Ketamine As An Alternative For Treatment Resistant Depression

Written by Jayma C. Sitton, LCSW

Ketamine has been a hot topic in the world of mental health in recent years. Approved by the FDA as an anesthetic, it is currently undergoing many studies for its effectiveness for refractory (treatment resistant) depression, pain with depression, bipolar depression, refractory OCD and ruminative suicidal ideation. As a result of its current success with many of these patients, doctors have been prescribing ketamine for these areas of treatment “off label,” meaning at the discretion of the administering physician. The ability of physicians to prescribe for clients who fit the criteria listed has caused an expansion of options, including IV infusion, intramuscular, sublingual and nasal. A nasal spray called Spravato, produced by a molecule taken from Ketamine (esketamine), was approved by the FDA in 2019, and has proven to have an anti-depressant effect when taken with oral anti-depressant medications. This is currently the only method of Ketamine that is approved by Medicare, but does not allow for variability in dosage as other methods of administration do. At higher doses, “Ketamine can produce feelings of unreality; visual and sensory distortions; a distorted feeling about one’s body; temporary unusual thoughts and beliefs; and a euphoria or a buzz,” says John Krystal, MD, chief of psychiatry at Yale-New Haven Hospital and Yale School of Medicine in Connecticut, where he is a leader in studying ketamine’s antidepressant effects. While there are risks of casual use, and the potential for addiction when taken regularly, researchers have taken notice of it’s profound impact on treatment-resistant depression. “Some people with long-term depression lose some important connections in their brains (called synapses) that let nerve cells communicate…But research shows that within 24 hours of the first dose of medically supervised ketamine, those lost connections start to regrow. The more synapses they grow, the better the antidepressant effects of ketamine are for them.” “Ketamine may work in other ways in the brain, too. Some nerve cells (neurons) in the brain involved in mood use a chemical (neurotransmitter) called glutamate to communicate with each other. The nerve cells need glutamate receptors — think of them like catcher’s mitts for glutamate — in order to join in this communication. In the brains of some people with depression, those nerve cells don’t get so excited by glutamate anymore. It’s as if the glutamate receptors — the catcher’s mitts — are deactivated or weakened. But after people with this particular problem receive ketamine, those nerve cell connections get restocked with new glutamate receptors. It’s as if ketamine helps make new catcher’s mitts for the glutamate, so that the nerve cells can respond to it again.” “As for the drug’s action on glutamate receptors: Regrowing and reactivating synapses helps the brain’s ability to change, which may help it shift out of depression. That may also explain why antidepressants or psychotherapy that didn’t help before ketamine may help afterward.” The tendency to get stuck in repetitive behaviors-buying into consistent negative thoughts that hold us back from our true potential, engaging in behaviors that are harmful to ourselves or negatively impact our relationships-are typically connected to the so-called Default Mode Network (DMN) in the brain. Studies show that ketamine reduces the functional activity of the DMN, acting almost as a reset button or clean slate following ketamine use. “Accordingly, by turning the volume down on the internal mental chatter, you can start creating new stories, empowering thoughts, phrases, and or beliefs that you have about yourself or about the world. Much of the suffering we experience in life comes not from the actual events or people around us, but rather from the stories and beliefs we have about them. The new meaning you create can be incredibly restorative and healing.” This is where the importance of being able to control the dosage of the medication comes in. Ketamine-assisted-psychotherapy (KAP) is growing in importance as researchers and clients recognize that progressive step-ups in dosage allow for deeper insights once the Default Mode Network turns off, thereby eroding ego defenses and giving clients guidance about how to move past maladaptive behaviors. The power of Ketamine-assisted-psychotherapy is the integration of images, metaphors, and insights into daily life, taken from the use of the medicine. While there is much touting of the benefits of ketamine as a stand-alone medicine, ketamine is best used as a tool that helps create the opportunity for real change in our lives. Setting intentions for what one hopes to achieve with this new “reset” is crucial, as is the work of understanding what the medicine shows us while under its influence. As with all experiences while in an altered state of consciousness, paying attention to and interpreting imagery, symbolism and archetypes will provide insight  into how to manifest the intentions we have set. For assistance in finding a ketamine-assisted psychotherapist in the Philadelphia area, please contact us.  Resources:

1. https://www.webmd.com/depression/features/what-does-ketamine-do-your-brain
2. https://www.resetketamine.com/blog/how-ketamine-affects-default-mode-network