Ketamine Treatment
Informed Consent for In-Office Ketamine Treatment
What is Ketamine?
Ketamine is a dissociative class medication that is considered a schedule III controlled substance. It is predominantly used in the emergency department and in the operating room as an anesthetic medication. Ketamine is FDA-approved for anesthesia and for pain relief during procedures. Ketamine is not considered FDA-approved to treat depression, PTSD, acute or chronic pain, or any additional conditions outside of anesthesia and pain relief during procedures.
The use of ketamine to treat the above conditions is considered “off-label” by the FDA. There is nothing wrong with using medication for off-label purposes, as a large percentage of medication prescribed in this country is just for off-label use. Ketamine treatment therapy for psychiatric conditions and acute or chronic pain is considered safe, even though it is considered “off-label.” Be aware that ketamine has been used safely over the past 50 years.
Ketamine has been shown to improve the symptoms of various psychiatric conditions and pain in certain populations. Everyone’s response to treatment will be different but individuals usually report improvements in psychiatric symptoms and pain but be aware that symptom relief cannot be guaranteed. You need to be aware that symptom relief can last from days to months, therefore multiple treatments might be recommended or required for long-term symptom relief.
There are no long-term studies to show the safety or effectiveness of repeated ketamine treatments, therefore the potential long-term risks or treatment efficacy cannot be established for the treatment of chronic pain disorders, depression, PTSD, anxiety, and other psychiatric conditions.
What Can I Expect with Treatment?
The procedure for ketamine treatment is straightforward. You will receive treatment by intramuscular injection in both of your upper arms or right and left thighs. You may also receive an intravenous (IV) line started into a vein of your hand or arm, an intramuscular (IM) injection in your upper arm, right and left thighs, and/or a subcutaneous (subq) injection in your hand or arm. We primarily do intramuscular injections.
You will have your vital signs monitored frequently during treatment to include but is not limited to your heart rate, blood pressure, and oxygen saturation under the supervision of a licensed medical provider and/or registered nurse.
After the treatment, you will have a recovery period of 30 minutes to 2 hours depending on your response.
You can expect at minimum to have up to 6 treatments over the course of 3 to 6 weeks for a complete loading series. Maintenance treatments are preferred. You may have 2 treatments the next month and only 1 treatment the month after. A total of 9 treatments in 3 to 5 months is preferred but may not be necessary depending on your progression.
Some clients can go longer without treatment, however, this is dependent on the client. Plan for at least a quarterly visit.
What Are The Risks?
Any procedure or medication carries with it possible risks and side effects. Even though significant side effects are rare, you need to be aware of all the possible risks and side effects before starting treatment. Unknown or unexpected side effects or risks could also occur.
What Are The Side Effects of Ketamine Treatment?
Most Side Effects are Mild in Nature
- Elevations in blood pressure and heart rate
- Laryngospasm
- Urinary frequency, urgency, hesitancy, or burning with urination
- Dizziness
- Headache
- Increased saliva production
- Restlessness
- Impaired coordination
- “Out of body” experiences
- Twitching of arms and legs
- Decreased appetite
- Nausea and vomiting
- Pain, rash, bruising, or possible infection at the IV site
- Blurred or double vision
- Hives and allergic reaction
- Increased ocular (eye) pressure
- Hallucinations and flashbacks
- Increased mania or hypomania in bipolar disorder
- Increased suicidal thoughts and ideation
- Cystitis
- Slowing of heart rate
- Irregular heart rhythm
- Low blood pressure
Other Potential Risk
Ketamine also carries with it a risk of abuse and tolerance, especially if you have a history of drug abuse or dependence. This is rare though as ketamine does not have a physiological withdrawal syndrome associated with it and most patients do not develop cravings for ketamine.
As with the administration of any type of medication, especially an anesthetic, there is a risk of dosing errors, drug interactions, and rare serious side effects that could require intubation, anaphylactic treatment, and/or hospitalization. These can be serious and life-threatening.
For this reason, it is imperative to be truthful with your medical history and all medications, supplements, or illicit drugs you are taking.
Female Only: You should not receive ketamine if you are pregnant, breastfeeding, could be pregnant, or are trying to get pregnant, as ketamine could harm the developing fetus. If you believe you could possibly be pregnant, a pregnancy test will be available for you before treatment. Please notify a staff member.
