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Summary: Question and Answer with Rita Rutland, APRN @ Restorative Health about common disagreements with ketamine infusion guidelines
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Question | How important is frequency with ketamine infusions?
Rita: What I have noticed with my patients over the last two years is that the frequency, as well as how close the visits are, does not affect whether the medication actually works. However, when it comes to depression, what ketamine does long-term is re-grow neuro-connecting sites, as well as make new ones. In order to have a noticeable lasting effect, most people need about three treatments. Usually, after the first treatment, patients will feel significant relief of symptoms or find that they feel more positive and hopeful for about two to three days, but then they notice that their mood tanks. This often is reported as feeling devastating because they actually felt good. It does not mean that patients drop lower than what their baseline was when they came in for a treatment. It's just that they really notice dropping back into that depressed state.
What I've noticed after the third treatment is that people feel a more lingering effect lasting several weeks. The studies involving six treatments usually done over 10 days to two weeks may have been affected by being done inpatient settings and patients can only stay inpatient for a short period of time. The other thing that we've noticed at our office is when patients do these treatments too close together, they don't have time to process what comes up during the treatment. Having more time spaced after a particularly intense, emotional or enlightening treatment where people are able to access past trauma or the root cause of their mood disorder, find that they need some time to process and integrate that experience before continuing on with another treatment. This is why we do not require patients to do these treatments in a set period of time. Every patient responds differently to ketamine and each treatment elicits a different response. This is why our approach is very individualized, rather than a set protocol.
Question | Which modes of administration work best?
Rita: On the psychiatric spectrum, both the IV and the injection seem to elicit similar response rates. However, with pain, I have noticed that the IV is definitely superior. People who have had the injection report much less pain relief than those who have done the IV infusion. The injection tends to be very therapeutic and effective when done in conjunction with talk therapy that allows you to go deep and access different parts that need to be dealt with that are affecting your overall mood and quality of life. It allows you to detach from the emotional and physical response and be able to talk through it and come out on the other side, knowing that you are okay, as well as developing new thought patterns or processes that may prove helpful in overall coping with life.
The nasal spray is really good for maintenance, however, it doesn't elicit the same level of response that the injection or IV treatment provides. It's more subtle and doesn't allow the depth of healing that IV treatments provide. The extensive exposure of your neuro-connecting sites to ketamine through the infusion facilitates a faster rate of healing, where the nasal spray is highly effective for maintenance dosing, between IV treatments to extend the amount of time needed between maintenance; those treatments. It's also very effective to utilize in a therapy session, as well as to have available as a rescue treatment for moments of suicidal ideation, severe depression and anxiety or panic states.
The troche tends to have a more physiological effect and is better for pain management, while the nasal spray is better for mood management. The troche can also be utilized as a gentle introduction to what ketamine feels like. It is a higher dose administered at one time, where the nasal spray is usually done a few sprays (1-2 sprays every 5 min up to 5 rounds or 10 sprays) total every few minutes over an hour. The troche is excellent, again, to combine with talk therapy, allowing you to sink into a deeper space and access areas that need to be adjust within your mind and be able to process through. It's also an excellent alternative, if there are severe financial concerns and the infusion or injection is not a viable option for some patients. We also use the troche as maintenance dosing, primarily for pain management or in combination for patients to utilize with their therapist.
The main difference between the injection and the IV drip infusion is the intensity of the experience. The drip allows for a gentle introduction and a slow sink into that deeper conscious state. It also allows for more control where we can speed up, slow down, or even stop the infusion if necessary. With the injection, the advantage is that you're not having to get IV access, you're not attached to any tubing and we don't have to worry about difficult veins. However, you are getting the entire dose of medication at one time and ultimately need to just work through that treatment experience, regardless of intensity. It does tend to be most intense at the beginning and lessened towards the end where the IV treatment tends to be the most intense towards the end.
Question | What music works best for ketamine therapy?
