Now What?

Many patients who engage in ketamine or esketamine treatments who experience benefit ask the same question: now what?  When a person feels depressed or otherwise beleaguered by psychiatric symptoms he/she/they might develop ideas about themselves that overvalue a negative self-perception (i.e., “I’m a loser,” “I’m ineffective,” I’m an unworthy partner,” etc.).  Habits develop around the symptoms that reinforce the pain and affirm the negative self-perception (i.e., a person underperforms at work or school, refrains from engaging a spiritual practice, becomes more socially isolated, stops maintaining household chores, stops taking care of himself/herself/themselves).  

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Ketamine and esketamine can ameliorate (or sometimes resolve) symptoms, and in certain situations provide experiences which can inform self-perception, but, independent of other action, are insufficient to bring someone into a life worth living.  

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Question

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“Doc, I’m sleeping better, I have more energy, the suicidal thoughts are fading into the background.  Now what?”

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or

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“Doc, I just started treatment, I haven’t noticed benefit, yet.  What should I do?”

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Answer

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Ketamine and esketamine can catalyze a person’s transition into wellness, but, independently, may be insufficient to provide the sorts of transformational experiences that would indicate that you are living a full and satisfying life.  These treatments can lift psychiatric/psychological impediments that have prevented you from accessing those transformation experiences, but this takes work…. Here are some ideas that others have found helpful in their journey toward wellness:

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• Practice
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  • Identify three areas of your daily life that have been impacted by your symptoms and practice them as if you were well.  Let’s talk about them and your goal acquisition during your next session.  Don’t worry about not wanting to do complete them; don’t worry about completing them in their full measure.  The effort and your own capacity to compel yourself to activity is good enough.
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  • Let’s work on building out the outside of you to be reflective of the internal improvement you are experiencing in treatment.
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  • Let’s be aware that changes are difficult and force us to confront vulnerability and a myriad of potential complications.  These reasons, independently, are not sufficient to dissuade us from the endeavor.  Recovery frequently incorporates rebuilding - this can be hard, and that’s ok.
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  • Practice builds pathways: ketamine and esketamine can promote the development of new pathways in the brain that can be reinforced through behaviors - much in the same way that walking trails can be reinforced by people enjoying them.  This is called “neuroplasticity.”
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• Challenge negative thoughts
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  • In truth, and in certain domains, we all have the capacity to fail, to underperform and underachieve, to experience ourselves as insufficient.  This is not the whole story!  We also carry within us remarkable capacity to affirm strength and capacities, even when we feel like have none.
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  • Acknowledge moments when we have achieved, even when said achievement is toward no other goal than the pursuit of wellness, itself.
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  • Create an inventory of personal strengths.  This inventory can serve as a resource from which you can draw when facing a challenge and need to figure out how to resolve it.  Examples:
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    • I am tenacious
    • I am a hard worker
    • I am funny
    • I am strong
    • I am connected to friends and/or family
    • I am a survivor
    • Etc.
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  • Bring the habit of affirming positive attributes into a daily practice.  Depression and other psychiatric symptoms may mount a debate against the veracity of a positive self-affirmation: that’s ok.  This is the reality of dealing with depression, etc.  Rather than negate a positive self image, consider accepting the fullness of ourselves, vulnerabilities included, but these vulnerabilities can stand with, and not against, our positive attributes.
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• Embrace wellness
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  • Wellness does not reside in psychological wellbeing, alone.
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    • Physical Wellness
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      • Diet - consider the Mediterranean Diet - it is full of nutrients, it decreases reliance on simple carbohydrates (which can throw our blood sugars out of whack, thereby causing mood swings)
      • Exercise - 20 minutes of cardiovascular exercise per day (6 days per week) has unequivocally been shown to improve mood and has some of the same biological impacts as ketamine and esketamine.  Consider building informal exercise into a daily routine (i.e., taking the steps, parking far away from the office and walking briskly to work, take walking breaks, etc.).
      • Sleep - No secrets here: getting a good night’s rest is important to mental and physical wellbeing.  Sleep does not necessarily need to be 8 hours of uninterrupted slumber.  Get what you can.  Build good habits around sleep.  Here are some sleep hygiene tips:
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        • Be consistent. Go to bed at the same time each night and get up at the same time each morning, including on the weekends
        • Make sure your bedroom is quiet, dark, relaxing, and at a comfortable temperature
        • Remove electronic devices, such as TVs, computers, and smart phones, from the bedroom.  If you use a phone/computer/tablet before bed, put it on “nighttime mode.”  This reduces the amount of blue wavelength light emitted from the screen.  This particular wavelength promotes wakefulness.
        • Avoid large meals, caffeine, and alcohol before bedtime
        • Get some exercise. Being physically active during the day can help you fall asleep more easily at night.
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      • Light exposure - Try to get sometime outside or in front of a window each day.  If this is challenging, then consider employing light therapy - this involves the purchase of a 10,000 lux (a unit of light intensity), full spectrum light, 3 feet away from you, in the peripheral visual field, for 30-60 minutes each day (preferably in the morning).  A light therapy box can sit in your office and help you get adequate light as you work.
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    • Spiritual Wellness - Spiritual wellbeing is often overlooked.  At ties, spiritual wellbeing takes the form of practicing a dogmatic faith and joining a worship service.  If this is not your “cup of tea,” then consider engaging in any spiritual practice as defined as an experience that makes you feel small but not diminished, connected with others/the world around you, and put in a position of wonder.
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    • Community Wellness - Time and time again, scientific literature has confirmed that people who are socially connected experience a diminished burden of symptoms.  The realities may not change, but the extent to which a person feels overcome by them decreases.
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    • Behavioral Wellness - As above, maintain healthy daily habits.  Showering, doing the laundry, picking up after oneself: these are simple and sometimes pesky tasks in which to engage, but they provide an environment into which one can recover and should not be neglected.
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Why do all of this.  Firstly, it helps.  Secondly, it uses the biological and psychological benefits of ketamine and esketamine to their intended end.  Finally: It affirms agency.  You know yourself better than anyone else will.  While you may spend an hour - or even several hours -per week with providers, you are with yourself and in management of your self for the overwhelming majority of the week.  One of the surest messages that provides a countervailing weight against depression and toward of recovery is that you can.  Let’s affirm that you, indeed, can.  When you set goals and self-generated expectations, and when you accept that is not necessarily the attainment of these goals  but the process of engaging goal-oriented behavior that is critical to recovery, you initiate a process that, in and of itself, disproves the immutability of depression and offer a different narrative: I am effective, I am in charge, I am competent, and the source of true healing is within.

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