The Ketamine Project
The purpose of this site is to foster communication between clinicians interested in using ketamine for psychiatric indications and pain, in order to make this treatment widely available for patients and to share information regarding variations in technique and results with different types of symptoms. This site will also provide information for patients considering ketamine therapy.
Several aspects of the clinical use of ketamine are novel and relevant. Treatment dissemination is one important topic, related to financial incentives for clinicians and hospitals to provide ketamine therapy. New treatments become widely available in psychiatry largely because they are driven by a profit incentive. This is a problem for ketamine, which is an old drug, long off patent and consequently not backed by a pharmaceutical company. Manner of administration and monitoring is an important issue relevant to dissemination.
Ketamine is a prime example of a major flaw in the method by which treatments are selected for use in modern psychiatry, and probably in medicine as a whole. In order for a treatment to be used, it has to be paid by by an insurance provider or medicare. Getting a treatment covered by insurance involves a considerable amount of time and effort, which pharmaceutical companies have for newly patented treatments. Any other treatments, including ketamine and other older medications, new forms of psychotherapy, new technologies such as TMS, and any treatments derived from nutritional supplements such as N Acetyl Cysteine, folic acid, and so forth do not generally have the personnel or support to get past the laborious review process involved in approving a new treatment for insurance or medicare coverage. There is currently no government agency charged with promoting treatments simply because they are effective and help patients. As psychiatrists, we have become increasingly conditioned to expect that valuable treatments will only come in the form of newly patented medications.
Ketamine is a dissociative anesthetic with a unique safety profile in that is does not suppress respiration or the gag reflex, so that it is often used in situations like the emergency room or in military settings, where extensive monitoring is not available. Ketamine is sometimes provided in a hospital setting with monitoring and supervision by an anesthesiologist, which greatly increases the cost of the treatment and reduces its availability. Ketamine can also be safely provided at a subanesthetic dose level in an outpatient setting by a psychiatrist with the assistance of an aide and with minimal monitoring. This greatly reduces the cost and increases the availability of the treatment. Neither approach is adequately reimbursed by insurance providers or medicare. Reimbursement for ketamine infusions is very low, on the order of $100 per treatment. These obstacles to the dissemination of ketamine remind us that our health care system is biased in favor of newly patented medications, at the expense of all other forms of therapy despite the fact that other approaches might be more effective.
Ketamine has been used for several clinical indications. Ketamine is most clearly indicated for certain forms of pain, such as complex regional pain syndrome, neuropathic pain, and visceral pain. Ketamine has an anti-allodynic effect and reduces tolerance to opiate medications. Higher doses are associated with a more robust and sustained effect in pain. An experimental treatment available in Germany and Mexico involves inducing a ketamine coma at a much higher dose, and there have been reports of long-lasting remission from otherwise untreatable cases of complex regional pain syndrome.
Ketamine has a robust effect in patients with treatment-resistant mood disorders, comparable to ECT but with fewer cognitive side effects. The duration of this effect is also likely to dependent on dose and number of treatments. For pain and depression, the psychedelic effect of ketamine is a side effect that must be minimized because it is uncomfortable for some patients.
Krupitsky et al in Russia and Kolp in the US have reported on the use of ketamine in addiction, where it is combined with psychotherapy. The so-called ketamine psychedelic therapy (KPP) has a one year sobriety rate in alcoholic patients of approximately 70%. For this indication, ketamine is deliberately used at a dose that produces a robust psychedelic effect, which is the basis for psychotherapy after the episode designed to enhance insight and motivation for treatment.
Finally, technique is an important topic in its own right. Dose and route of administration, use of adjunctive medications such as midazolam, and use of psychotherapy either during the ketamine session or afterward as well as the type of psychotherapy are examples of important issues here. Ketamine seems to increase the ability of the brain to break free from rigid, overlearned behavior patterns that are constantly triggered and reinforced. Apart from pain and depression, there is some data to suggest that ketamine might be helpful for conditions such as PTSD, OCD, and eating disorders. Combining ketamine with exposure-based therapies might be an especially effective approach to these conditions.
Scientific knowledge often advances serendipitously, starting with a careful observation by a patient or doctor. It is our hope that a free exchange of ideas and experiences between clinicians and patients might point the way toward more effective use of ketamine therapy, in broader range of indications.