Ketamine Assisted Therapy (KAT)

Psychedelics have been a part of the human experience for as long as humans have been around, and we're on the verge of an exciting new phase of history.

It is my view that we should all become more knowledgeable and better prepared as we enter the courageous new world of psychedelic research, acceptance, and exploration.

Psychedelics are a class of psychoactive drugs that produce changes in perception, mood, and cognitive processes.

The classic psychedelics are characterized by distorted perceptions and thoughts. Empathogens tend to induce a sense of belonging or connectedness and dissociative can induce disconnected, euphoric, floaty experiences.

The neurotransmitter we're most interested in when it comes to psychedelics is called serotonin.

Serotonin is related to the flexibility and sensitivity of the brain and is involved in learning and development.

Research shows that psychedelics can affect brain activity in several important ways.

The most well-studied are:

  • The effects on the default mode network
  • Their effects on mental flexibility
  • Their effects on neuroplasticity

The Default Mode Network (DMN) connects areas of the brain responsible for a range of functions including remembering the past, envisioning the future, thinking about others, and thinking about yourself.

When the default mode network is in overdrive, it can result in repetitive focus on negative thoughts—the preoccupation or rumination typical of a major depressive episode.

And that's where psychedelics come in as potential therapeutic tools. We know from brain scans that activity across the Default Mode Network decreases while under the influence of psychedelics. This temporary decrease in default mode network activity is thought to explain the common ego-dissolution experience—the feeling of connection, interconnectedness, and loss of self.

Studies have shown that during psychedelic-assisted therapy an ego-dissolution experience can be positively associated with therapeutic outcomes. Turning down the default mode network with the help of psychedelics might help repetitive, negative brain patterns become unstuck, providing a fresh slate on which to build new and healthy mental habits.

A key feature of mental health is mental flexibility, or the ability to adapt and shift our thought patterns.

There are two types of mental flexibility:

  • Psychological flexibility is the ability to feel and think with openness, to voluntarily focus on the present moment, and to build habits based on values and aspirations.
  • Cognitive flexibility is the ability to move your attention from one thing to another - basically not getting stuck in repeating or ruminating thoughts. People with high cognitive inflexibility tend to get stuck in negative thought patterns.

Psychedelics have been shown to increase both psychological and cognitive flexibility by temporarily increasing the entropy or disorder of brain activity.

During a psychedelic experience, regions of the brain that normally don't communicate with each other are communicating, and doing so in patterns that are very different from a normal waking state. This temporary change in brain activity, allows for the relaxation of prior beliefs, and increases the potential for new ideas and insights.

Even though this drug-induced brain pattern change is temporary, the new pathways established during a psychedelic experience can persist after the experience, and their effects can be long-lasting.

Neuroplasticity is the brain's ability to reorganize its structure, function, and connections in response to a changing environment or a shifting set of demands. Psychedelics can enhance neuroplasticity, increasing the brain's ability to form new connections. In other words, during a psychedelic experience, your brain's ability to change how it's wired goes way up.

Neuroplasticity just means the capacity to change it doesn't indicate what type of change. Research has shown a supportive environment and a positive mindset going into the psychedelic experience can result in better outcomes or higher chances of those changes being productive and sustainable.

Working with professional therapists and trained sitters is recommended to achieve those long-lasting therapeutic benefits.

Many reputable organizations like MAPS have been leading the charge in systematically studying the properties of psychedelics to address some of the more challenging mental health conditions.

Ketamine is now an off-label treatment for various chronic treatment-resistant mental health conditions and is currently the only legal psychedelic medicine available to mental health providers for the treatment of emotional suffering.

Integrating psychotherapy and psychopharmacology with psychedelic-assisted psychotherapy can be highly effective in difficult to treat mental health conditions.

I have forged a collaborative partnership with TheKetamineClinicLondon to provide a Consultant Lead Ketamine Assisted Therapy (KAT) Service that offers intravenous (IV) ketamine infusions with the option of maintenance KAT with weekly oral ketamine lozenges, for up to 30 weeks.

