How Ketamine Facilitates Healing

by Dr. Reid Robison, MD MBA

If you haven’t checked it out yet, I highly recommend Michael Pollan’s 2018 book How to Change Your Mind. It’s a deep dive into the history, research, and resurgence of psychedelics as a valid modality of psychiatric treatment.

In chapter 5, Pollan explores what brain imaging has been teaching us about the effect of psychedelics on the brain. One of the most notable findings is that psychedelics lessen the activity of a series of neurological pathways in the brain known as the Default Mode Network (DMN).

The DMN serves a multitude of functions in navigating our daily lives and plays a major role in how we define the self (our definition of who we are), very similar to what is often referred to as the “ego.”

The DMN is also often referred to by psychologists as “The great orchestrator of the brain.” Let’s explore how psychedelics, like ketamine, affect these DMN functions and discuss why these effects can facilitate healing.

Daydreaming
Where does the mind go when it is not occupied by an immediate task?

Individuals suffering from depression may default to ruminations or feelings of worthlessness. People suffering from substance abuse may default to thoughts of guilt or the urge to use. Those battling eating disorders may default to obsessions with control and relentless thoughts about body image. People suffering from anxiety may default to an unrelenting need to get things done and have everything perfect.

This list could go on and on. For individuals whose minds tend to wander to such places, psychedelic medicine may help. Ketamine and other psychedelic medications reduce the activity of the DMN, allowing the mind to daydream in a different way and form new pathways for the brain to use.

A psychedelic experience can act as welcome reprieve from the unrelenting negative thoughts that many battle every day. It allows for a chance to cognitively and emotionally interact with life in a new way, and see ourselves with a fresh perspective.

The Self
The way each of us defines ourselves is wildly complex. In our brains is the wiring for thousands and thousands of rules and definitions that make up our unique experience of self (who we are).

Embedded in our sense of self are the rules and defense mechanisms for how we deal with things like guilt, shame, grief, and trauma. Many of our defense mechanisms were written in our minds when we were very young and entirely without our awareness.

Defense mechanisms that may have protected us as children may now only serve to drive our negative self-image. In a psychedelic experience, as the DMN is dialed down, the overpowering definitions of self are softened. This allows us to see and possibly even define ourselves in a new way. The ruts and trenches of how we think about ourselves are filled in and new definitions of who we are materialize and are given a chance to flourish.

The Great Orchestrator
Our brains receive and process enormous amounts of information. As a child, this information is not filtered. Over time, however, our brains learn to create short cuts and filter out extraneous information through a process called specialization.

This process is seen in language acquisition and motor skill development, as well as an assortment of other skills essential to daily life. As a part of specialization, the DMN comes online and orchestrates the cognitive short cuts or filters that are essential to daily life.

The downside to this is that the cognitive short cuts and filters imposed by the DMN make it more difficult to see the forest from the trees, so to speak. If we are perpetually seeing ourselves or the world in a negative way, then turning down the DMN through the use of psychedelics may facilitate new insights into life and a reframing of a negative self-image into a more honest and kinder one.

Mental health problems steal peace away from us in a myriad of ways. One of the most powerful tools for combatting this is found in our perception. Many people with mental illness wish they could change their reality.

To one degree or another, we all have a list of “I could-be-if…” statements. The problem with these statements is that they often give our power away. The world is never going to be perfect, but there is more than enough joy in it to have a rich and fulfilling life regardless of circumstances.

I once heard a man in a Narcotics Anonymous meeting share that he felt addiction could be defined as the inability to accept life on life’s terms. I think this profound statement can be expanded beyond the world of addiction to the struggles of life faced by many.

Ketamine may be a viable tool that enables us to come to terms with the world as it is. By quieting the DMN and its rigid response to the world, ketamine facilitates seeing our world and the suffering in it in a new way.

Reid Robison

About the author

Reid Robison, MDA MBA is the Chief Medical Officer at Novamind. He is a board-certified psychiatrist who was named Best Psychiatrist in Utah by Salt Lake City Weekly’s Best of Utah Body & Mind 2020.

