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Ketamine Assisted Psychotherapy

Kerri Husman, MD

  noNovelIf you have a treatment resistant mental health condition, ketamine and ketamine assisted psychotherapy may be a treatment option for you. 

Dr. Husman is trained in ketamine administration and offers IM (intramuscular) racemic ketamine in the office for treatment resistant conditions. Dr. Husman is also trained in psychedelic assisted psychotherapy which includes ketamine assisted psychotherapy (KAP). Racemic ketamine is the generic form of ketamine, which means it is a racemic mixture of two enantiomers, (R)-ketamine and (S)-ketamine. (S)-ketamine by itself is marketed as esketamine (brand name Spravato), a nasal spray FDA approved for treatment resistant depression and major depressive disorder with suicidal ideation.

Information on KAP:
Ketamine Assisted Psychotherapy: A Systematic Narrative Review of the Literature, Drozdz et al., 2022.

Ketamine Assisted Psychotherapy (KAP): Patient Demographics, Clinical Data and Outcomes in Three Large Practices Administering Ketamine with Psychotherapy, Dore et al., 2019.

Ketamine-assisted psychotherapy treatment of chronic pain and comorbid depression: a pilot study of two approaches, Batievsky et al., 2023.

Safety and tolerability of intramuscular and sublingual ketamine for psychiatric treatment in the Roots To Thrive ketamine-assisted therapy program: a retrospective chart review, Tsang et al., 2023.

Ketamine is not the last resort on a list of treatments, but it is an option for those who medically qualify (healthy enough to tolerate the treatment) in situations where patients have tried a variety of treatments for their condition and meet criteria for treatment resistance. This typically means the patient has completed adequate trials of a minimum of two, but often multiple medications from different classes, medications augmented with other medications, medications along with TMS (transcranial magnetic stimulation), ECT (electroconvulsive therapy) or PHP (partial hospitalization program – intensive group therapy), individual psychotherapy, or some combination thereof. The definition of treatment resistance varies between insurance carriers.

What else can be tried if racemic ketamine does not help enough or is not effective?

-ECT (electroconvulsive therapy)
-Other medication class trials such as TCA (tricyclic antidepressant), MAO (monoamine oxidase inhibitor) or medication augmentation strategies (other mood stabilizers)
-Other integrative strategies (thyroid augmentation, light augmentation, sleep deprivation, other mineral or herbal evidence-based supplementation)
-PHP (partial hospitalization program)
-Research trials with other treatments
-Spravato (esketamine, FDA approved for treatment resistant depression and major depressive disorder with suicidal ideation)
-TMS (transcranial magnetic stimulation)

Is racemic ketamine covered by my insurance?
It might be in the future if it is not now. Racemic ketamine is generic and has been approved for other anesthetic use since 1970, and approval has not yet been sought for use for psychiatric disorders. Unfortunately, approvals are driven by brand name manufacturers seeking approval for a new drug and it is an expensive process. There is a branded racemic ketamine product seeking approval in 2024, Ketarx, but it is seeking approval for specific neurologic conditions initially. The most recent literature now demonstrates that racemic ketamine is not inferior to ECT.

Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression, Anand et al., 2023.

At this time, racemic ketamine use for psychiatric conditions is considered experimental/investigational by Wellmark Blue Cross. It is reviewed annually. As a result, treatment with racemic ketamine is not covered by the insurance Dr. Husman is in network with. A flat fee is charged to cover all of what you would be expected to need for your appointments (racemic ketamine, antinausea and antihypertensive medications, oxygen, and continuous medical monitoring, Mindfold, Sea-Bands, journaling and integration materials). An Advance Benificiary Notice (ABN) is signed by the patient if they wish to be provided this treatment. The charge is based on what would have been billed if it were submittable to insurance, and the cost is less than IV infusion treatments, but includes prep and some integration during your appointment, which is not typically provided with IV infusion treatment. Dr. Husman will do her best to stay on top of any changes to coverage, and you are certainly encouraged to reach out to your insurance provider with any questions.

