By Steve Levine, M.D.
October 9, 2019
About the Author Dr. Steven P. Levine is a board-certified psychiatrist internationally recognized for his contributions to advancements in mental health care. Though he is a psychiatrist who places great emphasis on the importance of psychotherapy, medication is often a necessary component of treatment, and he was dissatisfied with the relatively ineffective available options with burdensome side effects. Dr. Levine pioneered a protocol for the clinical use of ketamine infusions, has directly supervised many thousands of infusions and has helped establish similar programs across the country and around the world.
Ketamine is a novel treatment for several psychiatric disorders including Major Depressive Disorder, Bipolar Depression, Obsessive-Compulsive Disorder (OCD), and Posttraumatic Stress Disorder (PTSD). Ketamine was originally FDA approved for anesthesia but is now frequently used off-label due to its positive effects on the various disorders listed above. PTSD is an interesting disorder in that it has become more and more common but medical treatments overall are still lacking. This makes ketamine for PTSD an even more intriguing option when comparing the options presently available.
PTSD Develops after a Traumatic Experience
Such trauma typically involves combat, car accidents, natural disasters or sexual assaults. Up to 80% of individuals in their life will experience at least one traumatic event but, fortunately, most people do not go on to develop PTSD. The lifetime prevalence of developing PTSD is about 10% and women are twice as likely as men to develop PTSD. Those who do go on to develop PTSD typically will have one or more of the following symptoms:
- traumatic nightmares
- flashbacks taking them back to the event
- distress after exposure to traumatic reminders or stimuli
- avoidance of certain thoughts and situations
- negative thoughts and mood including shame, despair and depression.
A constellation of these symptoms must persist for at least a month for a diagnosis of PTSD to be made.
Currently, there are two main types of treatment options for the symptoms of PTSD: psychotherapy and medication management. Many times these two treatment options are combined for optimal management.
Psychotherapy for PTSD can be subdivided into Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR).
- CBT is the most effective treatment for PTSD and there are two main types of CBT:
- Cognitive Processing Therapy – Understanding how the trauma changed your thoughts and feelings so that you can change how you think and feel about the trauma.
- Prolonged Exposure Therapy – Talking about the trauma repeatedly until the memories of the trauma are no longer upsetting.
- EMDR is frequently used by some therapists to treat PTSD, but unfortunately, the evidence for its effectiveness is controversial with some reviewers concluding that it is less effective than Prolonged Exposure therapy.
Medication options for PTSD currently include SSRI antidepressants (Paxil and Zoloft), Prazosin (which works as an alpha-antagonist for PTSD-related nightmares), atypical antipsychotics and now ketamine. Antidepressants play a role but unfortunately take several weeks before any real effects can be noted and the track record of successfully treating PTSD with antidepressants alone is poor. Atypical antipsychotics are relegated for only extreme cases of PTSD, particularly those with psychotic symptoms. These antipsychotics carry with them the risk of developing diabetes, high cholesterol and possibly, in rare instances, producing movement disorders that can be permanent.
Ketamine for PTSD
Ketamine therapy has now been introduced as a new alternative treatment for those that have not responded well to other options for their symptoms. It is given intravenously at sub-anesthetic doses (0.5 mg/kg) making it safe to use in the office and the major side-effects (mildly elevated blood pressure and feeling of dissociation) are transient and dissipate within two hours or so. One huge benefit of ketamine infusions over oral medications is that if an individual is going to respond positively to ketamine, he/she will notice an improvement in his/her symptoms within hours to days rather than weeks to months. Research has shown that even a single infusion of Ketamine (over 40 minutes) can cause a rapid decrease in PTSD symptoms (Feder 2014) and if an individual is going to respond to ketamine infusions, both the patient and the physician will know after 1-2 infusions. This allows the patient to quickly determine if ketamine is a viable treatment option for them without wasting excess money, time, or suffering any long-term medication side effects. If a patient does respond, as most do, a series of 6 treatments over 2-3 weeks is performed.
In summary, PTSD is a disorder that is increasingly becoming more common in society. Currently, there is no one magic treatment for PTSD that works above all others. Many treatments take several months of trial and error and can cause some unwanted and even permanent side effects. Using ketamine for PTSD treatment may be a viable option as a way to avoid those side effects and also provide a faster relief of PTSD symptoms. To achieve optimal symptom reduction, we recommend combining Ketamine infusions with psychotherapy.