Ketamine infusion therapy has eased its way into people’s consciousness, thanks to widening media coverage and the tireless efforts of health advocates. Patients unresponsive to traditional pain or antidepressant medications now see it as their new hope. It rests on you, the ketamine provider, to guide them on what to expect when undergoing the treatment.
A detailed discussion of the ketamine patient experience accomplishes three things. First, it helps you establish rapport with patients, which is proven essential to treatment adherence. Second, it gives you an opportunity to manage expectations. Third, it lets you initiate the process of obtaining informed consent, which is part and parcel of medical therapy (Griffiths et al., 2021; Sanacora et al., 2017).
So what are the most important things to discuss with a patient asking about the ketamine experience?
1. Most People Observe an Emotional Upliftment
Clinical trials demonstrate the efficacy of ketamine infusion in treating refractory depression and neuropathic pain (Murrough et al., 2013; Zarate et al., 2006; Cohen et al., 2018). If your patient has been suffering from either condition, there’s an excellent chance that the treatment can improve their symptoms.
Besides that, qualitative studies further describe what patients experience emotionally while on ketamine therapy. During a session, they report feeling high and relaxed. Afterward, they experience mood elevation, happiness, and less anxiety. Many say that the gloominess they’ve had for a while has gone away. Some even feel like they’re back to their old selves (Griffiths et al., 2021; Lascelles et al., 2021).
2. Cognitive Enhancement Can Come Quick
During a ketamine infusion procedure, patients feel as if they are having an out-of-body experience and an altered sense of reality (Griffiths et al., 2021). They may become disoriented and drowsy right after the session, but reassure them that they will regain full cognitive function by day's end (Davis et al., 2021).
A day or two after the session, positive cognitive changes develop alongside the emotional boost. Patients start to have a renewed sense of self-worth and purpose. They feel more motivated and goal-oriented. They experience mental clarity and a greater ability to focus. Suicidal thoughts go away (Griffiths et al., 2021; Lascelles et al., 2021).
They may be concerned about ketamine treatment’s long-term neurocognitive side effects. You can tell them that you’re giving the medication only at a low dose, and studies show that repeated subanesthetic treatments do not impair brain function (Souza-Marques et al., 2021).
3. Most Develop Positive Behavioral Changes
With their spirits and cognition up, patients also improve behaviorally. Sleep and eating patterns begin to normalize. People become more sociable and communicative. Their overall functionality improves (Griffiths et al., 2021; Lascelles et al., 2021).
4. The Medication Can Trigger Physiological Fluctuations
No drug is totally free of side effects. In ketamine’s case, it interacts with the sympathetic and parasympathetic branches of the nervous system. However, the manifestations vary for every patient. At subanesthetic doses, the blood pressure and heart rate can increase or decrease. Breathing may remain normal for some, but others experience respiratory fluctuations during ketamine infusion (Griffiths et al., 2021).
Assure your patient that if these events happen, they would be short-lived, resolving as soon as you stop the drip. Also, tell them that you will monitor them closely throughout the procedure and have medications ready to prevent these changes from getting out of hand (Sakurai et al., 2020).
5. Other Side Effects May Occur, but They Are Manageable
Aside from dissociation and altered perception, some patients report having blurred vision and nausea during a ketamine therapy session. Meanwhile, post-infusion side effects that have been described include:
Reassure the patient that these symptoms go away on their own within a few hours or may be treated with the appropriate medication. Also, encourage them to have a responsible adult accompany them to your ketamine clinic. They may need assistance when going home (Lascelles et al., 2021; Sakurai et al., 2020; Griffiths et al., 2021; Short et al., 2018).
6. Some Need Help During the Maintenance Phase
Long-term ketamine infusion therapy does not come cheap for people needing it for chronic pain or psychiatric disorders. Blame it on insurance firms denying coverage for the drug’s off-label applications.
Cost can be a barrier to completing a ketamine treatment course or scheduling maintenance sessions (Griffiths et al., 2021; Lascelles et al., 2021; Jilka et al., 2019). But you can offer your patient various options for making the therapy more affordable, which we discuss in another article.
Accessing your clinic may also be an obstacle to continued treatment. If that is the case, you may want to coordinate with the patient’s family or friends to get the support they need (Griffiths et al., 2021; Jilka et al., 2019).
7. There Is a Risk of Failure or Relapse
Ketamine therapy works for most treatment-resistant depression (TRD) and neuropathic pain patients. However, neither mental health nor pain medicine experts have set an endpoint for declaring futility (Sanacora et al., 2017; Cohen et al., 2018).
