What to Expect During Ketamine Infusions
During one of our original podcasts we discussed a basic overview of ketamine with a little bit of background info: how ketamine, a dissociative anesthetic, was used in the Vietnam War era. How this type of drug can take a lot of pain away quickly and makes you forget about your experience of the pain when used at anesthetic doses. And how, by a happy accident, we found that very same drug used as an anesthetic, when used at much lower doses, could act as a rapid-acting antidepressant. In the past couple of years, there has even been some research as to how people with addiction issues, like alcohol and cocaine abuse and dependence, could benefit from the ketamine infusion therapy! It lowers both the substance cravings and can help aid in withdrawal.
What I’d like to do now is provide you with more information about what to expect DURING and after ketamine infusions. I figure if we provide a little education about what happens, we can significantly decrease both the public’s and patients’ fears of the unknown.
Disclaimer: the knowledge contained within these podcasts and blogs is for educational purposes only and should not replace the advice from your own personal medical professional. Also, the discussion of ketamine treatment advances and outcomes does not guarantee a particular outcome or of the effectiveness of treatment for a specific individual.
Typically, we receive a call from patients suffering from long-standing depression, anxiety, and PTSD who have tried and failed multiple oral antidepressant options. They schedule a visit to come chat with me to review their medication and medical illness history. During that time, we discuss all available options and whether or not they are medically stable enough to receive ketamine infusions. While ketamine in general is well-tolerated, there are a few medical illnesses and certain medications where ketamine may not be a good idea and you can ask your doctor about those. That’s why it is so very important to have a doctor review your history prior to receiving these infusions.
So a patient comes in, we review their medications and illness history, what types of therapies they have tried in the past, and if it is safe for the patient to proceed, we make them comfortable in the infusion suite, take their vital signs, and begin the infusion. Beforehand, we will have asked that the patient forego any type of food for 4 hours and any type of drink for 2 hours prior to the infusion, just to reduce the risk of vomiting and choking. But while ketamine is considered an anesthetic, it is given at much lower than anesthetic doses such that you still maintain control of your faculties.
It is important for the patient to recognize and be aware that they are in a safe and controlled, calm, peaceful environment. Folks who have suffered a lot of childhood trauma, specifically, are prone to feeling the need to be in control of all situations, make sure they can have their eyes on the door at all times, and want to know who can come and go in the room where they are receiving treatment.
We do our best to make the environment as relaxing as possible, with comfortable chairs, neutral art and room paint colors, and quiet surroundings. Sometimes if the patient cannot relax, we guide them through a brief breathing meditation, or even suggest a sleeping eye mask and/or earphones to be able to listen to soothing music. I recently learned that there are actually ketamine “Playlists” on pandora and spotify you can download for the occasion! In general, though, anything that is relaxing, has no words, and a slow beat can be conducive to putting your mind in peaceful state of being.
A big fear and a common question among patients is: “What if I lose control during the infusion?” If you’ve ever heard the Latin phrase, “in vino, veritas,” or “in wine, truth,” then you may recognize the feeling of saying too much or of losing your inhibitions. Ketamine, much like alcohol, can dissolve your self-consciousness and lower your defenses. If you’ve been trying to hold back a lot of anxiety, for example, then panicky feelings may come forth during the infusion. If you’ve been trying to suppress a lot of sadness, you may become tearful. If you’ve been quashing your anger, you may become agitated. So, what’s the deal with all these emotions spilling out? Part of what can inhibit a person from getting well is working TOO HARD to hold these emotions in. Ketamine is a sort of “fast-track” to allowing yourself to feel these things in order for your brain to be able to process them on a conscious level. FYI, it makes undergoing therapy TREMENDOUSLY easier when your feelings are on the table. We recommend to all comers that they seek out and receive psychotherapy if they do not already have a therapist because it can make talking about scary things far less scary and helps to carry the momentum of working on your issues into the fast lane.
