When Ketamine is Working (and it is Not)

When Ketamine is Working

Ketamine has been used as a medication to treat several pain and mood disorders and has a 70% success rate. Patients considering ketamine for their conditions should remember that ketamine is a treatment and not a cure for pain and mood disorders. Patients will require ongoing treatment, and it can sometimes be difficult to see progress when a patient is in a lot of physical and emotional pain. It is always recommended that patients work with their medical team to discuss alternative treatments in the case that ketamine is not the best fit. This section aims to summarize what progress with ketamine treatment can look like and what to consider if ketamine is not working.

Measuring Success

Clinicians use various scales to understand the level of depression and pain for patients, including the PHQ9, GAD7, McGill and BPI questionnaires. These questionnaires ask patients a series of scaling questions by which the total value provides a sense of symptom severity. It is important that patients are honest and candid with their medical team about how they are feeling, including feelings of suicidality, so that treatment can be optimized. Pain and mood are subjective concepts, and patients should be careful to report an objective view of their symptoms, which sometimes can be difficult if patients are uncertain about how they feel. Outlining daily activities, selfcare routines, social life, stressors with work and family, etc. can hint to mood and pain severity.

Knowing When Ketamine Is Working

Ketamine is often touted in social media as a miracle drug transforming the lives of patients. While transformative experiences are possible, most patients have a range of responses to ketamine from excellent to mild and still require additional medications to support their pain and mood conditions. Ketamine maintenance is common, and most patients need ketamine “boosters” which can range from every two weeks to three months.

Mood and Pain improvement on ketamine is often incremental, meaning that small improvements happen over time to create a big cumulative effect. These changes can be small shifts in mood or activity (i.e. small wins) that might be hard to spot at first from the patient perspective, especially if they’re still sad or in pain. Sometimes these changes can be so small, the patient’s friends and family might notice before the patient. Knowing how to spot the signs of improvement is important to really consider ketamine successful.

Small (and big) wins might include:

Ability to rejoin the workforce
Changes in daily routines
Improved relationships with family and friends
Ability to start and/or rejoin physical and mood therapy
Medium to long term life planning
Joining a support group
Rebounding from disappointment more quickly
Improved sleep and/or appetite
More concentrations
Returning to old hobbies

When Ketamine Is Not Working

Roughly 30% of the time, ketamine is not effective at treating pain and mood disorders. Additionally, some patients who are seeing some benefits do not feel it is enough to effectively treat their symptoms.

There could be a number of reasons why ketamine might not be as effective as expected. There could be underlying undocumented conditions such as hypothyroidism and low testosterone that could be impacting ketamine efficacy and requires further investigation. There might also be medications interacting with ketamine, such as benzodiazepines that have been suggested to blunt the uptake of ketamine in the brain. The dose might be too low and/or the patient might not have given enough time for ketamine treatment to take effect. Life events might also be complicating a patient’s ability to objectively rate their own mood and or pain symptoms. Patients should work closely with their medical team to understand all the factors that could be contributing to a stalling in treatment before giving up.

Because improvement with ketamine is incremental, patients can also fall into a period of disequilibrium called the “therapeutic bends.” This period is associated with a difficulty in adjusting to the incremental changes associated with improvement, including over-reliance on old coping styles, distress from a loss of identity associated with their pain or mood disorder (e.g. what is life after depression?), or difficulty seeing small scale improvements over such a large feature in a patient’s life. Patients should continue to engage with their medical team to understand how to move forward with their pain and mood disorders as part of their broader treatment in conjunction with ketamine and other medications.

When a treatment does not appear to be working, patients might be tempted to just give up. However, it is important to remember that ketamine treatment includes at least a series of six to eight treatments up front to see the effects. If a patient is early in their treatment course, it is best to continue treatment and openly discuss with their medical team how they are feeling and any changes to other medical conditions and/or medications that could impact treatment.

Ketamine has been rapidly changing the landscape of psychiatry and pain management. If ketamine is ultimately not successful in treating a specific patient’s condition, there are new medications in development that will provide other options. Many ketamine patients move on to different psychotherapy types (DBT, EMDR) or interventions (TMS, ECT) if ketamine is not successful. Furthermore, there has been anecdotal clinical evidence to suggest that patients will respond to medications they previously had not responded to after a course of ketamine. Therefore, take hope that there is likely a treatment modality out there that will be effective.