What is the ideal dose of ketamine to treat severe depression, PTSD and other mood disorders? What is the ideal amount of time to administer this dose? These are two of the most common questions that we at Klarisana get asked by potential patients. The very short answer is that we believe that the correct dose is one that addresses both the biochemical and experiential components of ketamine therapy. We have seen that it is critical to allow a patient to experience what we call the Psychotropic Therapeutic Response or “PTR.” I will discuss the PTR in more detail shortly but first, let’s start with some big-picture issues involved in ketamine therapy…
In high doses, ketamine is a dissociative anesthetic. When I use it in the ER, the purpose is to allow me to perform a painful procedure on a patient without him/her feeling it. I generally give the patient a respectable dose as a fast IV push and this rapidly causes a disconnection between the central and the peripheral nervous system…thus allowing me to perform a painful procedure such a joint reduction. An analogy would be that this is like depressing the clutch on a manual transmission car; it completely disconnects the engine from the drive train. It does not, however, turn off the engine. When we use ketamine to treat mental health indications we are drawing upon certain elements of that dissociative property but it is actually a fundamentally different intent and desired outcome. We are using ketamine not as an anesthetic but rather in the role of psychotropic infusion therapy (PIT). To extend the previous analogy further this would be like depressing the clutch just a little bit…” riding the clutch” so to speak.
Some people…especially in the pharmaceutical industry…would have you believe that these experiential effects are undesirable. Critics would suggest that any of the psychomimetic effects and alterations in a patient’s perception of reality with ketamine are purely side effects…ones that need to be eliminated. In fact, in their minds, if these effects could be removed then the ideal end-state would be the creation of a (patented) pill or nasal spray which would “revolutionize” the treatment of mental health disorders. This mindset is very much in keeping with the American paradigm of creating a pill for every malady. This point of view holds that the only way that ketamine works is by attaching to certain receptors and causing changes in the brain that ultimately treat the symptoms of severe treatment-resistant depression, post-traumatic stress disorder (PTSD), post-partum depression, bipolar disorder and so on.
What we have observed in our patients however is that the experiential side of ketamine infusion therapy is NOT a side effect at all…it is an essential element of the therapeutic experience. This is especially powerful if combined with the opportunity to work with a therapist during the ketamine infusion…a process called facilitated psychotherapy. I find it fascinating that for years, many clinicians in “mainstream medicine” follow the paradigm that we just need a better pill for each condition…someday there will be a breakthrough and we will cure depression etc. Others who recognize the value of alternative and complementary healthcare have extolled the virtues of meditation, yoga, exercise, and the concept of “food as medicine.” Ketamine therapy is a very unique overlap of these two paradigms. There is clearly an important and powerful biochemical component to how it works but that is just the start. Our colleagues at the NIH who did the initial studies on ketamine for depression used a protocol of 0.5mg per kg of patient body weight administered over 40 minutes. These numbers are totally arbitrary and were basically pulled out of thin air. They are useful though in the sense that they give us a “floor” in terms of how much ketamine is needed just to affect the biochemical changes needed. Most American adults weigh between 80-100 kg. This means that 40-50 mg ketamine is needed to hit the receptors and take care of the biochemical side of the treatment. The question then becomes; how much is needed to create a therapeutic experiential effect?
This is where it gets a little tricky. As a clinician treating someone with ketamine for a mood disorder, my goal is to bring the patient to a point where he or she starts to have some mild dissociation and a powerful experiential journey. As I previously mentioned, this is what we call the Psychotropic Therapeutic Response (PTR). The PTR is hard to put into words but the most common analogy that I use for new patients is The Motorcycle Ride. Imagine a beautiful day in Malibu California and imagine yourself riding a motorcycle on the Pacific Coast Highway (wearing a helmet of course). You would have the beautiful homes on one side of you and the Pacific Ocean on the other. Now if you ride too slow (too low a dose) you have a bad experience…people honk at you and a motorcycle will fall over if you go too slow. If you are going to fast (too high a dose) then you would also have a bad experience because you have to weave between cars and be “white-knuckling it” down the road…there is no way to enjoy the experience. The PTR is where you are going just fast enough to “have your groove on” so to speak and you are going the perfect speed where you can maximize the enjoyment of the ride. To help a patient experience the PTR does not lend itself to a cut and dried protocol. Ketamine therapy is not like dosing an antibiotic where a simple weight-based protocol. This fact makes a huge difference if you are the patient. Many clinics are starting to add on ketamine therapy as an additional revenue stream and advertising that they “treat severe depression.” Many of these clinics simply put you in a room with several other patients and give you their “standard protocol” of 0.5 mg per kg over forty minutes…these are what I call “oil change clinics.” Their paradigm is simply that they need to get some ketamine into your bloodstream and the rest will take care of itself. That is a fine paradigm for many of the infusions given to rheumatoid arthritis patients (Remicaid etc.) or for chemotherapy but this falls far short when it comes to ketamine therapy.
If a clinic wants to really help a patient find his/her PTR, then this takes time and effort. After each infusion, I or one of my nurse practitioners sits and talks with each patient and asks them about their experience. Additionally, my medics who sit with our patients have seen infusion after infusion after infusion and are able to provide very important observations and insights as to how a given patient is responding to a certain dosing strategy. Based on these discussions, we then adjust the dose for subsequent infusions. Now here is where it gets even trickier and more frustrating for clinicians who simply want to add ketamine as another revenue stream. What I have seen is that each ketamine journey is a little different because of who you are as a patient changes. With each infusion, the patient becomes more skilled at how to interact with the experience and the biochemical changes are starting to take place so there may very well be a shift in a patient’s mood and outlook between infusions. This is fundamentally different than simply giving penicillin to treat strep throat.
I hope this has given you some insight into what goes into the dosing strategy for ketamine infusion therapy. As one can see, achieving the proper dose for a given patient is not just a matter of following a cookbook for ketamine. If you would like to learn more about how we administer ketamine treatment at Klarisana please contact us through our website at Klarisana.com. If you are considering a clinic in another part of the country, please make sure and ask them for clear details about how they decide on their dosing strategy and how much interaction you will have with a clinician during your infusion series.