So what if all of these tremendously intense feelings come up? We remind you that you are in a safe environment. If you have a full-blown panic attack, we can slow down or even stop the infusion at any time; that’s the nice part about doing an intravenous infusion. If you have a negative reaction, we can stop the IV and the feelings will dissipate in minutes. When using alternative delivery methods like intranasal, intramuscular, or oral, if you have a negative side effect, sorry about you’re luck because you’re stuck with it for a while! If you have serious concerns about too-intense or panicky feelings happening and decreasing the enjoyable experience of the infusion, we may also pre-medicate, so you can tolerate the infusion more comfortably. All these are perfectly within the range of “normal” responses we see. You’re not losing control. You’re allowing the medicine to take effect and letting it do its job.
Another common question we have is: will I hallucinate? While it’s super unlikely, it’s entirely possible. Ketamine has inherent hallucinogenic properties. So during the infusion, you may see things that aren’t there, like shadows or “animals in the clouds,” for example. But these are more of what we call “illusions” because there IS a visual stimulus but your brain is just misinterpreting it, like when you see a shadow and think there’s a burglar in your house but it’s just the dog. The good news is these illusions go away quickly with the termination of the infusion and should last no longer than two hours. Again, worst-case scenario—and we’ve never had this happen—we can stop the infusion entirely if your experience is too intense. The speed you receive the medication does not increase or decrease its effectiveness. It only allows you to tolerate any possible side effects better. If you see something big, purple, or hairy/scary, you should notify your doctor immediately. If you have a predisposition to psychosis, or if you are particularly sensitive to anesthetics, or you’ve gone a long time without sleep, all could put you at risk for having hallucinations and you should let your doctor know beforehand.
Most people experience a mild sense of dissociation during and/or shortly after an infusion. The best explanation I’ve heard: It’s a similar feeling to receiving nitrous oxide (laughing gas) during a dental procedure when you’re a kid. There’s a strange sense of “otherness” you may experience, where you believe you have a limited ability to speak or move your limbs. For instance: I know I see that this is my hand and it is attached to me but is it really my hand? Do I have control over it? Am I moving it or is it moving itself? The answer is an unequivocal yes, you are controlling it, yes it is attached to you. It just doesn’t feel like it. You may even feel as if your mind has floated out of or above your body, and frequently we all have dreams in which we both play a part and are floating above the situation, in a detached observer position. Again, this is totally normal, but it is the reason why up to 30% of patients who have motion sickness may experience nausea. Let your doctor know if you have a predisposition to a sick stomach, sensitivity to anesthetics, or have had motion sickness in the past and they (or we) can pre-medicate with anti-nausea medications.
People only feel detached/floaty/or nauseated sometimes during or immediately after the infusions. Some folks don’t experience any of the above. Most patients don’t feel “weird” at all—just extremely relaxed and calm.
There are a lot of people looking for an epiphany or religious experience when they receive ketamine. Some worry if they don’t experience that feeling that they won’t get better. Many people describe a type of euphoric sensation. Some say the infusions help to “clear up the cobwebs” in their minds, which helps them come to a decision about a difficult situation a little easier, improves clear thinking and cognition. Others say it allows them to see connections in their minds where there weren’t any before. And some say they had reactions similar to an “epiphany.”
Does this happen to everyone? No. Some research says it’s not a “necessary reaction” in order to get better, while others studies say it improves outcome overall. We have not yet noticed a correlation in our clinical practice. We’ve had patients who DID have euphoric or epiphanous moments during the infusions but didn’t improve much at all symptomatically in terms or depression or anxiety. We’ve also had patients who felt nothing but relaxation during the infusions and went into complete remission of their depressive or anxiety-based symptoms. So you can’t assume the infusions are not working if you don’t have an exciting epiphany moment. The infusions just work differently in different people, just as many medications do. Another bonus benefit is that a lot of patients who have chronic pain find mild to moderate relief of symptoms and find they may need less pain medication, muscle relaxants, and anti-inflammatories on the day of and immediately after infusions.