We offer Ketamine Assisted Therapy for the treatment of difficult to treat psychiatric disorders such as:

  • Treatment Resistant Depression
  • Depression with Suicidality
  • Suicidality
  • Post-traumatic Stress Disorder (PTSD)
  • PTSD with Chronic Primary Pain
  • Major Depressive Disorder with Chronic Primary Pain.
  • cPTSD
  • Anxiety
  • Obsessive-Compulsive Disorder (OCD)
  • Substance abuse co-occurring with a primary psychiatric disorder
  • Relationship and existential issues such as existential distress
  • Bipolar I and II depressive phases (not mania)
  • Psychological reactions to physical illness and life-threatening illnesses substance
  • Chronic secondary pain (often requires higher doses of ketamine in a medically supervised setting such as a clinics or hospitals)

These are medical and psychiatric conditions that render people unable to receive ketamine therapy.

Medical Contraindications

  • Untreated hyperthyroidism
  • Untreated hypertension
  • Epilepsy or other seizure disorder
  • Aneurysm or dissection
  • Brain tumour
  • Heart disease, including heart failure, heart attack (in past 12 months) or arrhythmias, advanced valvular disease.
  • Severe breathing problems
  • Kidney disease
  • Advanced liver disease
  • Active interstitial cystitis (bladder wall inflammation)
  • Glaucoma (unless cleared by an ophthalmologist)
  • History of allergy to ketamine
  • Stroke or transient ischemic attack in the past 12 months
  • Pregnancy
    • Please note there may be special circumstances if the mother is suicidal.
    • I will carefully evaluate each client and do a risk benefit analysis and I must ensure the benefits outweigh the risks.

Psychiatric Contraindications

  • Schizophrenia
    • Schizophrenia is not an indication for ketamine, and schizophrenic clients can worsen from a psychiatric perspective if given ketamine.
  • Other psychotic disorders
  • Acute mania
  • History of hallucinogenic perception disorder

Suicidal Patients

  • Patients who present with suicidal ideation represent some of the most challenging and difficult clinical cases seen in mental health treatment.
    • Studies have shown that clinicians are able to recognize, and even predict acute suicidal behaviour with reasonable accuracy in the short term.
    • However, as more time goes by following a suicidal presentation, the worse clinicians are at predicting suicide.
    • Even when protocols have been applied to an inpatient psychiatric population with a higher baseline risk for suicide, positive predictive values remain less than 11% (Pokorny et al.1983).
    • Because suicide is a relatively rare phenomenon in society, it remains difficult to predict.
    • Suicide screening is not only a crucial part of evaluating depressed patients but is also important when evaluating patients presenting with a host of other psychiatric issues including acute stress, trauma, substance use, severe anxiety, and a recent history of suicidal behaviour.

Ketamine and Suicidal Ideation

  • Ketamine has emerged as a viable way to treat patients with suicidal ideation.
    • This is important and exciting because until recently, when a suicidal patient is referred to an emergency room, the priority has always been to ensure safety through containment without immediate treatment of the suicidal thinking.
    • Conventional antidepressants can take weeks to work (sometimes worsening the situation), and it can take days to weeks for a patient's suicidal ideation to calm down through milieu therapy on a psychiatric unit.
    • This is why the ability to quickly treat suicidal ideation with ketamine has been a major discovery.
    • This suggests that ketamine has the ability to disrupt the suicidal thought loop.
    • Numerous studies have shown that IV ketamine infusions can reduce suicidal ideation in some patients, and the response can be in a matter of hours (Dadidimov et al. 2019).
    • Studies have shown that in some cases, suicidal thinking was reduced only hours after one ketamine treatment.
    • These studies were done using IV ketamine and not sublingual ketamine.

Medications and substances that should be either avoided or carefully reviewed in patients who are being treated with ketamine

  • Theophylline or Aminophylline
    • Both can lower seizure threshold.
  • Benzodiazepines, opioid analgesics, or other CNS depressants can all cause profound sedation and respiratory depression, and they can also interfere with the mental health benefits of ketamine. They may repress what needs to be accessed.
    • All patients on benzodiazepines or opioid analgesics will be evaluated by me on a case-by-case basis in order to determine how best to proceed.
    • There is some question as to whether or not benzodiazepines interfere with the healing potential of ketamine.
    • Please note that rapid tapering off of benzodiazepines is not recommended as it can be associated with withdrawal leading to potential serious illness including withdrawal seizures and fatalities.
    • Only tapering under the care of a psychiatrist is recommended.
  • Lamotrigine may block the clinical efficacy of ketamine.
  • Monoamine Oxidase Inhibitors (MAOls)
    • Phenelzine, Tranylcypromine and Isocarboxazid
    • All can cause blood pressure problems.
  • Selegiline
  • A dopaminergic anti parkinsonism agents also classed as a MAOI.
  • Naltrexone and naloxone may blunt the response to ketamine.
  • Sedating medications like Mirtazapine, Quetiapine, Zolpidem, Zopiclone and Benadryl can all contribute to marked sedation but are not usually a major issue and I will review and advise on a case-by-case basis.
  • There is no interaction between SSRls, and other antidepressants and ketamine and I will review and advise on a case-by-case basis.
  • Ketamine has very few drug-drug interactions which makes it an even more desirable treatment option.