Meanwhile, we do know that, in successfully treated TRD patients, the drug’s antidepressant effect is usually observed after one or two sessions. By the third infusion, it will be clear if an individual will continue to improve, relapse or remain unresponsive (Griffiths et al., 2021; Lascelles et al., 2021; Sanacora et al., 2017).
Mental health and pain medicine authorities recommend increasing the dose carefully if you do not see improvement after an IV ketamine treatment session. Pharmacokinetic variability causes some patients to respond only at high doses (Sanacora et al., 2017; Cohen et al., 2018).
In any case, you should tell your patient about the possibility of relapse or therapeutic failure before they sign an informed consent form. If they ask if switching to esketamine nasal spray (Spravato) will help, explain what studies found—that it is not better than intravenous ketamine (Bahji et al., 2021).
8. It Can Get Worse Before It Gets Better
Rarely, ketamine therapy may worsen some symptoms before they improve. Specifically, patients may become more deeply depressed, suicidal or anxious during an infusion. Some may even have panic attacks (Lascelles et al., 2021; Griffiths et al., 2021).
But remember that this phenomenon is also observed with traditional antidepressants, such as the frequently prescribed SSRIs. It is attributed to the patient’s renewed energy brought about by antidepressant treatment (Stubner et al., 2018; Reeves et al., 2010; Sinclair et al., 2009).
Reassure the patient that you will monitor them at every step and have remedies ready to prevent these untoward incidents.
9. Ketamine Has Other Potential Risks
Ketamine infusion treatment’s high cost may prompt some individuals to buy the drug off the streets. If they end up obtaining it outside your clinic, you will not be able to monitor them while they take it. Worse, you may lose them to follow-up (Jilka et al., 2019).
To keep patients from taking that course of action, you may counsel them about the risks of ketamine abuse. Chronic heavy consumption of this drug leads to dependency, neurocognitive deficits, and urinary tract damage (Short et al., 2018; Morgan et al., 2014). Additionally, you may offer them options for making the therapy more affordable, as we mentioned above.
10. Following Up with Their Primary Physician or Referring Specialist Is Important
If you are not the patient’s primary healthcare provider, it is best to advise them to follow up with their primary or referring physician. That way, there will be another set of eyes to monitor their progress or detect any adverse events. Collaborating with other specialists may also help the patient address the mounting challenges of long-term treatments (Sanacora et al., 2017; Jilka et al., 2019).
Because We Are Responsible for What Our Patients Know
Ketamine infusion therapy has sparked fresh optimism for backs-against-the-wall mood disorder and pain patients. As health providers, we wish we could promise them that it is a magic bullet for all their ills. But this novel treatment has limitations as it has benefits that we must explain before getting informed consent.
The good thing about ketamine patients is that they appreciate medical expertise and professionalism. In fact, they consider these traits as important enhancers of their treatment experience (Griffiths et al., 2021). So tell them what they need to know, and do it with compassion. Remember that what protects your patients also protects you.
Bahji, A., Vazquez, G. H. & Zarate, C. A. J. (2021). Comparative Efficacy of Racemic Ketamine and Esketamine for Depression: A Systematic Review and Meta-Analysis. Journal of Affective Disorders, 278, 542-555. https://doi.org/10.1016/j.jad.2020.09.071
Cohen, S. P., Bhatia, A., Buvanendran, A., Schwenk, E. S., Wasan, A. D., Hurley, R. W., Viscusi, E. R., Narouze, S., Davis, F. N., Ritchie, E. C., Lubenow, T. R. & Hooten, W. M. (2018). Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine and the American Society of Anesthesiologists. Chronic and Interventional Pain, 43(5), 521- 546. https://doi.org/10.1097/aap.0000000000000808