Benefits of Ketamine Treatment
Ketamine therapy for depression, PTSD, and anxiety has been associated with decreases in the symptoms associated with such psychiatric conditions. Every patient’s response to treatment is different.
The length of time of symptom relief can vary from person to person as can the intensity of relief. Your individual response to therapy will be monitored by your treating provider and additional treatments could be recommended depending on your response.
Before, During, and After Your Treatment
- Plan to be at the clinic at least 20 minutes before your treatment/injection.
- Arrange to have someone available to drive you home after the treatment/injection
- Plan to be in the clinic for an additional 1 – 2 hours after the treatment/injection for monitoring and recovery. For example if you are going to have a 40-minute treatment, be prepared to be here for about 2 hours.
- Avoid eating any solid food 4 hours before treatment. You may have clear liquids up to 2 hours before treatment
- You must abstain from the use of alcohol, cannabis, and other illicit substances for a period of 24 hours before treatment and 24 hours after treatment.
- Do not take any opioid pain medication for at least 6 hours prior to your treatment
- You can take your regular medications as normal on the day of treatment. If you are taking any of the following medications you must hold them the day of your treatment:
- Stimulants that can increase your blood pressure or heart rate
- Benzodiazepines such as Xanax, Klonopin, or Ativan
- Lamictal (Lamotrigine)
- MAOIs
- You must abstain from the use of alcohol, cannabis, and other illicit substances for a period of 24 hours before treatment and 24 hours after treatment.
- You should not make any life-changing or legal decisions for up to 12 hours after the treatment.
- You may not eat for at least 4 hours prior to treatment.
- You may have clear fluids up to 2 hours prior to treatment.
- You may not operate heavy machinery or drive motor vehicles for 24 hours after the ketamine treatment.
- You can take your regular medications as normal on the day of treatment. IF you are taking any of the following medications, you must hold them the day of your treatment:
- Stimulants that can increase your blood pressure and heart rate
- Benzodiazepines such as Xanax, Klonopin, or Ativan
- Lamictal 9Lamotrigine)
- MAOIs
- You must also notify your medical provider who is overseeing your mental health and/or pain conditions that you are seeking treatment with ketamine. It is important that you maintain seeing your mental health provider and the provider managing your pain for ongoing therapy and treatment outside of ketamine therapy.
Tips for More Positive Results from Your Ketamine Treatment
- Blocking outside noise is helpful; we have noise-canceling headphones or earplugs for you to use
- Many people find music very helpful; we have a playlist of meditative music without words that we can play for you. You may use your own phone with your own playlist, but an incoming text or call can be extremely disruptive to your session
- Many patients prefer to keep their eyes closed during their treatment, but we also have eye masks for you to use if you like.
- Dress comfortably so that you may relax during your treatment; even kicking off your shoes may make you more comfortable
- Optimizing your state-of-mind prior to and during a treatment is vital. Many things can have either a positive or negative effect on your session.
- The day before treatment & the day of the treatment, avoid situations that will bring you stress, anxiety, or anger, such as a difficult family member or neighbor. Also avoid sad or scary movies/shows the day before a treatment. Again, what goes into your brain prior to and during a treatment can impact whether your session is positive or negative.
- Whomever is driving you to and from your session should understand that being supportive and positive is the most helpful thing they can do for you.
- If your phone is nearby during treatments, please remember to mute it or turn it off.
- Bring sunglasses to wear when you leave; you may be more light sensitive after your treatment.
- You are welcome to bring a blanket or pillow; we also have those things here for youtube use.
- Hydrate well the day before and choose nutrition that is healthy; avoid alcohol, marijuana, and benzodiazepines the day of your treatment.
- Practice meditating; choose several positive and happy mantras. If your ketamine treatment begins to cause anxiety, these practices can help you redirect your thoughts away from the anxious ones.
- Please communicate with us during your treatment if you begin to feel anxious or tense. We can help you talk through your feelings and redirect your thoughts.
Ketamine is not a cure…it will not cure your chronic pain, it will not cure your depression, it will not heal your underlying traumas, it will not cure any other illnesses. It is a tool to help, just like other medications and treatments. But like other treatments, you will need to keep utilizing it to continue receiving the benefits that it brings you.
It is a myth that ketamine will make a depressed person happy. In reality, ketamine treatments will make you feel more resilient. The stressors don’t change…what changes is your ability to cope and your willingness to engage in other treatments, both for mental health and physical health.
