Sweetgrass Psychiatry is Now Offering Intramuscular (IM) Ketamine
Due to patient request, we have added intramuscular (IM) ketamine treatments to our arsenal at Sweetgrass Psychiatry to defeat depression. Ketamine is well researched and has demonstrated clinical efficacy in treatment resistant depression research studies. Be aware that ketamine is not currently FDA approved for the treatment of treatment resistant major depression, however Spravato/esketamine is.
Ketamine is now an increasingly clinically applied “off-label” treatment for various conditions, such as major depression. Ketamine is a DEA Schedule III medication that has long been used safely as an anesthetic and analgesic agent and now, often effectively for treatment of depression, substance use disorders, PTSD and other psychiatric diagnoses.
Ketamine is classified as a dissociative anesthetic, dissociation meaning a sense of disconnection from one’s ordinary reality and usual self. At the dosage level administered to you, you will most likely experience mild anesthetic, anxiolytic, anti-depressant and, potentially, psychedelic effects. Non-ordinary (“altered”), transpersonal (“transcendental”, “mystical”, “spiritual”, “religious”) peak experiences often occur. Research has demonstrated the possibility of an antidepressant response to low dosages of ketamine– administered intravenously or intramuscularly. The antidepressant effect tends to be more sustained with repeated use—in other words, a cumulative effect.
It is our view that psychedelic, ‘dissociative’ experiences may well be instrumental in providing a catalyst for deep change. This may well include a positive change in outlook and character that we term a ‘transformative’ response. Essential to the method is an altered state of consciousness, typically lasting 30 minutes to 90 minutes, that tends to be related to dose and route of administration. It is our view that relief from challenges provided by ketamine, and the exploration and experience of other possible states of consciousness are singularly impactful.
Indications:
Ketamine is a schedule III FDA approved medication for anesthesia. At lower doses, ketamine can be used off-label for treatment resistant depression, but it is not FDA approved for this indication. Treatment resistant depression means that a patient has failed 2 adequate trials of 2 different FDA approved antidepressant medications.
Ketamine may improve severe depressive symptoms
Ketamine alters a chemical called glutamate by blocking NMDA receptors in the brain and may produce a more rapid antidepressant effect compared to drugs that work on serotonin, dopamine, or norepinephrine.
The duration of effect is specific to the individual patient.
Effects of Ketamine
Ketamine is a dissociative anesthetic that can feel like a psychedelic
Onset of IM ketamine is typically within 5 minutes
It is typical to feel like your mind is separated from your body while you are on ketamine for about half an hour up to an hour.
There may be unusual physical sensations, emotions, visual effects and mystical experiences. Often the body feels very relaxed.
Experiences may feel pleasant or unpleasant, often both within the same session
Occasionally folks feel nauseous.
As much as you can, relax and breathe as the effects begin to occur.
Who Can Receive Ketamine:
A diagnosis of treatment resistant major depression.
Willingness to refrain from alcohol, drugs and marijuana for at least 24 hours before and after ketamine treatments.
Willingness to wean current use of benzodiazepines (such as Alprazolam, Clonazepam, Lorazepam) to 0.5mg or less per day.
Willingness to hold controlled medications on the day of ketamine treatments.
Willingness to have a ride home from the clinic and not drive until the next day.
Who Should not Receive Ketamine:
Significant (Class 2 or above) cardiovascular disease
Uncontrolled hypertension (systolic blood pressure greater than 150-160 at baseline)
History of intracranial bleeds, strokes, seizure, or migraines
Increased intracranial pressure
Uncontrolled glaucoma
Known hypersensitivity to ketamine
Renal failure and dialysis
Need for more than 4L O2 support
Liver disease that may affect metabolism of ketamine
Pregnancy
Active substance abuse or dependence on any substance in the past sixty days except caffeine or nicotine
Receiving medication that may blunt responses or change affect
High risk for suicidal ideation or behavior
Current diagnosis of uncontrolled bipolar illness
Primary psychotic disorder
Dissociative identity disorder, or significant personality disorder
High risk of destabilization due to ketamine or being in group process
Poor internal and external resources / support system
Overview of Ketamine Therapy:
The length of IM ketamine effect is typically about one hour. You will be mostly internally focused for the first 30 minutes to one hour or possibly longer. You will continue to remain under ketamine’s influence at a lesser level for at least one hour. Your medical provider will check your vital signs and then will give you a dose within the range of 0.25mg per kg to 0.5mg per kg body weight, using a well-researched weight-based protocol. The determination of dose will depend on body weight, prior exposure to ketamine and other psychedelics, and sensitivity.
