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INCREASING ACCESS to Psychedelic Ketamine Assisted Psychotherapy vs a narrative of the "proliferation of ketamine clinics"

Psychedelic and psychiatric medicines have been studied for over 100 years as adjuncts to psychotherapy, with over 60 years of ongoing research on the off-label use of racemic ketamine, a generic medicine in various routes of administration with varying levels of support care
INCREASING ACCESS to Psychedelic Ketamine Assisted Psychotherapy vs a narrative of the "proliferation of ketamine clinics"
Psychedelic Ketamine assisted psychotherapy

(ongoing edits...)

If you've ever been written a psychiatric medication prescription by your primary care provider, their NP, PA, or a psychiatric specialist, you’ll have noted the questions to assess for a mental health diagnosis like anxiety or depression take 5 minutes to fill out, at most. An ER visit for acute kidney stone pain where after a 9 hour wait, the attending physician prescribes an amount of opioid drugs for pain, after 37 seconds of seeing you takes 9 hours and 37 seconds. Regular primary care doctor appointments in the US are billed in 15 minute increments. If you tell your medical provider you're anxious or depressed, meet the diagnostic criteria, and have decided the risks outweigh the benefits, you may walk out of the appointment for a medication that for some, a side effect is literally not being able to stop taking the daily medicine or risk withdrawal symptoms,thoughts of suicide, and risks of all types of misuse leading to harm to your Self or others.

Antidepressant Withdrawal Syndrome - Therapeutics Letter - NCBI Bookshelf
Therapeutics Letter 112 examines antidepressant withdrawal syndrome. Conclusions: Antidepressants should be added to the list of drugs associated with tolerance, dependence and a withdrawal syndrome. Withdrawal symptoms occur in at least one-third of patients who stop. Before starting an antidepressant, patients must be informed of the possibility of withdrawal symptoms. The requirements for informed consent are analogous to recommendations before initiating long-term opioid therapy. Some symptoms may improve upon stopping but this is not captured in the studies of antidepressant withdrawal. Any decision to abruptly stop or taper an antidepressant must consider the potential that recurrent depressive symptoms or increased suicidality may represent withdrawal or re-emergence of the original condition.

Antidepressant Use by Country 2024

How many millions of people around the world are on some form of daily psychiatric medication as a treatment for their mental health? The clinicians who follow this approach see the issue as an individual's medical problem, with a daily treatment that may improve some symptoms based on how you answer the diagnostic criteria. Licensed medical clinicians practicing this way were trained this way and are practicing within their scope. It is not, however, within a physician's scope of competency (usually) to provide psychotherapy.