Dr. Robison is the co-founder of Cedar Psychiatry and serves as the Medical Director for the Center for Change, a leading Eating Disorder center. He was previously a coordinating investigator for the MAPS-sponsored MDMA-assisted psychotherapy study of eating disorders.

New Research Behind Ketamine’s Molecular Process

At Numinus, we’ve watched ketamine help our patients, and we’re witnessing it change the landscape of psychiatry for good. Compared to traditional medications, ketamine has rapid antidepressant effects, often evident within an hour. For people with treatment-resistant depression, ketamine has shown 50-70% response rates. And we know that here at Cedar. We’ve seen it.

Scientists are rushing to understand the molecular process that makes ketamine so fast-acting and effective. This new research from Sweden focuses on serotonin, which has long been implicated in depression. Researchers studied a specific serotonin binding site and found that after ketamine treatment, patients had an increase in serotonin 1b receptors. While this illuminates a particular aspect of the molecular mechanisms behind ketamine’s efficacy, the total process is still evolving. Concluding the study, the scientists called for more research to help us understand this powerfully therapeutic drug.

We know intimately the low clinical response rates and delayed onset of action of traditional antidepressants, and while they help for some, others need alternatives. That’s why new treatment options are vital. It’s why we stay up to date on current studies and host research of emerging neuropsychiatric treatments—it’s why our Principal Investigator and founder Reid Robison MD MBA has led over 100 clinical trials.

Call us anytime at 1-833-NUMINUS (686-4687), we’re here to help.

Psychedelics & Safety Considerations

It’s common for people to have questions about the safety of psychedelic drugs and whether there are risks associated with them. Fortunately, classic psychedelics have little to no abuse potential. In fact, studies suggest they might even be anti-addictive. Even in vulnerable populations, it’s rare for complications like psychosis to arise from the use of psychedelics.

That being said, psychedelics may not be for everyone—which is why we take such great precaution before proceeding down the psychedelic path at our clinics.

 

What screening is done before deciding on psychedelics?

We only use psychedelics when there is a mental health-related diagnosis on record. We also complete thorough medical and psychiatric screening including reviewing pertinent factors such as personal or family history of psychosis and any history of substance abuse. Only after these precautions are in place do we consider psychedelic-assisted therapy.

 

Are these drugs safe?

According to many studies, the short answer is YES. Psychedelics have significantly lower risks than alcohol, cannabis, tobacco, and other drugs. Data from a study of psilocybin found that cases of mental health complications following a psychedelic are rare (<.1%), even in vulnerable populations (<.2%), and rarer still with proper screening. Another notable study, examining the classical (serotonergic, or 5-HT2A receptor agonists) psychedelics, LSD, psilocybin, & mescaline, found that no evidence of increased rates of mental health problems, and psychedelic use has been associated with reduced psychological distress and suicidality. Additionally, studies examining use patterns in humans & self-administration in animals suggest that classic psychedelics possess little or no abuse liability and may even be anti-addictive. These conclusions come from a comprehensive review of several kinds of psychedelic compounds, including classical psychedelics (psilocybin, LSD, &  mescaline), indirect 5-HT agonists, (e.g., MDMA), NMDA antagonists, and κ-opioid receptor agonists (KOAs).

 

Why do some people experience brief psychotic episodes even days after use?

There are several factors that can play into this. As a general guideline, people with cognitive & emotional conditions associated with disorganized or diminished ego strength are not good candidates for psychedelics. Regardless, however, the short-term psychological effects that accompany psychedelic use are profound. Sympathetic nervous system arousal may occur both because of fear, and from direct effects of the drugs--particularly during the initial phase of sessions when barriers between physical senses dissolve; touches, smells, and tastes can take on sounds, shapes and colors. Proper supervision is also important. These drugs’ effects are sufficient to require that professionals skilled in managing adverse effects are present, for safety & to guide patients through their experiences. Additionally, when taken without adequate preparation and when surroundings are anxiety-provoking—either physically uncomfortable or emotionally intimidating—the psychedelic experience predictably results in fear, a prolonged sense of dread, or full panic. Conversely, in controlled settings with elements of soft light, art, and appropriate music, or nature, and gentle, compassionate people, such adverse reactions are rare.

 

What conditions can Ketamine-Assisted Therapy (KAT) treat?