Procedure:
Prior to the administration of ketamine, some medical tests may be required, including weight, potential labs, potential drug screen, Beta-HCG pregnancy test for women, and we recommend an electrocardiogram.
Ketamine dosing for depression is weight based and usual doses are between 0.5 mg/kg and 0.75 mg/kg. Higher doses are often associated with more side effects and are not necessarily associated with better depression treatment outcomes.
We will measure your blood pressure and pulse before, in the middle, and after your ketamine treatment.
We recommend using the restroom just prior to receiving the medication.
The injection is given as a deep intramuscular (IM) injection using a needle into a deltoid muscle. This route tends to have fewer adverse effects compared to an IV administration.
Patients are observed for 2 hours with periodic assessments at 15-min intervals. There will be an evaluation of the injection site for any signs of an adverse reaction (redness, swelling, itching). The provider will look for signs of confusion, disorientation, or any unusual perceptual sensations. There will be monitoring for the presence of suicidal thinking and vital signs will be taken.
Side Effects/Risks:
Your sense of balance and coordination will be adversely affected until the drug’s effect has worn off–generally two and up to four hours after the injection. It is possible you may fall asleep, though this is a rare event. Although rare, you may experience some temporary adverse effects, including blurred and uncomfortable vision, slurred speech, mental confusion, excitability, diminished ability to see things that are actually present, diminished ability to hear or to feel objects accurately including one’s own body, anxiety, nausea or vomiting.
Visual, tactile and auditory processing are affected by the drug. Music that may be familiar may not be recognizable. Synesthesia—a mingling of the senses may occur.
Common (between 1 and 10% of patients)
— Temporary increase in heart rate and blood pressure
— Respiratory depression
— Blurred vision
— Dizziness
— Nausea/vomiting
— Reduced coordination
— Reduced concentration
— Pain at the injection site
Rare (between 0.1 and 1% of patients)
— Increased muscle tone presenting as jerking movements or tremors
— Hallucinations
— Dissociation (“out of body” experiences), altered body and altered time perception
— Confusion/altered mental status
— Laryngospasm (abnormal muscle tone of the vocal cords leading to difficulty with speaking or breathing)
— Ketamine is a potential drug of abuse and dependence and tolerance can occur
Navigating Difficult Experiences
Difficult experiences are not necessarily bad trips.
Psychedelic experiences conventionally are often described as “good” or “bad.” The idea behind psychedelic-assisted therapy is that experiences are not “good” or “bad.” As Stan Grof put it, psychedelics are non-specific amplifiers.
We welcome very challenging psychological and physical experiences that appear during a psychedelic-assisted therapy session because with the right support such experiences usually lead to deeper healing and integration, helping us turn toward things we may have suppressed.
If a challenging experience occurs, we will ensure staff is present for extra support as needed
Bring a neutral witnessing presence to what is happening and use the music as an anchor to ride the waves of the experience.
Use your breath to help through moments of challenge.
When it’s Safe for Discharge:
When it has been at least 2 hours after IM ketamine administration
Vital signs are within 10-20 points starting blood pressure and pulse
Oxygenation level above 92%
Tolerating oral intake
Ambulating/walking normally
Coherent/clear/alert mental status
Going home with trusted other/ride
Follow up/next appointment scheduled
Discharge instructions:
No driving for 12-24 hours (or after a good night’s sleep)
No signing legal paperwork
No alcohol, drug, or controlled medication use that day without clearance from your physician
No going into work
No “big” discussions with family
Phone number to call if emergencies when the office is closed
An understanding that there is no one right way to feel
Patient Instructions: The patient may:
Take their usual medicines in the morning with the exception of stimulants (can increase blood pressure) and controlled medications that interfere with ketamine (ex - benzodiazepines).
Avoid sedating medicines including benzodiazepines or narcotic pain medicines within several hours of receiving ketamine.
Not drive on the day after receiving ketamine.
Avoid conducting major business transactions, arrange for child care as necessary, and try not to make any important decisions the remainder of the day after the injection.
Refrain from alcohol or other substances prior to, and for 24 hours after, the injection.
In addition to calling the office, call 911, or go to the emergency room should there be any serious symptoms or decline in health after leaving the clinic.
Alternative Treatments: (Include but are not limited to the following)
Other Antidepressant Medicines
Spravato/esketamine
Psychotherapy/Counseling
Electroconvulsive Therapy
Transcranial Magnetic Stimulation
If you have treatment resistant depression and feel you would be a good candidate for IM ketamine, please give Sweetgrass Psychiatry a call after filling out our new patient intake form. We look forward to scheduling your new patient intake at one of our beautiful offices in Mount Pleasant, SC or Isle of Palms, SC.