24035344; PubMed Central PMCID: PMC4105157.
Li L, Vlisides PE. Ketamine: 50 Years of Modulating the Mind. Front Hum Neurosci. 2016 Nov 29;10:612. eCollection 2016. Review. PubMed PMID: 27965560; PubMed Central PMCID: PMC5126726.
Luckenbaugh DA, Niciu MJ, Ionescu DF, Nolan NM, Richards EM, Brutsche NE, Guevara S, Zarate CA. Do the dissociative side effects of ketamine mediate its antidepressant effects? J Affect Disord. 2014 Apr;159:56-61. doi: 10.1016/j.jad.2014.02.017. Epub 2014 Feb 18. PubMed PMID: 24679390; PubMed Central PMCID: PMC4065787.
Schoevers RA, Chaves TV, Balukova SM, Rot MA, Kortekaas R. Oral ketamine for the treatment of pain and treatment-resistant depression†. Br J Psychiatry. 2016 Feb;208(2):108-13. doi: 10.1192/bjp.bp.115.165498. Review. PubMed PMID: 26834167.