So what about feeling better in general? When does that begin to happen? Ketamine is not a panacea, or cure-all. Many people are led to believe that it is some sort of “magic bullet” and will take away all of your symptoms of depression, anxiety, and PTSD in the first visit. But here’s the thing…that rarely happens. Maybe 5% of the time patients go into spontaneous depressive remission during or shortly after the first visit. And trust me when I tell you EVERYBODY WANTS TO BE THAT GUY. We’re human, we all want the quick fix. But it is FAR more common, in what we’ve seen in this clinic, at least, to have a Bell Curve of responses. There are the rare folks who go into remission in one to two visits. The majority of our patients start responding between infusion visits three to five. And then, there is another small subset of our people who don’t even START responding until 6-plus visits—or even after the treatment series is over! The latter is usually more common in our folks with OCD, the elderly population, or people who are taking medications that actively work against the ketamine. Don’t fret, though. Like the majority of treatments out there, everyone responds differently.
How many total visits you may need depends on your response to the treatments. How we measure this is based on something called neurocognitive exams given prior to treatment, halfway through treatment, and at the end of your treatment series. We have different exams for different issues. The one we use for depression is called a PHQ-9 depression screening inventory. The one for anxiety is called the GAD-7. The one for PTSD is called a PCL-5. Typically the higher the number, the more symptomatic you are. This is like a game of golf, the lower number the better. We hope to see the number decrease during the course of the infusions, and in a perfect world we’d like to see that number in the single digits by the time you finish your treatments.
If you get into the realm of “minimal-to-no symptoms” over the course of the six visits in 2-3 weeks (which is the baseline standard treatment number given by the National Institute of Mental Health), the frequency of return visits greatly decreases. We also give you a take-home PHQ-9/GAD-7 or PCL-5 (depending on your symptoms and what you need) to be performed weekly on the anniversary of your last infusion day to chart your own progress. I believe there are several apps you can download on your phone to track your progress as well instead of using the dinosaur pen and paper method.
Our clinic recommends follow-up maintenance infusions when you “jump up” a category of severity, or if your score is greater than 10 for two weeks consistently. If it has been a few weeks to months since your last series of infusions and your symptom severity is increasing, you likely will need 1-3 visits instead of a full set of six like the initial treatments (as long as we can catch the symptoms quickly enough). I tell people it’s a lot easier to “course-correct” a plane blown off course a little bit versus trying to pull out of a nosedive. In plain speaking terms, don’t wait!
In terms of side effects, outside of the floaty or dissociated feelings, or the intense emotions you could feel, about one-third of our patients do experience headache or mild nausea. We can help with medication in advance of or during the infusions. Also, the best way to stave off these TWO MOST COMMON side effects of an infusion is HYDRATION, HYDRATION, HYDRATION. Work up to drinking one-half of your body weight in ounces to ensure you’re getting enough to drink. Try to avoid caffeinated beverages if you can, and DEFINITELY avoid drinking alcohol or taking stimulants on the days of infusion. IF you are prescribed medications that may counteract the ketamine’s effects, speak with your doctor. It may not be appropriate to discontinue them (like if you’re taking clonazepam for seizure disorder, for instance) or it may be ok to hold them on the days of infusion. Only by working with your doctor or provider, can you safely take the infusions.
In terms of your regular meds, say for instance you are taking zoloft or prozac or abilify. We don’t want you to stop taking your psych meds! You could have a negative reaction to the immediate withdrawal symptoms of these meds, and in addition, we wouldn’t know if it was withdrawal symptoms, or a negative reaction to the ketamine treatment. Same goes for starting new meds as you’re initiating ketamine infusion treatment: it’s not generally recommended. This way, we’re only changing one treatment variable at a time.
We know we’re a little bit biased, but we’d really like you to be in psychotherapy during the course of your treatments. No medicine exists in a vacuum. And while yes, the medicine can help you look at your perspective of the world and your problems in a different way, it doesn’t make those problems no longer exist and you still need coping skills to be able to handle your stressors. If you don’t have a therapist, seek one out. If you have a therapist, we recommend increasing the frequency of the therapy that you’re already doing so you can get a little more momentum going. This can help you get the most out of ketamine infusion treatment as well as your therapeutic treatment.
So, if you found this information helpful, please like, subscribe, and follow us! Tell your friends. We’re @AndersonClinicCincy on Facebook, Instagram, and TikTok. And you can find our Psych Waves podcast on Apple and Spotify. And if you happen to be in the Cincinnati area and are looking for assistance with treatment-resistant depression, anxiety, concussions, or PTSD, give us a call at (513) 321-1753. Start feeling better faster.