  • Depressive disorders
  • Post-traumatic stress disorder, post-traumatic stress and anxiety
  • Addictive disorders, including substance use and behavioural

 

What conditions are not suited Ketamine-Assisted Therapy at Numinus?

Absolute Contraindications - KAT is not a fit for those with the following conditions: 

  • Allergic reaction to ketamine
  • History of ketamine abuse
  • History of stroke or brain aneurysm
  • Uncontrolled high blood pressure
  • Acute Angle Glaucoma
  • Uncontrolled thyroid disorder
  • History of mania/bipolar 1
  • Age 14 and under
  • Current diagnosis of schizophrenia, schizoaffective disorder, major depressive disorder with psychotic features, psychotic disorder
  • Pregnancy (individuals who can become pregnant must use contraception if sexually active)

 

Relative Contraindications - We can some times treat those with the following conditions, on a case-by-case basis, with additional medical support: 

  • Active or unstable substance use disorder that is not an indication for treatment will be evaluated on a case by case basis by the screening physician
  • History of heart disease
  • Dissociative identity disorder
  • History of psychosis

 

Sources

Byock, Ira. “Taking Psychedelics Seriously.” Journal of palliative medicine vol. 21,4 (2018): 417-421. doi:10.1089/jpm.2017.0684

Heal, David J et al. “Evaluating the abuse potential of psychedelic drugs as part of the safety pharmacology assessment for medical use in humans.” Neuropharmacology vol. 142 (2018): 89-115. doi:10.1016/j.neuropharm.2018.01.049

Studerus, Erich et al. “Acute, subacute and long-term subjective effects of psilocybin in healthy humans: a pooled analysis of experimental studies.” Journal of psychopharmacology (Oxford, England) vol. 25,11 (2011): 1434-52. doi:10.1177/0269881110382466

Krebs, Teri S, and Pål-Ørjan Johansen. “Psychedelics and mental health: a population study.” PloS one vol. 8,8 e63972. 19 Aug. 2013, doi:10.1371/journal.pone.0063972

Physician Information — Ketamine-Assisted Psychotherapy

What is ketamine-assisted psychotherapy?

As you will likely know, ketamine is an anesthetic and analgesic used widely internationally. Ketamine also has antidepressant and psychedelic effects at certain doses, and international research has increasingly demonstrated that the combination of ketamine with structured psychotherapy can have benefits for a range of mental disorders. The ketamine assisted psychotherapy protocol at Numinus is distributed over approximately 4-6 weeks, depending on the patient’s schedule and how the visits are scheduled. Generally, the therapeutic protocol is expected to include two 50 minute introductory psychotherapy sessions without the use of ketamine, three ketamine dosing sessions of 2.5 hours in duration each followed within 24 hours by 90-minute psychotherapeutic sessions where insights from the ketamine experience are integrated, and a closing 50-minute psychotherapy (non-ketamine) session. Throughout this process, the psychotherapy delivered is focused on support, integrating insights, and identifying and reinforcing change as part of the therapeutic process.

Who is eligible for ketamine assisted psychotherapy?

Though research indicates that ketamine assisted psychotherapy may be effective for a number of mental health indications, Numinus is currently focused on addressing treatment-resistant depression. If you have a patient suffering from treatment-resistant depression that is interested in ketamine assisted psychotherapy, our team will work directly with them to determine whether the patient is a good candidate for treatment by taking a full medical and psychological history. To be eligible for ketamine assisted psychotherapy at Numinus, the patient must be referred by their primary care providers, such as a family physician or nurse practitioner.

What are the contraindications of ketamine assisted psychotherapy?

Those conditions that may make ketamine assisted psychotherapy contraindicated (i.e., potentially unsafe) include, but are not limited to, a history of psychosis (e.g. hallucinations), mania, cerebrovascular or cardiovascular disease, seizure, and severe liver disease. At present, youth, pregnant women and nursing mothers are not eligible for ketamine assisted psychotherapy since the effects of ketamine on pregnancy, nursing children, and youth are unknown. Additionally, the ketamine product monograph lists other risks which will be reviewed with all patients as part of an informed consent process at Numinus.