Ketamine and Addiction
Questions often asked include:

  • Is ketamine habit forming or addictive?
  • Is it prone to abuse.
  • What will happen if I treat a patient with ketamine who suffers from either an active or stable history of substance use disorder?
  • Does ketamine help patients with addiction?
    • If so, which ones?

These are some of the leading questions that are being investigated with regards not only to any potential risks involved with using ketamine in patients with addictive disorders, but also to ketamine's ability to treat patients with these conditions.

Bill Wilson, the founder of Alcoholics Anonymous, first used LSD in 1956 when it was still legal and used psychedelics extensively. He credits his use of LSD as helping many people gain the spiritual awakening that is central to the AA twelve-step program. He described the psychedelic experience as creating a great broadening and deepening and heightening of consciousness. In letters he wrote to Carl Jung, he discussed this in great detail. This is an often unknown or ignored fact that many people who participate in many of the fellowships such as AA, NA or CA never learn about.

It is well known that ketamine has been used as a drug of recreational abuse for decades, particularly in the nightclub subculture. While rare, cases of ketamine addiction have been described both anecdotally as well as in the medical literature. However, a recent study has demonstrated that ketamine actually has a very low addiction potential.

The results of the study by Simmler et al. explains that like other addictive substances, ketamine does interact with the neurotransmitter dopamine in brain areas involved with addictive disorders such as the nucleus accumbens (NA) and the ventral tegmental area (VTA).

However, while ketamine does stimulate dopamine, it does not have the reinforcing properties that other drugs have because it does not let dopamine activity run rampant in the brain. Instead, ketamine seems to put the brakes on further dopamine involvement in brain areas associated with addiction, and thus is unlikely to cause addiction.

Other studies demonstrate that ketamine, in combination with certain forms of psychotherapy, can be effective in treating clients who suffer from alcohol use disorder (Grabski et al. 2022) cocaine use disorder (Dakwar et al. 2019) and heroin/opiate addiction (Krupitsky et al. 2007).

When thinking about ketamine as a way to treat addictive disorders it is important to remember that many people who suffer from addiction also suffer from underlying psychiatric problems such as depression, severe anxiety, PTSD, bipolar disorder, and other problems related to severe trauma.

These are commonly known as Co-occurring disorders. The self-medication hypothesis suggests that many people who suffer from these co-occurring disorders actually _self-medicate with drugs of abuse as a way to ease the underlying symptoms of these disorders.

Unfortunately, however self-medication with drugs of abuse can lead to more complicated problems with substance abuse and addiction.

Some patients are able to manage their substance use problems and even achieve remission from addictive disorders once the underlying psychiatric problems are stabilized, so ketamine can be effective for patients who suffer from substance use issues.

Ketamine Doesn't Help Everyone

Some patients do not respond to ketamine, even at higher doses. Additionally, some patients with rigid personality structures, including those with severe OCD or personality disorders and possibly those with profound PTSD, may not be able to go into a trance-like state and may find it challenging to maintain the benefits of the treatment experience, if they find any relief with the experience at all. There is some data that suggests that the elderly are less likely to benefit from KAT.

So even though we don't yet know enough about who won't benefit, I will consider KAT on a case-by-case risk/benefit ratio basis, especially if no contraindications exist, and nothing else has worked as Ketamine is a safe and well-tolerated therapeutic option.

If you would like to find out more about KAT, then please contact me directly via my contact page Get In Touch but only once you have familiarised yourself with the fee structure for KAT as detailed If you would like to find out more about KAT, then please contact me directly via my contact page Get In Touch but only once you have familiarised yourself with the fee structure for KAT as detailed under my Fees structure.