Davis, M. T., DellaGiogia, N., Maruff, P., Pietrzak, R. H. & Esterlis, I. (2021). Acute Cognitive Effects of Single-Dose Intravenous Ketamine in Major Depressive and Posttraumatic Stress Disorder. Translational Psychiatry, 11(1), 1-10. https://doi.org/10.1038/s41398-021-01327-5
Griffiths, C., Walker, K., Reid, I., Da Silva, K. M. & O’Neill-Kerr, A. (2021). A Qualitative Study of Patients’ Experience of Ketamine Treatment for Depression: The ‘Ketamine and Me’ Project. Journal of Affective Disorder Reports, 4, 1-8. https://doi.org/10.1016/j.jadr.2021.100079
Jilka, S., Murray, C., Wieczorek, A., Griffiths, H., Wykes, T. & McShane, R. (2019). Exploring Patients’ and Carers’ Views about the Clinical Use of Ketamine to Inform Policy and Practical Decisions: Mixed-Methods Study. BJPsych Open, 5(5), e62-e67. https://doi.org/10.1192/bjo.2019.52
Lascelles, K., Marzano, L., Brand, F., Trueman, H., McShane, R. & Hawton, K. (2021). Ketamine Treatment for Individuals with Treatment-Resistant Depression: Longitudinal Qualitative Interview Study of Patient Experiences. BJPsych Open, 7(1), e9-e16. https://doi.org/10.1192/bjo.2020.132
Morgan, C. J. A., Dodds, C. M., Furby, H., Pepper, F., Fam, J., Freeman, T. P., Hughes, E., Doeller, C., King, J., Howes, O. & Stone, J. M. (2014). Long-Term Heavy Ketamine Use Is Associated with Spatial Memory Impairment and Altered Hippocampal Activation. Frontiers in Psychiatry, 5, 1-11. https://dx.doi.org/10.3389%2Ffpsyt.2014.00149
Murrough, J. W., Iosifescu, D. V., Chang, L. C., Al Jurdi, R. K. Green, C. E., Perez, A. M., Iqbal, S., Pillemer, S., Foulkes, A., Shah, A., Charney, D. S. & Mathew, S. J. (2013). Antidepressant Efficacy of Ketamine in Treatment-Resistant Major Depression: A Two-Site Randomized Controlled Trial. The American Journal of Psychiatry, 170(10), 1134-1142. https://doi.org/10.1176/appi.ajp.2013.13030392
Reeves, R. R. & Ladner, M. E. (2010). Antidepressant-Induced Suicidality: An Update. CNS Neuroscience and Therapeutics, 16(4), 227-234. https://doi.org/10.1111/j.1755-5949.2010.00160.x
Sakurai, H., Jain, F., Foster, S., Pedrelli, P., Mischoulon, D., Fava, M. & Cusin, C. (2020). Long-Term Outcome in Outpatients with Depression Treated with Acute and Maintenance Intravenous Ketamine: A Retrospective Chart Review. Journal of Affective Disorders, 276, 660-666. https://doi.org/10.1016/j.jad.2020.07.089
Sanacora, G., Frye, M. A., McDonald, W., Mathew, S. J., Turner, M. S., Schatzberg, A. F., Summergard, P. & Nemeroff, C. B. (2017). A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders. JAMA Psychiatry, 74(4), 399-405. https://doi.org/10.1001/jamapsychiatry.2017.0080
Short, B., Fong, J., Galvez, V., Shelker, W. & Loo, C. K. (2018). Side Effects Associated with Ketamine Use in Depression: A Systematic Review. The Lancet Psychiatry, 5(1), 65-78. https://doi.org/10.1016/s2215-0366(17)30272-9
Sinclair, L. I., Christmas, D. M., Hood, S. D., Potokar, J. P., Robertson, A., Isaac, A., Srivastava, S., Nutt, D. J. & Davies, S. J. C. (2009). Antidepressant-Induced Jitteriness/Anxiety Syndrome: Systematic Review. The British Journal of Psychiatry, 194(6), 483-490. https://doi.org/10.1192/bjp.bp.107.048371
Souza-Marques, B., Santos-Lima, C., Araujo-de-Freitas, L., Vieira, F., Jesus-Nunes, A. P., Quarantini, L. C. & Sampaio, A. (2021). Neurocognitive Effects of Ketamine and Esketamine for Treatment-Resistant Major Depressive Disorder: A Systematic Review. Harvard Review of Psychiatry, 29(5), 340-350. https://doi.org/10.1097/hrp.0000000000000312
Stubner, S., Grohmann, R., Greil, W., Zhang, X., Muller-Oerlinghausen, B., Bleich, S. Ruther, E., Moller, H., Engel, R., Falkai, P., Toto, S., Kasper, S. & Neyazi, A. (2018). Suicidal Ideation and Suicidal Behavior as Rare Adverse Events of Antidepressant Medication: Current Report from the AMSP Multicenter Drug Safety Surveillance Project. International Journal of Neuropsychopharmacology, 21(9), 814-821. https://doi.org/10.1093/ijnp/pyy048
Zarate, C. A. J., Singh, J. B., Carlson, P. J., Brutsche, N. E., Ameli, R., Luckenbaugh, D. A., Charney, D. S. & Manji, H. K. (2006). A Randomized Trial of an N-Methyl-D-Aspartate Antagonist in Treatment-Resistant Major Depression. Archives of General Psychiatry, 63(8), 856-864. https://doi.org/10.1001/archpsyc.63.8.856