How is racemic ketamine administered at this office?
Dr. Husman uses IM (intramuscular) racemic ketamine in the office on M, W, and once a month on Sa. It is given using a safety needle into the deltoid muscle in your upper arm(s). Other muscles can be used if need be. Patients are encouraged to wear a tank top or t-shirt for easy access. Depending on your dose, which is based on weight and potency of medication available, there may be more than one injection. Lidocaine is offered to numb the area of your arm as well. While you may feel the medicine enter the muscle, with a slight burning or tingling sensation, it quickly diminishes, and patients do not typically report bruising or discomfort in the arm afterward, but this is possible. Ketamine is often administered in group in the office as there can be additional benefits of receiving ketamine with group grounding, presence, community and integration. By offering IM, Dr. Husman will monitor up to 4 patients at a time. In the days following ketamine administration, an additional session where psychotherapy includes KAP integration session is recommended, to help further integration changes in perspective, outlook and mood. If you have your own therapist who is psychedelic integration trained, they can provide this service for you. 

Real-world depression, anxiety and safety outcomes of intramuscular ketamine treatment: a retrospective descriptive cohort study, Ahuja et al., 2022.

Why does Dr. Husman not offer Spravato (esketamine)? 
Spravato is already offered at other sites in Iowa City, including UIHC and Corridor Ketamine. In Dr. Husman’s training for ketamine administration, which included Spravato, it was made clear that variations in experience due to nasal congestion (colds, allergies), angle of the nasal inhaler, medication leaking back out the nose and down the throat, patient preference, dose limitations that do not address weight or tolerance, and clinical outcomes, that all of her instructors had moved their practices away from using Spravato in their offices. This is covered for treatment resistant conditions, and while it is not offered at this clinic, it does not mean you should not consider it for treatment resistant depression.

Comparative efficacy of racemic ketamine and esketamine for depression: A systematic review and meta-analysis, Bahji et al., 2021.

The acute antisuicidal effects of single-dose intravenous ketamine and intranasal esketamine in individuals with major depression and bipolar disorders: A systematic review and meta-analysis, Xiong et al., 2021.

Ketamine and esketamine in suicidal thoughts and behaviors: a systematic review, Jollant et al., 2023.

Why does Dr. Husman not offer IV racemic ketamine?
Again, there are other options in the community, such as UIHC, Corridor Ketamine, Quad Cities Ketamine Clinic and elsewhere for IV, if that is the form you desire. Intravenous may be given at higher doses at infusion centers, and as a result, may require more monitoring and confer more risk at higher doses. Dr. Husman does offer KAP after IV sessions performed elsewhere for her patients.

Double-blind, placebo-controlled, dose-ranging trial of intravenous ketamine as adjunctive therapy in treatment-resistant depression (TRD), Fava et al., 2020.
The range used in IV form is the same as what is provided IM in the office.

Why does Dr. Husman not offer home-based telehealth treatment with oral or sublingual racemic ketamine?
There are other offices in the community that offer this form of treatment, such as the Rein Center. In this model, oral ketamine is administered in the office or at home right before the session with a psychedelic integration trained therapist. Typically, although not always, the dose is a lower psycholytic dose, rather than a more moderate psychedelic dose available with IM or IV dosing. There are also nationwide programs providing home based treatments. Oral absorption of compounded forms is variable, and tolerance due to nausea and vomiting and the bitter taste are additional factors, as well as patient preference. The anti-suicidal effects, which are essential for many patients, have not been found consistently in the literature using oral dosing. There have been recent studies, however, supporting safety in offering home based treatment with racemic ketamine. 

Oral Ketamine for Depression, 1: Pharmacologic Considerations and Clinical Evidence, Andrade, 2019.

Oral Ketamine for Depression, 2: Practical Considerations, Andrade, 2019.

Safety, effectiveness and tolerability of sublingual ketamine in depression and anxiety: A retrospective study of off-label, at-home use, Hassan et al., 2022.

What conditions have a growing body of literature reporting on and reviewing the use of ketamine?
MDD, OCD, PTSD, AN, Pain, and some substance use disorders. Below is a list of recent studies. This is not an exhaustive list, new studies are continually becoming available, and the most robust data by far is the use of ketamine for treatment resistant depression. 

Major Depressive Disorder (MDD):
Ketamine and depression. Jelen and Stone, 2021.

Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation, McIntyre et al, 2022.

Maintenance ketamine treatment for depression: a systematic review of efficacy, safety, and tolerability, Smith-Apeldoorn et al., 2022.

