Should You Use Ketamine to Treat PTSD?
Our "Panic in the Streets" columnist speaks to a doctor who’s been treating patients for years. Here’s what he found out.
I’m always looking for new ways to deal with my PTSD, but as someone who lived through 1990’s rave culture, I never thought Special K—that’s what Gen-Xers called ketamine—could be used to treat my symptoms. Then, on March 5 of this year, a nasal spray derived from ketamine called esketamine (Spravato) was approved by the FDA as the first new medication in decades for treatment-resistant depression. Truth is, clinics long have offered off-label intravenous ketamine treatments—the internet is full of first-person accounts and success stories. But now that the FDA is on board with Spravato, the general public is getting hip to the potential therapeutic benefits for depression, anxiety, and PTSD.
But despite the buzz, I’m not sure I’m on board (yet). Because once, in college, this really awesome guy I know who’s totally not me tried ketamine and found himself trapped in K-hole on a dorm room floor, physically paralyzed but mentally aware as seconds crawled by like hours. Is it just me, or does that sound like the worst possible scenario for someone with PTSD?
To find out, I reached out Rand McClain, D.O., and chief medical officer of LCR Health, a physician who offers ketamine infusions for veterans with PTSD in Santa Monica, CA. (Since Spravato is only approved for depression, people who want treatment for PTSD must still go the infusion route.) He says therapeutic ketamine is not nearly as scary as it sounds (also not as fun as you might remember).
What Is Ketamine?
In urban mythology, it was a horse tranquilizer and party drug (both true), but it turns out that ketamine is also a dissociative anesthetic widely used during Vietnam War and beyond. It sedates the patient, helps with pain management, puts you in a trance-like state, and causes memory loss.
About 20 years ago, doctors began to see results with using ketamine “off label” via intravenous infusions as an alternative treatment for depression at dedicated clinics. With the recent FDA approval of Spravato for treatment-resistant depression, it went fully legit (though even with the nasal spray, patients still need to get their doses under doctor supervision at a certified medical facility).
Ketamine is still popular in veterinary medicine as a tranquilizer or analgesic for animals large and small, though, for some reason, it doesn’t work too well on cows.
How Does It Work for PTSD?
Unlike antidepressants that work by increasing serotonin levels, ketamine dampens glutamate (a stimulating neurotransmitter) signaling in the brain, according to research from the National Institute of Mental Health. While SSRIs may take weeks to have an effect (if they work at all), ketamine seems to alleviate depression and PTSD symptoms right away.
“PTSD is definitely not all cognitive. You're at a higher state of alert all the time,” says Dr. McClain. “It's very visceral.” That means the best treatment must also be physically felt, not just talked about in therapy. By inducing a dissociative state, ketamine allows you to “see your problems without that emotion attached,” he says. Once the actual treatment is over, many people can maintain that detached view when symptoms, like being gripped by fear, strike.
After treatments, Dr. McClain says, one veteran described it as “turning the volume down” on his PTSD. In other words, he didn’t feel it as intensely. A 2014 study from the Icahn School of Medicine at Mount Sinai in New York City showed that “ketamine infusion was associated with significant and rapid reduction in PTSD symptom severity.”
Dr. McClain compares the repeated trauma of PTSD with a deeply-etched drawing on an Etch-a-Sketch. Ketamine infusions help shake it all up and erase the pattern. But that doesn’t mean you don’t have to do any work. He says the drug is most effective when paired with cognitive-behavioral therapy (CBT) because if you don’t develop new pathways, you’ll just wind up drawing the same old thing. It’s the CBT that can help you “develop new, improved routes to digest information and react to it,” he says.
This really resonates with me. I’m a believer that there’s no magic bullet for curing PTSD—you’ve got to do all the things, including medication, meditation, exercise, mindfulness, therapy, and whatever else works for you.
How is Ketamine Therapy Different From That Time I Fell into a K-Hole in College?
First off, Doc’s medical IV treatment is way too expensive for recreational users (approximately $300 to $800 per session, with patients often starting with six sessions and usually non-reimbursable by insurance), and not just anyone can get their hands on it.
“There’s a meticulous screening process to ensure it might benefit the patient, and treatments are supervised by medical professionals,” he says. “We're using a controlled dose— usually a half milligram per kilogram of bodyweight—infused over roughly 40 minutes.” That is way, waaaaay less than what a recreational abuser would snort.
Screening is equally rigorous for Spravato, but thanks to the FDA, it may be covered by insurance. (Without insurance, the spray costs anywhere between $2,000 to $7,000 per month—the drug’s maker, Janssen, helps patients navigate that bureaucratic mess.)
“When ketamine is properly dosed, disassociation occurs very calmly,” says Dr. McClain, who says patients describe an out-of-body experience of looking at their life from far away while being completely removed emotionally. The idea of being in a situation that spurs panic reactions without some kind of fight, flight, or freeze reaction freaking me out sounds like something I’d definitely be down for.
What Can You Expect From a K-Clinic Visit?
Doc talked me through his process: You’re relaxing in a comfy chair in a quiet room, wearing Bose noise-cancelling headphones or maybe listening to your favorite music (some people bring their own playlist).
You’re wearing a blood pressure cuff and you’re attached to an IV, monitored by a nurse, physician's assistant, or doctor. They’re sitting in the room with you, making sure everything is safe. The entire treatment lasts about an hour. The infusion is timed for 40 minutes, but they give you an extra 20 minutes to chill because people may be a little loopy for a while. In fact, patients are required to have someone escort them home. Don’t even think about driving yourself.
Some patients are one and done, reporting that they feel dramatically better after a single session, but Dr. McClain has only read about those people in the medical literature: “Normally, they do six treatments over the course of two or three weeks. After that, patients may come back to ‘top up’ every three to four weeks” (ideally, concurrently with their CBT practice), until their symptoms have abated.
Who Should NOT Try Ketamine Infusions?
If you have been diagnosed with schizophrenia, ketamine is not for you. “The mechanisms by which it works in the brain are similar to the things that exacerbate schizophrenia,” he says. Ditto for recreational users of psychedelics. Lastly, people with uncontrolled hypertension should also skip it, since ketamine raises blood pressure and heart rate. “That's why we always keep a beta blocker on hand, although I've never had to use it,” he says.
While PTSD may not ever completely go away, ketamine treatment has shown promising results, quickly reducing the severity of the symptoms. I’m encouraged to know that there’s a new option for treatment available.
I’m always on the lookout for ways to improve my condition, and if ever I have a few extra (thousand) bucks in my pocket, I’m willing to go under the ketamine needle with an open mind. Maybe I’ll even write an article about it.