One treatment will not do much, even if you feel a positive result. Ketamine needs to build up in your system in order for the effects to be longer-lasting. It needs time to reset the NMDA receptors and help your synapses heal. Don’t give up early…trust the process.
“What dose is best for my ‘X,Y,Z,’ diagnosis?”
Because every person is different, it is difficult to know what your best dose will be. But there are guidelines for starting points and we can go up or down from there, based on your feedback. So being honest with your provider is important. A good clinic and provider will be willing to adjust up or down as needed.
Whether you’re getting ketamine for chronic pain or mood disorders (or both), it’s very common that you’ll still have good days and bad days. Some people even get a little worse after a treatment before they begin to feel better overall; it’s called a treatment flare. Utilize all of the tools that you know to manage your times of down-swing. And know that it will get better!
“Do some people develop a tolerance to ketamine?”
Yes it is possible. Just like with many medications, there doesn’t seem to be a way to prevent it. Communicate with us if your treatments aren’t helping as they used to. Neuropsychiatry TX has a protocol where we can increase your dose by 10% if your dose seems to start to lose its effectiveness. From what we’ve observed and heard from other providers, this may happen to long-term ketamine users about once a year. That’s why it can be important to start at the lowest dose that’s effective for you.
I’ve heard that some people are able to come off of their antidepressants…is that true?
In some cases, with the supervision of their mental health provider, some people have been able to reduce or eliminate their antidepressants, mood stabilizers, and/or anti-anxiety medicines. However most people do continue to utilize antidepressants in combination with ketamine; they find that the ketamine seems to cause the antidepressants to work more effectively.
If you develop pain that feels like it’s in the location of your bladder, it’s possible that the ketamine is causing this pain. It’s rare with lower doses for mood disorders, but with higher doses for pain, the ketamine being metabolized by your body can irritate your bladder. Let us know… we have a list of OTC medications that can help. Also, if you’ve been diagnosed with interstitial Cystitis, it’s important that we know…we will have you take those same OTC medications from the start.
Remember to visit the bathroom before each treatment!
Wherever you receive your ketamine treatments, that clinic should be willing to share with you what dose you are receiving, over how much time, and what other medications you will receive along with the ketamine. You should always be told what you are being given; if any place doesn’t want to tell you, consider avoiding them.
We enroll you in Mood Monitor, an app that helps you track how you’re feeling. You can also try keeping a journal of your daily mood as a way to track your progress. This is especially helpful if your changes happen more slowly. However, if you have OCD, keeping a journal may not be a good idea as it may cause you to obsess over it. Your entries don’t need to be very long, just meaningful to you. Maybe even give your mood a number…something that you can use to quantify your current status. When you read back over several days or a week of entries you’ll be surprised at your progress!
And finally, if you don’t think ketamine will work, then it won’t work. You must tell yourself that the ketamine is making changes in your body, it’s healing your synapses that have become damaged through stress over time. Sometimes the changes are subtle and you may not pick up on those small clues that things are improving.
The improvements have been described by some as “sliding a dimmer switch” rather than “flipping a switch”…things may brighten slowly!
Part of the process is knowing that the ketamine truly is healing your body; the other part of the process is becoming aware of those subtle changes. You will not go from 0 – 60 overnight, and if you’re convinced that it isn’t working, then it won’t and you’ll be back to square one with yourself. As you are trusting the process, do small things that bring you pleasure.
To have a SAFE and EFFECTIVE treatment, it is important that you adhere to the following before and after visit instructions
A light meal is recommended after the treatment
Monitor your IV, IM, or Subcutaneous site for redness, pain, warmth, or swelling. This could be a sign of infection or an adverse reaction.
Do not take benzodiazepines or opioid pain medication for at least 4 hours after your treatment
Continue routine follow up with your mental health provider for continued treatment.
You should not make any life changing or legal decisions for up to 12 hours after the treatment
You may not operate heavy machinery or drive motor vehicles for 24 hours after the ketamine treatment. Ensure you have someone to drive you home that you trust.
If any mild side effects occur such as increased anxiety, hives, nausea, restlessness, or any additional non-life threatening symptoms, please call NeuropsychiatryTX at 888-468-9669 immediately. If it is after hours or your call happens to get missed, then please report to your closest urgent care or emergency department.
If any type of adverse events occur such as suicidal ideation, psychosis, shortness of breath, trouble swallowing, chest pain, severe headache, changes in consciousness, or anything else that is concerning call 911 or report to the emergency department immediately.
