Tripping Toward Wellness

Dr. Nathan Carter, a psychiatrist in Concord, North Carolina, didn't know if ketamine would work for his patient suffering from treatment-resistant depression. Still, he wanted to see if an injection of the psychedelic could make a difference. After administering ketamine to this patient, Carter was amazed by the results. "In a matter of 24 to 36 hours, his depression was remarkably better. Before the shot, he was bed bound and didn't eat. Two days after the shot, he asked for double portions of food and talked about his family," Carter says. Carter's experience in 2019 with his patient's complete turnaround after receiving ketamine isn't an isolated incident. A study in Current Neuropharmacology indicates that ketamine does make a marked difference in those suffering from treatment-resistant depression. Ketamine is likely here to stay, as evident by clinics where ketamine is administered popping up nationwide in the last few years. Defining treatment-resistant depression Evaluating whether an individual has treatment-resistant depression is an important step in determining whether ketamine will be a potential form of therapy. Tamia Pleasants, a licensed clinical professional counselor and owner of Ny Lu Therapeutic Solutions in Maryland, has a particular metric to diagnose treatment-resistant depression. "When a patient comes in complaining of at least two years of feeling depressed, and they have tried a variety of things with little or no movement or alleviation of those symptoms," it may be time to consider alternative treatments like ketamine. Typically, Pleasants has noticed these individuals have faced depression for several years, and medications may help for a few months, but then, she says, the cycle of "low mood, social withdrawal, tearfulness and hopelessness" appears again. Sometimes several years of combining medication and talk therapy haven't worked. Adequately screening depression Licensed psychologist Gabrielle Jones, Ph.D., and owner of Steady LLC in California, believes that in BIPOC communities, there is a responsibility to ensure an individual is not misdiagnosed. "Depression is thrown around, just haphazardly, but it may be that there is race-based trauma, and it's important to really parse out if it's PTSD," she says. Carter also stresses screening patients before recommending ketamine as an option. "We want to make certain there is no history of psychosis or substance use disorder," he says. Pleasants agrees with Carter and Jones. A nurse practitioner on her staff screens patients for drug-seeking behavior and other mental illnesses where ketamine wouldn't be an appropriate solution. Also, the nurse practitioner reviews the medical history to "make sure the patient isn't taking any other medications," Pleasants says. Other medications may interfere with ketamine's effectiveness. How ketamine works in the body Ketamine has been effective for many, Carter says, because of how it works. Instead of increasing serotonin levels the way traditional antidepressants do, ketamine works with a neurotransmitter called glutamate. A 2020 study in Therapeutic Advances in Psychopharmacology found working with this neurotransmitter impacts mood. "This is why we see a change in people who are on ketamine within a matter of hours because it reduces anxiety and impulsivity," he says. Although the FDA has approved the nasal spray, called Spravato, which is a derivative of ketamine, other uses of ketamine are prescribed off-label and available through pills and intramuscular injections. Administering ketamine to patients In Pleasants' experience, ketamine is usually effective within four to six sessions. Patients are given an injection, like a flu shot, and dosage depends on the individual. Pleasants generally sees a shift in symptoms around the third or fourth session. "Patients start to invite different thoughts, feelings and actions," she says. She reminds her patients that sometimes the shift is subtle and may not appear the way they expected. Most patients come in for one session every seven days over a six-week period and then wait about two months to schedule their first maintenance injection. Jones has noticed most patients feel better around the month marker, but she cautions that this is anecdotal evidence. Patients will receive at least six injections and can return for maintenance shots months later if necessary.

Rate of success of ketamine Carter administers ketamine in an inpatient psychiatric setting and has been using intramuscular ketamine since 2019. In terms of success with his patient pool, at least 20 individuals who have been hospitalized due to treatment resistant depression and other mental health issues have been discharged after receiving ketamine. Not all are success stories, however. Some of Jones' patients complain they don't "feel like themselves" after a couple of sessions with ketamine. And Pleasants adds, "Sometimes they just don't believe it is working because they are looking for a grand gesture of how they should feel, and there's a lot of expectation, and even though I do my best to manage that," they want to discontinue using ketamine. Pleasants recommends that ketamine, to be effective, should be used with another form of therapy, whether it is eye movement desensitization and reprocessing (EMDR), cognitive behavioral therapy (CBT), or somatic therapy. Integrating another therapy along with the ketamine sessions is a holistic approach, Pleasants says, because it targets healing in the mind and body. Use of ketamine in BIPOC communities In considering the use of ketamine as a treatment for marginalized communities, Jones cautions that, "There is a healthy distrust of the medical industry of putting something in their body that is foreign." Citing the history of Tuskegee, where Black men died because the government was testing them, or the unapproved vaccines given to marginalized children in Los Angeles in 1989 that caused serious neurological damage, Jones says, "There are several examples where the medical industry has either manipulated or lied to communities of color and caused harm." When Jones talks to a client of color about ketamine treatment, she says, "I am very aware and intentional about presenting it to them in a way that promotes safety and trust in my recommendation." Carter believes some barriers are based on unfamiliarity with the treatment, so there must be outreach. Another barrier is cost. Ketamine injections could cost hundreds of dollars. "If you don't have top-tier insurance, you're just not going to be able to afford it," he says. Pleasants knows ketamine is not going anywhere. "I think there's a lot of growth with psychedelic-assisted therapy. This is a good thing because I think it is a nice addition, especially when talk therapy alone cannot help the patient," she says.

First published in Black Mental Health Today, Spring 2023 (Vol. 7).