Partner Perspectives Q&A with Dr. Reid Robison (Chief Clinical Officer, Numinus)

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Why do you think there has been so much interest in ketamine in the past few years? Why do you think ketamine is needed in psychiatry?

I think the ever-expanding interest in ketamine stems from the fact that, unfortunately, traditional antidepressant treatment options just have not worked well enough for enough people. This has left too many suffering. So, when it was discovered that ketamine has potent and rapid antidepressant properties, that was an exciting development in the field of mental health. Not only because it offered a more effective treatment option, but also because it works quicker than traditional options which typically take weeks to kick in.

Interest in the therapeutic potential of ketamine has also grown because of its psychedelic properties. With appropriate preparation and dosing, ketamine can bring about a unique experience of time, space and form, one that transcends ordinary consciousness to a state where the mind feels liberated from its usual constraints, ruminations and pre-occupations. In this non-ordinary state of consciousness, the client has the opportunity to think and feel differently. They may more easily revisit past traumas and be better able to actively participate in the work that healing requires. This is why we're so excited at Numinus about what can happen when ketamine is paired with psychotherapy for individuals with mental health conditions, especially ones that are lacking effective options or difficult to treat.

For which psychiatric disorders might ketamine be helpful? Are there new studies showing new potential uses?

The initial psychiatric research on ketamine was focused on depression and suicidality, and as a result, most ketamine studies have focused on depressive disorders. However, there is a growing body of evidence now beyond depression, suicidality, bipolar depression including conditions like PTSD, OCD, eating disorders, and even addiction. This additional research suggests the promising potential for ketamine to be a catalyst in the healing and recovery process.

How does ketamine compare to traditional treatment strategies in terms of short- and long-term efficacy and safety?

Ketamine, as a rapid antidepressant, can alleviate depressive symptoms within 24-48 hours for many patients, unlike traditional treatment options such as SSRIs that often take weeks to show efficacy. Ketamine also appears to have response rates that outperform traditional treatment options, without the need to take a daily pill. For example, numerous ketamine studies have shown 60-70% response rates–that is, 60-70% of people who receive the medicine have at least a 50% reduction in their depressive symptoms. An important note on ketamine is that while it does appear to be a rapid and effective antidepressant for the majority of people, the antidepressant effects may be temporary. Therefore, many clinicians consider ketamine to be a bridge to other therapeutic strategies, such as psychotherapy or traditional antidepressants. That being said, psychedelic therapies, including ketamine (which is currently the most readily available), are some of the most rapid transformative methodologies known to us. While the chemical effects of ketamine may wane, there are more and more cases and mounting studies pointing toward the potential for lasting change when ketamine is paired with skillful psychotherapy.

When should a clinician consider referring their patient for ketamine therapy? When would it be contraindicated?

Clinicians often consider referring a client for ketamine therapy only when other treatments have failed, but as the evidence continues to grow in its favor, many clinicians, including myself, are introducing ketamine earlier in the treatment algorithm, before other treatment options have been exhausted. This is because ketamine has a very strong and compelling safety profile, not just from psychiatric studies but also from decades of anesthesia research and clinical use. When paired with the right psychotherapy and psychological support, we are finding that it can be an effective intervention to help people not only get out of a rough depressive episode, but also stay well.

Ketamine is typically not given when people are in, or have had a recent, episode of mania or psychosis, due to the possibility of worsening psychotic and manic symptoms. There are also other medical factors to screen for and consider when starting a course of ketamine, such as cardiovascular status. For example, ketamine is known to briefly and mildly increase heart rate and blood pressure; therefore, individuals embarking on ketamine therapy should have any hypertension or serious cardiovascular disease well-managed first.

What should clinicians tell their patients about ketamine therapy? What are some of the common myths about ketamine therapy that might worry patients?

Clinicians should make their patients aware of ketamine therapy as an option, especially for those with Treatment Resistant Depression or in cases where there may be a need for a quicker response rate than traditional therapies.

There are many myths out there about ketamine. For example, many believe ketamine to be quite addictive. While it is true that caution needs to be used when prescribing ketamine, especially for individuals with a history of addiction, there is a growing body of evidence to show that when paired with psychotherapy and given under the care of a skilled treatment team, ketamine can be anti-addictive. There are now positive studies in support of ketamine therapy to help individuals recover from problematic use of alcohol, opiates, cocaine, and even cannabis.

Where do you think ketamine therapy will be in psychiatric practice in the next 5 years? 10 years?

Some clinicians think that ketamine is merely a stepping-stone towards other psychedelic compounds that are being developed. I believe, however, that ketamine on its own will remain an important tool in psychiatry, due to its unique fast-acting impact in depressive episodes and its ability to bring about a therapeutic state of altered consciousness. I see ketamine always having a place in the individualized treatment algorithms for many clients and I have witnessed countless times how ketamine can be a powerful facilitating agent for healing and growth.