Real-world effectiveness of ketamine in treatment-resistant depression: A systematic review & meta-analysis, Alnefeesi et al., 2021.

Long-term safety of ketamine and esketamine in treatment of depression, Nikayin et al., 2022.

Ketamine-induced hippocampal functional connectivity alterations associated with clinical remission in major depression, Zhang et al., 2023.

Racemic Ketamine as an Alternative to Electroconvulsive Therapy for Unipolar Depression: A Randomized, Open-Label, Non-Inferiority Trial (KetECT), Ekstrand et al., 2022.

Obsessive Compulsive Disorder (OCD):
Ketamine in the Treatment of Obsessive-Compulsive Disorder: A Systematic Review, Bandiera et al., 2022.

Ketamine Augmentation of Exposure Response Prevention Therapy for Obsessive-compulsive Disorder, Bottemanne et al., 2021.

Clinical utility of repeated intravenous ketamine treatment for resistant obsessive-compulsive disorder, Sharma et al., 2020.

Post Traumatic Stress Disorder (PTSD):
Ketamine as treatment for post-traumatic stress disorder: a review, Liriano et al., 2021.

A Randomized Controlled Trial of Repeated Ketamine Administration for Chronic Posttraumatic Stress Disorder, Feder et al, 2021.

A Cohort-Based Case Report: The Impact of Ketamine-Assisted Therapy Embedded in a Community of Practice Framework for Healthcare Providers with PTSD and Depression, Dames et al., 2022.

Anorexia Nervosa (AN) and other eating disorders:
Ketamine as a Treatment for Anorexia Nervosa: A Narrative Review, Keeler et al, 2021.

Ketamine and Zinc: Treatment of Anorexia Nervosa Via Dual NMDA Receptor Modulation, Mitchell et al., 2022.

Case report: Intramuscular ketamine or intranasal esketamine as a treatment in four patients with major depressive disorder and comorbid anorexia nervosa, Keeler et al., 2023.

Psychedelics in the treatment of eating disorders: Rationale and potential mechanisms, Calder et al, 2023.

Ketamine as a Novel Psychopharmacotherapy for Eating Disorders: Evidence and Future Directions, Ragnhildstveit et al, 2022. 

Substance Use Disorders (SUD):
Adjunctive Ketamine with Relapse Prevention-Based Psychological Therapy in the Treatment of Alcohol Use Disorder, Grabski et al., 2022.

Pain:
Assessment of Initial Depressive State and Pain Relief With Ketamine in Patients With Chronic Refractory Pain, Voute et al, 2023.

Healthcare Worker Burnout: 

A Cohort-Based Case Report: The Impact of Ketamine-Assisted Therapy Embedded in a Community of Practice Framework for Healthcare Providers With PTSD and Depression

Ketamine-Assisted Group Psychotherapy for Frontline Healthcare Workers with COVID-19-Related Burnout and PTSD: A Case Series of Effectiveness/Safety for 10 Participants

MISC articles of interest:
Therapeutic Potentials of Ketamine and Esketamine in Obsessive–Compulsive Disorder (OCD), Substance Use Disorders (SUD) and Eating Disorders (ED): A Review of the Current Literature, Martinotti et al, 2021.

Ketamine and neuroticism: a double-hit hypothesis of internalizing disorders, McNaughton et al., 2020.

After treatment integration:
Just like preparation may include mindset, intention setting, creating a safe space for your medicine session, and creating a safe and supportive space for yourself at home afterwards, integration of your experiences and discovering next steps within yourself are part of your aftercare plan. Dr. Husman is trained in a variety of types of integration techniques, including those used for MDMA, psilocybin, breathwork, and ketamine. This depth of exposure is ideal, as what works well for one person may not work well for another, and bringing a beginner’s mind to all new integration techniques is ideal. We owe a deep debt of gratitude and respect for those integration strategies utilized by indigenous peoples in ceremony around the globe for millennia. Returning to nature in a big or small way can be a very healing first step in the days after your session. Dr. Husman will provide some integration materials for you. There are many integration workbooks on the market, but here is one that is available as a download or in print.

Psychedelic integration: An analysis of the concept and its practice. Bathje, Majeski, and Kudowor, 2022.

Restorative Retelling for Processing Psychedelic Experiences: Rationale and Case Study of Complicated Grief, Gonzalez et al., 2022.

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