MHM Magazine

Issue 1 | 2025 | MENTAL HEALTH MATTERS | 13 MHM exploration of one’s inner world to allow for profound insights, deep self-awareness, radical shifts in perspective about limiting negative self-beliefs, which can create immense benefit and accelerate the works of psychotherapy when carefully and ethically curated by trained professionals. While this can be beneficial for many patients, it’s not necessarily valuable for all of them. Patients who have a history of cardiac disease require medical screening and changes in blood pressure brought on during infusions can be dangerous if not properly managed. Patients with a history of bipolar 1 disorder can become manic as a result of infusions and a history of psychosis is a contraindication for this treatment as these infusions may trigger or perpetuate psychotic symptoms. A comprehensive medical and psychiatric screening is crucial to limit these and other risks for patients as ketamine- assisted psychotherapy (KAP) is not a panacea. As is the case in all healthcare, one person’s medicine can be another’s poison and so evangelical use of these molecules for all should be replaced by cautious and thoughtful selection. While not for everyone, ketamine, unlike the classic psychedelics, actually presents unique advantages as a treatment agent: 1. Global legality and general acceptance for in research as indicated for treatment- resistant depression (TRD). 2. Limited interaction with SSRIs and many other psychiatric medications due to its mechanism of action involving the glutamate system. As such, patients can stay on their medication while undergoing infusions which is not possible with classic psychedelics. 3. Logistical convenience of clinics as opposed to retreats in the wilderness. 4. Safety and tolerance studies using this molecule have been conducted. 5. Unlike classical psychedelics which involve one 4–6-hour medicine-administration session, ketamine is a 40–60-minute infusion and one typically does 3-6 sessions at a rate of once a week allowing for therapy to occur in an ongoing basis rather than only afterwards. 6. Unlike classic psychedelic experiences, this state can be stopped quite rapidly due to the infusion (drip) method should there be any adverse reaction which increases a sense of psychological safety for patients. While ketamine, according to research, has shown promise for the treatment of chronic pain conditions, addiction, PTSD, anxiety and obsessive-compulsive disorder, the strongest evidence for its use related to TRD and suicidality. Multiple studies show that 84-86% of suicidal patients are no longer suicidal after a single ketamine infusion. While seemingly miraculous, the effect has been shown to wear off about a week later. In some cases, this can result in increased suicidality for patients who feel hope was given and then torn away. In other cases, many patients who undergo numerous infusions don’t show the benefits proclaimed for this therapy despite much effort and expense. In both cases, the research shows a clear message - the magic is not only in the medicine. While ketamine will create an opportunity for self-exploration and also allow for the downstream upregulation of brain-derived neurotropic factor (BDNF) to make the brain far more neuroplastic, these benefits are found to be most impactful and meaningful when couched within a robust therapeutic framework that firstly, prepares patients for the psychedelic experience and, second assists them in translating the emotional breakthroughs and insights of the experience into meaningful behavioural change that creates lasting benefits. As a brief illustration, one patient who was suffering from TRD decided to attempt KAP since traditional therapy and medication had not yet benefitted him optimally. He was intrigued that while his medications typically served to dampen his emotions, KAP would amplify them. After a thorough screening two preparation sessions which included setting intentions (treatment goals), writing his life story to prime relevant emotional material for processing and developing a sense of trust with his therapist, Gary underwent his first infusion. It should be noted that while the therapist is present during the infusion in some cases, more often therapy occurs a few days before and after infusions as therapy with someone in an NOSC can carry its own clinical and ethical complexities. During his post-infusion (integration) session, where one ‘integrates’ or translates the insights into behaviour change, Gary remarked that he finally understood something. In his mind, he encountered a demon. Rather than fleeing, he followed his therapeutic preparation to ‘trust, be open, and let go’ and instead spoke to the demon. It informed him that he is his anger and wishes to no longer be locked away since his childhood where he learned never to be angry. Gary embraced the demon and it dissolved. This abstract experience allowed him to realise that much of his depression was an internalisation of anger. Through therapy, Gary learned healthy assertiveness skills which improved his marriage and work life. By identifying a limit core belief that underpinned his suffering, Gary improved considerably. He recognised that without therapy, the experience and benefit would have been lost. In conclusion, while KAP presents some risks, most of the problems result from not including therapy in the process. Ketamine is a potentially powerful agent of change that may accelerate therapy, but it’s by no means a silver bullet. Careful and continuous therapeutic work remains necessary as there is no route around behaviour change. In short, it seems that while the medicine can make you well, therapy will keep you well. References available on request. MHM | 2025 | Volume 12 | Issue 1 | Ketamine-assisted psychotherapy: gimmick or breakthro gh? MHM