Rita: Due to the way that ketamine works, it is sometimes distracting or difficult to process music with lyrics. Your tendency is to want to try and respond to verbalization or to the lyrics, but your brain is unable to integrate those words the way that it normally would and so for some people, that can be distracting. The other part of it is, those words in the music can provide guidance that isn't necessarily positive, as far as where it guides that journey. On the other side, if you pick music that is very positive and soothing and speaks to you, it can also help to make that treatment experience more positive. So again, with music, it is a very individualized treatment experience and we encourage patients to choose music that is soothing and speaks to them. It tends to be a bit of an experiment for individuals that will choose music that they feel will guide their experience in the manner that they wish, and then find that it is overwhelming or distracting from the actual treatment experience.
I am not against lyrics, however, just for people to be mindful of how that's going to affect them while their mind is in a very pliable and vulnerable state. Music without lyrics that is more quiet or soothing, tends to have a more calming effect. Music plays a very important role in your ketamine journey in that it can help to guide you and as the music shifts so will your thought processes, which can help keep you moving if you get stuck on a specific thought. Doing ketamine treatments with a sound therapist, skilled and guiding that mental state can be extremely healing. When managed appropriately, it can really help to shift and move through different thought processes to come out at the end with a conclusion that is helpful or shifting in perspective.
The main reason that I would caution people against lyrics is the level of distraction or potential irritation that they can cause because your brain can't fully comprehend what those lyrics mean. Music is also a fairly important because silence actually becomes very loud with ketamine and it helps to quiet the silence so that it doesn't feel like a roar. It's soothing when you're dropping into a deeper state, as well as when you are coming out. It provides a grounding or a lifeline back to your body should you wander far in your journey.
Question | Other common disagreements about ketamine?
Rita: The biggest discrepancy that I see is dosing. Dosing is very individualized and current recommendations are based off weight. However, there are numerous factors that play into how your body processes the medication. So some people can be very small, have a low body weight and still process the medication very quickly, while other people can have a large muscle mass, be very tall and need a lower dose. So while it's appropriate to stay within the recommendations of milligram per kilogram, it remains an individualized process to find the appropriate dose for a patient. The most important part that I see is that patients get a dose that allows them to reach that sub-anesthesia state and mild dissociative state and maintain that state for about 15 minutes.
Without reaching that sub-anesthesia state, people tend not to experience the reset aspect that the medication provides and tend not to have as lasting effects at lower doses. The medication recommendation put out by the ketamine manufacturer and up to date protocol is 0.5 milligrams to 2.0 milligrams per kilogram. I do find that many clinics stay on the conservative side of that dosing and patients are not getting the appropriate results that they have the potential to reach. Another aspect that has a significant effect on the effectiveness, but mostly just the treatment experience itself is the setting. We've found that patients who have been treated in a very, very clinical setting have not had as positive experience or results as patients who are provided a more calming, soothing and comfortable environment with minimal stimulation and very supportive staff.
Ketamine is a very intense medication and it's important to have -- It's important to feel safe and supported through that. Due to that, we try to ensure that patients always have someone with them, whether it's one of our staff members, or if they bring someone in with them, unless a patient is experienced in ketamine and is comfortable in a room by themselves, we do not ever leave them alone. The other aspect that can significantly affect the effectiveness of ketamine is the mindset in which it's entered into. Having someone available to talk with or arranging for integrative sessions with their therapist, post-treatment, plays a significant role in how fast patients are able to respond and heal, utilizing these treatments.
Question | Your opinion on daily ketamine infusions?
Rita: This isn't an area I have a lot of experience with, as again, going back to what was previously discussed as far as frequency of visit, I feel that patients need time to integrate. However, when someone is in a severe state of depression or suicidal ideation or a severe pain, doing back to back treatments can help shift out of that space faster. However, I think there's a potential of fatigue, over stimulation and decreased effectiveness when these treatments are done too close together, as it does not provide that reset effect once certain neuro receptor sites have been stimulated. My recommendation is usually to have at least one to two days between treatments where possible. However, we do have patients that travel to see us and need to do several treatments in a row to accommodate their schedules. So, it is something that we've done. However, I believe having several days between will be more effective due to how the medication affects neuro-connecting sites.