Among the recreational drugs currently entering the psychiatric stream (MDMA, LSD, etc.), ketamine is an exceptional thing. Most people have a rough idea of what “supposedly” or “molly” it does, even if they have never tried it. Meanwhile, ketamine is left out of a compromised sect“An enigma.” Not much popular recreational drugs. There is no standard Hollywood version of ketamine travel. There is talk of ki holes of some occasional allusion to its use as a tranquilizer for horses, but little about its real effects and less about what it is like to take it in a clinical setting, which is increasingly patients with depression and mood disorders he will soon. To correct the record, for this week Giz Question we contacted several people who have conducted clinical trials of ketamine.
Michael Tiger
Researcher, Clinical Neurosciences, Karolinska Institute
In one of my studies, we treated thirty patients with ketamine depression.
During treatment, most patients reported intense dissociation. They were disconnected from reality in various ways and perceived things differently. One patient heard the radio play in 3D, which she found intensely absorbing. Then, going back to the same program, he realized that it was actually quite boring.
About 20% of patients had hallucinations, and most found the experience interesting; some compared it to drunkenness. (Ketamine is addictive for this reason.) Two out of thirty thought it was a horrible experience, even though, since they responded to treatment, they were willing to do it again. It was generally thought to be quite intense.
The drug was administered in a hospital and nurses were present for the duration of the experiment. These were nurses who had worked intensively with patients with severe depression and who had helped administer ECT, which as a treatment is (in a sense) closer to ketamine therapy than LSD or psilocybin therapy. With ECT, as with ketamine, the goal is to get the patient into what we call remission, to get him back to his life before the onset of severe depression. This is different from, say, psilocybin therapy, where the psychotherapy component is really important. With ketamine, people don’t get information that they can integrate into their day-to-day lives, just as they could with psychedelic therapy. They had a strange experience, but no knowledge.
Antidepressant effects appeared after treatment. This is very new: most normal antidepressants take weeks to perceive an effect. 70% of the patients in our trial woke up the next morning feeling much better.
Michael Grunebaum
Associate Professor of Psychiatry at Columbia University
The vast majority of patients with mood disorders treated with ketamine infusions report feeling strange and / or spatial. Some have the feeling of floating. Some record that their arms or legs feel different in some way, larger than usual, or numb, or harder to move. Some have a kind of numbness around the face or mouth. Sometimes people feel cold. A few rare people experience mild hallucinations: shapes or colors on the walls or ceiling.
A small percentage of people may feel anxious when they receive ketamine, possibly because the sensations are unfamiliar; some people may find it more difficult to find the right words, which can lead to anxiety. A small minority may also feel sad or cry, or experience a burst of memory. In contrast, a small percentage of patients experience a kind of euphoria. But more often, what you experience most is this strangeness / spatiality. Usually, all these effects disappear after about 15-30 minutes after treatment.
The drug is usually given intravenously, with a slow drip of more than forty minutes, but a nasal spray version has recently been approved. People can receive two or three treatments a week for a few weeks and then decrease the frequency. There is still a lot of research on what is the right frequency for maintenance treatment, as well as how long the treatment should last, how many are safe, and so on. Studies on ketamine addiction show serious risks for long-term use of ketamine, although therapeutic doses are much lower, perhaps one-tenth as large as typical street doses.
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Adam Coupling
Clinical Director of the Sketamine Psychiatric Clinic and Assistant Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University
One of our patients, each time, turned off the lights and entered a dreamlike state, during which he flew over New York City, where he used to work. He was waiting for her, his little trips to the city. Another woman swore we were hiding lemons in the room. We had a patient for whom the colors would vibrate outside the window: he described a green different from any green he had seen before. Another heard voices and saw the spiders crawling through the door.
Which means it has a wide range and depends largely on the patient. But virtually no one we dosed said they didn’t want to continue. When ketamine works, it works dramatically: in the first dose or two, people improve dramatically; some even feel they have returned to their old selves. Having this response in people with treatment-resistant depression, after a few doses, is amazing.
The people who felt most distressed were people who had never experimented with drugs. One person we treated, a musician, had treated his body like a temple, without drugs or alcohol all his life. So for him, ketamine was a terrifying experience: he just didn’t know what would happen. But usually people who have used drugs in the past find it a great experience.
One thing that helped with the side effects — and I swear I won’t get any money for that — was Enya. Invariably, Enya calmed our patients, even patients who were supporters of hard rock. It was Enya who really did it for them.
Rebecca Price
Associate Professor, Psychiatry and Psychology, University of Pittsburgh
During and immediately after a ketamine infusion, most patients feel sedated, somewhat “high,” or euphoric, and some feel separated or somewhat removed from what is happening around them. Some get dizzy, nauseous, or have a headache. Usually, researchers do not think that there is anything too special in the acute experience of receiving ketamine. When ketamine therapy is successful, “special” things appear downstream, in the form of an accumulated feeling of relief from depression and other negative emotional symptoms, which reach a maximum approximately 24 hours after the infusion, which s ‘has been related to changes in neuroplasticity that occur after time points. In general, we think that the things that happen during and around the infusion are mostly annoying side effects, rather than anything especially therapeutic. This makes ketamine quite different from other drugs that are now being investigated, such as psychiatric treatments, such as psilocybin.
Joshua Berman
Assistant Professor of Psychiatry and Clinical Head of the Ketamine Program at Columbia University
Patients report a number of experiences while receiving ketamine therapy for depression, but overall, the psychiatric dose of ketamine is a “more domestic” experience than many might imagine. Most patients describe that they feel “spacious,” starting 5-15 minutes after initial treatment, and that the sensation occurs from 30 to 90 minutes. Some describe it as high and a small number of patients become slightly dizzy. Some patients describe almost hallucinations, such as seeing patterns around them. While almost everyone describes some sense of dissociation, very few really feel outside their bodies and even fewer feel that they have lost touch with reality even for a short time. These feelings can be intensified if higher doses are used and there is no universal agreement among ketamine doctors on whether a high degree of dissociation is required to achieve the desired antidepressant effect.
Ketamine is administered intravenously or via an intranasal inhaler in a medically controlled environment where vital signs and patient response can be monitored. Treatment sessions are usually two hours, after which the patient can return home.
Acute effects (spatial sensation, dissociation, or high) disappear within an hour or two after administration, but any reduction in depressive symptoms may persist for hours or days. It can take several treatments for the antidepressant effect to consolidate and become more lasting. Once fully established, the antidepressant effect can be persisted with maintenance treatments that can be separated by 2 to 4 weeks. For some patients, a long period of maintenance treatment is required, while other patients have sustained remission after only a few months of maintenance.
Many patients report a rapid improvement in mood, anxiety, and hedonic function, which is what initially attracted the psychiatric profession to the use of ketamine. It is the first treatment for depression that can work in a matter of minutes to hours. But for many, the first one or two (or even four) treatments produce a much more subtle sensation, with a variable improvement in overall mood: at first it fluctuates, but then it consolidates. Approximately one-third of patients have no response or no sustained response.
For most patients, the experience is very pleasant or neutral, but sometimes patients may feel sad or crying briefly.
Ketamine treatment is different from psychedelic guided therapies designed so that the altered states achieved produce therapeutic knowledge. The dominant model for ketamine therapy is more like a physical treatment designed to improve synaptic connections through mechanisms that work faster than those used by conventional antidepressants. That said, some patients describe having ideas or changing their perspective during ketamine treatments in ways that may contribute to their recovery from depression, and some therapists are exploring whether it can be used as a booster for “dissolution of ego, ”as best established with MDMA and psilocybin.
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