Ketamine, Esketamine and Experiential Medicine
Treatment with ketamine and esketamine (Spravato) is phenomenologically different from treatment with other antidepressant medications (and other general medications, for that matter!). The Western pharmacopeia (the book of all the medications Western physicians prescribe) is full of chemicals that help people feel better through direct action on a person’s biology. While ketamine and esketamine certainly work through activity on biological processes they stand out among all other medications in that they also work by impacting a person’s mind through the subjective changes that occur when the medicines are in one’s system.
This aspect of ketamine and esketamine renders them unique as treatments. To say it another way: how ketamine and esketamine (Spravato) change how we fundamentally think in addition to how the medications materially change the biology of the brain are how they work, a partnership that is special in medicine.
What Does Treatment with Ketamine and Esketamine Feel Like?
Each person’s experience with ketamine and esketamine is special to that individual and also to the individual treatment experiences, themselves. No person has the same experience twice. With that in mind, there are some similarities shared between people and the individual treatments that are worth reviewing. Once ketamine (through an intramuscular shot or an intravenous infusion) or esketamine (through an intranasal “insufflation” – this is the term for blowing medications into an orifice, like the nose) is administered, a person might not feel anything for a minute or two. As the medication is delivered to the brain, changes begin to occur. At first these changes can feel very physical, like a sense of physical relaxation, warmth, or tingling in the fingers and toes. Slowly, the relaxation deepens and other changes begin, as well. Regular light can seem quite bright (and most people close their eyes). Some people describe hearing a buzzing sound or describe being able to hear all of the ambient background noises all at once (many people prepare for this by listening to music to distract the ear). There can be changes to something called “proprioception” – a term used to describe how we feel our body in space. Legs and arms can feel stretched or very small. Some patients describe this feeling like looking into a funhouse mirror. These changes can create a sense of playfulness and curiosity. For those who suffer from chronic pain, there can be some marginal relief. Some people can begin to see patterns behind closed eyes or shimmering colors. Time can feel quite different, as well.
From there, changes to how a person thinks and experiences the world sets in. Patients describe feeling like observers to their own thoughts. These thoughts can feel linear (i.e., connected to each other) or disconnected from each other. For some, internal psychotherapeutic work can come in these moments as the nature of the way that thoughts associate with one another changes. Furthermore, people can be surprised at the sorts of feelings that come up while having these thoughts. In this different mental space, people can think and feel very differently about what had, up until that point, felt like stuck and immutable truths. Some people might find this sort of experience confusion. Others find it a creative space to wonder.
There are moments in the ketamine and esketamine experience that can “tight” or anxiety provoking. The medications can cause one’s heart rate and blood pressure to elevate a little, and some pick up on this and interpret as anxiety. For others, it is the “otherness” of the experiences themselves that can generate anxiety. If this happens, taking slow, deep breaths and practicing visualization exercises can help the mind and body calm.
Usually, after an hour (give or take), the medications begin their process of leaving the system. “Coming down” from the experience is usually fairly fast, although it can still take some time before a person feels back to themselves. It is normal for people to experience a sense of wonder or curiosity for some hours after the treatment is over. Tiredness, a little headache, and even some dizziness and nausea might also last for several hours after treatment.
Are ketamine and esketamine medications psychedelics?
Based on the above description, many people wonder if ketamine is a psychedelic medication. The term “psychedelic” was coined in 1956 by Dr. Henry Osmond and is a combination of two Ancient Greek root works meaning “mind/soul” (psyche-) and “to make visible, reveal” (-deloun). The term has typically been applied to medications and substances that directly impact a part of the brain called the “5HT2A receptor” (the target for LSD and psilocybin). Ketamine and esketamine do not directly impact the 5HT2A receptor but can certainly cause some of the same subjective changes as chemicals that do. For that reason, many us regard ketamine and esketamine as psychedelic substances, but because of small differences, I like to say that “ketamine and esketamine are different houses in the same neighborhood.”
- Benjamin Yudkoff, MD, MA
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