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Ketamine and therapy
Ketamine-assisted therapy has gained considerable empirical support in many clinical trials over the past 20 years. It has proven to be an effective treatment for depressive disorders in particular, and in recent years its indications have expanded to include anxiety and eating disorders.
Due to its pharmacological properties, ketamine offers a relatively high success rate in providing rapid-onset relief from depressive symptoms, which lasts for an average of 5 days. Within a safe and professional setting, ketamine treatment can also facilitate psychotherapy, which, in turn, can significantly prolong the beneficial effects of ketamine.
This so-called facilitated psychotherapy can help clients gain perspective on their emotional, cognitive, and behavioral patterns and assist them in shaping these patterns toward lasting adaptive change. Long-term efficacy is the main advantage of KAT over the mere administration of subanesthetic doses of ketamine, which produces only a transient antidepressant effect that typically lasts less than a week.
Treatment model at Psyon
The basic model of our KAP includes preparatory session(s), ketamine session(s) with off-label administration of an oral or intramuscular subanaesthetic dose of ketamine, and integration session(s). Where appropriate, the treatment can be extended by providing additional ketamine administrations and integration sessions. Fully trained staff is present at all times, including one or more therapists (at least one medical doctor or clinical psychologist). A physician is always present during the administration of ketamine and for the duration of its effects.
Our practice has shown that our treatment makes a big difference and allows for therapeutic change even in people with treatment-resistant conditions, including some cases of personality disorders (as long as clients are motivated to participate in psychotherapy). Even after a single dose of ketamine, the positive effects of our KAT on the symptoms of depression, anxiety, and somatization remain statistically significant at 6 months after its completion. At the same time, approximately 50% of our clients receive repeat treatments, which can lead to improved efficacy and even remission of the disease.
Indications and contraindications
Indications for ketamine-assisted psychotherapy include depressive syndromes (of various diagnostic units), anxiety disorders (social phobia, generalized anxiety disorder, OCD), posttraumatic stress disorder (PTSD), and/or eating disorders, in combination with an age of 18 years or older and motivation for therapeutic cooperation. We focus on clients with and without prior psychotherapy experience, and adapt the treatment model accordingly.
Main psychiatric contraindications include psychotic disorders, family history of continuous or relapsing psychotic disorders, currently active addiction, risk of suicidality, and severe personality disorders.
Other contraindications include severe medical conditions (particularly cardiovascular and/or hepatic), pregnancy or breastfeeding, acute infection, allergy to ketamine, and concurrent use of medications that interact with ketamine.
Detailed list of all indications and contraindications for ketamine-assisted therapy:
Every person interested in ketamine-assisted therapy undergoes a comprehensive screening process that includes an initial interview followed by a thorough psychiatric and internal examinations.
1) Severe mental illness not responding to at least one standard treatment (i.e., pharmacotherapy or psychotherapy). The spectrum of these mental illnesses must include at least one of the following diagnoses:
- Depressive syndrome (ICD code(s) F32.0, F32.1, F32.8, F32.9, F33.0, F33.1, F33.8, F33.9), bipolar disorder type 2 (F31.3, F31.4)[JT1] , cyclothymia (F34.0), dysthymia (F34.1), and/or mixed anxiety and depressive disorder (F41.2). This includes secondary depression attendant to other diseases (unless contraindicated).
- Generalised anxiety disorder (F41.1) and/or social phobia (F40.1).
- Obsessive-compulsive disorder (F42.X).
- Eating disorders (F50.X).
- Post-traumatic stress disorder (F43.1).
2) Level of therapeutic alliance appropriate for ketamine-assisted therapy.
- The client is motivated to cooperate with the therapist(s) and is capable of self-reflection.
- 18 years of age or older.
1) Psychiatric
- Lack of clear indication for KAT (e.g. a client is applying only out of personal interest, as a result of a personal journey, seeking new experiences, currently in spiritual bypass, etc.).
- Diagnosis of schizophrenia, schizoaffective disorder, delusional disorder, clinically severe bipolar disorder with manic episodes and psychotic symptoms, and/or any other psychotic disorder (except toxic or drug-induced psychosis) in the client’s medical history.
- Increased susceptibility to develop psychosis as determined by the client’s clinical record, psychiatric examination, and family history (occurrence of psychosis of the F.2x type in first-degree relatives).
- Active substance addiction other than tobacco addiction (F17.x), unless abstinent for at least 1 year. This criterion does not apply to patients who are currently undergoing institutional treatment for their addiction and are completely abstinent, as confirmed by repeated negative drug tests. KAT may be administered if the physician treating the client’s addiction approves.
- Severe personality disorder that would prevent or significantly interfere with the patient’s cooperation in this form of treatment (especially of the paranoid and borderline types). Exceptions include a comorbid personality disorder (e.g. with depression) or cases in which KAT is intended as a supportive treatment for the personality disorder itself, as long as at least partial evidence for such use can be found in the literature. Such cases may warrant a consultation with other Psyon psychiatrists.
- Regular use of psychotropic drugs that may interact with the effects of ketamine, unless these are discontinued 4 elimination half-lives prior to ketamine administration (these include primarily opioids such as tramadol, MAOIs and other antidepressants, and benzodiazepines), at the discretion of the examining psychiatrist.
- Severe clinical risk of suicidality: If the client has specific suicidal ideation with the intent to act on it (requiring an intervention and hospitalization) and/or has made a serious suicide attempt in the past 6 months (as assessed by a psychiatrist).
2) Somatic
- Pregnancy and lactation.
- Severe cardiovascular disease: World Health Organization (WHO) stage 2 or higher arterial hypertension or decompensated stage 1 arterial hypertension, hemodynamically significant heart defect, and other types of severe cardiovascular disease (e.g. cerebrovascular accident, myocardial infarction, and clinically significant arrhythmia in the past year).
- Uncontrolled or insulin-dependent diabetes mellitus.
- Acute hepatitis infection or severe impairment of liver function.
- History of intracranial hypertension, glaucoma, pre-eclampsia, or eclampsia.
- Untreated or inadequately treated thyroid disease.
- Epilepsy.
- Other serious somatic conditions as determined by the examining physician in consultation with an internist and/ or anesthesiologist.
- Any acute infection or recent respiratory infection associated with a risk of laryngospasm.
- History of allergic reactions to ketamine.
- Regular use of medications that may interact with the effects of ketamine, as determined by the examining physician.
- Consumption of grapefruit juice (20 hours prior to the ketamine session) and/or St. John’s wort (one week prior to the ketamine session).
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