Prescribing Pharmacotherapy for Major Depressive Disorder: How Does a Clinician Decide?
Selection of treatment according to evidence-based medicine relies primarily on randomized controlled trials and meta-analyses. However, this evidence applies to the “average” patient and ignores the fact that customary clinical taxonomy does not include patterns of symptoms, severity of illness, effects of comorbid conditions, timing of phenomena, rate of progression of illness, responses to previous treatments, and other clinical distinctions that demarcate major prognostic and therapeutic differences among patients who otherwise seem to be deceptively similar since they share the same diagnosis [1].A rational use of drugs depends on the balance of potential benefits and adverse effects applied to the individual patient [1]. The clinician needs to have a clear account of the potential benefits of a specific treatment, as well as of the predictors of responsiveness and of the potential adverse events that may be triggered by the therapeutic act, which might include side effects and iatrogenic effects. These aspects can only be appraised by clinical judgment, which derives by a refined and comprehensive assessment [2], and not simply by comparing treatment options for the average patient in the treatment of the acute episode of depression and in prevention of relapse, as it occurs with clinical guidelines [1]. Further, many patients in clinical practice would not be eligible for trials, and this further limits the applicability of guidelines [1, 3].For the treatment of the acute episode of unipolar depression, pharmacotherapy appears to be the most viable strategy for most of the patients who present with a major depressive disorder [1]. Antidepressant drugs offer a number of advantages in specific clinical situations: they are readily available, they can be administered by nonpsychiatric physicians without specialized training, they act in a few weeks.Psychotherapy (i.e., cognitive behavioral therapy, interpersonal therapy, behavioral activation, problem solving) may yield comparable results [4]. However, compared to pharmacotherapy, it may present a few disadvantages (patients need motivation for psychotherapy; competent psychotherapists may not be available; remission from depression tends to be slower than with pharmacotherapy) [4, 5]. Combined treatment, in particular pharmacotherapy and psychotherapy, may offer slight advantages compared to each of the treatments alone in the average case of depression. The benefits are, however, clearcut in chronic forms of mood disorders and double depression [4].If a patient suffers from severe depression there is little doubt that pharmacotherapy may yield substantial benefits, even though, of course, response may vary from patient to patient, and meta-analyses have challenged the notion that the magnitude of benefit compared with placebo increases with severity of depression [6]. However, if symptoms of mild or moderate intensity are present, clinical trials indicate that benefits may be minimal or nonexistent [7].As important is assessing the stability of symptoms over time. One may postpone prescribing an antidepressant drug and see the patient again after a couple of weeks. If symptoms are mild or moderate and suicidal and/or psychotic ideations are absent or if symptoms have improved to a certain degree, the need of antidepressant drug treatment may be low. In case of persistence or worsening of symptoms, the use of antidepressant drugs appears to be more justified and worth pursuing.Time to recovery is very individualized, but at least 6 months of drug treatment appear to be necessary for most patients to reach a satisfactory level [8]. This time can be shortened if the sequential combination of pharmacotherapy and psychotherapy is employed [4].There is a tendency to extend drug treatment for long periods of time, with the assumption that it may be protective against relapse [9, 10]. The evidence supporting this strategy, however, is mainly based on clinical trials where remitted patients were randomized to drug continuation or placebo, without any differentiation between withdrawal and relapse. Withdrawal symptoms following discontinuation of antidepressant treatment are common with any type of antidepressant drugs (but particularly with SSRI and SNRI) [11] and are likely to be misunderstood as indicators of impending relapse [9]. We have no way to know how many of the relapses were actually withdrawal syndromes in the group that underwent drug tapering and discontinuation [10].Even when a certain degree of severity is established (a major depressive disorder), the clinical threshold provided by diagnostic criteria can be lowered by the presence of anxiety disturbances. Anxiety and depression coexist more commonly than thought [12], and this co-occurrence is less likely to respond to antidepressant drugs compared to nonanxious depression [1]. In the setting of comorbidity, that is in the majority of cases, a possibility is that of placing particular emphasis on specific symptoms, instead of simply counting them [1]. For instance, the characteristics that are most predictive of a positive response to antidepressants (e.g., anorexia, weight loss, middle and late insomnia, and psychomotor disturbance) can be given more emphasis than other symptoms. Another important issue is concerned with the primary/secondary distinction of depression that is based on chronology [1]. Secondary depressions which are superimposed on a pre-existing psychiatric disorder (e.g., agoraphobia) are unlikely to fully remit with the use of a single therapeutic agent. Anxiety disturbances may also characterize the residual phase of major depression, which favor residual disability and increase the risk of relapse [12]. Finally, when the severity of a major depressive episode is established, attention should be given to features that may be suggestive of a bipolar course or family history.An issue that is frequently neglected is the fact that often patients who present with a major depressive episode may have a long history of use of different antidepressant drugs, with frequent switches and augmentation strategies, that may predict reduced responsiveness and/or greater risk of relapse [13]. The term “iatrogenic comorbidity” refers to the lasting effects that previous treatments may entail, well beyond their time of administration [2, 14]. An alternative explanation is that current treatments of depression are simply inadequate in the majority of patients and thus entail a high degree of chronicity.Vulnerabilities related to antidepressant drugs are generally conceived as the serious and bothersome physical side effects that may ensue with long-term treatment, particularly with SSRI and SNRI, such as gastric toxicity, cardiac problems, bleeding, weight gain, risk of fracture and osteoporosis, and hyponatremia [15, 16]. There are, however, clinical manifestations that may be subsumed under the rubric of behavioral toxicity [2, 17]. In 1968, Di Mascio and Shader [18] specifically addressed the behavioral toxicity of psychotropic drugs. Such a concept referred to the pharmacological actions of a drug that, within the dose range in which it has been found to possess clinical utility, may produce alterations in mood, perceptual, cognitive, and psychomotor functions that limit the capacity of the individual or constitute a hazard to his/her well-being.Behavioral toxicity related to antidepressant drugs may be explained on the basis of the oppositional model of tolerance [19]: continued drug treatment may recruit processes that oppose the initial acute effects of a drug. This may explain loss of treatment efficacy and the fact that certain side effects (such as increased appetite and weight gain) tend to ensue only after a certain time. These processes may also propel the illness to a more malignant and treatment-unresponsive course [14], as with bipolar manifestations or paradoxical reactions. When drug treatment ends, oppositional processes may encounter no more resistance, resulting in the appearance of new withdrawal symptoms, rebound symptomatology, persistent postwithdrawal disorders [9, 11], hypomania, or resistance to treatment if it is reinstituted. In the long run, antidepressants may increase chronicity, vulnerability to depressive disorders, and comorbidity. The number of clinical studies supporting the oppositional model of tolerance [19] has progressively increased over the years [2].The sequential design is an intensive, two-stage approach, where one type of treatment (e.g., psychotherapy) is employed to improve symptoms which another type of treatment (e.g., pharmacotherapy) was unable to affect [4, 20]. One course of treatment is often insufficient for the complex comorbidities that are encountered in clinical practice and a two-step approach is therefore needed. The sequential design is different from maintenance strategies for prolonging clinical responses that therapies of the acute episodes have obtained, as well as from augmentation or switching strategies because of lack of response to the first line of treatment [4, 20]. The most commonly tested form of sequential design in depression involved use of pharmacotherapy followed by psychotherapy addressing residual symptomatology and/or increasing psychological well-being [4]. It was used in a number of randomized controlled trials and was found to entail significant benefits in terms of relapse rate [21]. Other forms of sequential model involve use of psychotherapy followed by pharmacotherapy, or sequential use of two different pharmacological or psychotherapeutic treatments [20]. The sequential use of psychotherapy and pharmacotherapy deserves more research attention, particularly in forms that are not likely to respond to drug treatment, such as anxious depression.Antidepressants are important and potentially life-saving drugs if the proper indications are endorsed. However, the prescribing physician is currently driven by an overestimated consideration of potential benefits, with little attention to the likelihood of responsiveness and neglect of potential vulnerability to the adverse effects, both side effects and iatrogenic effects, of treatment. Managed health care in underresourced systems may drive the use and overuse of medication and the neglect of psychotherapeutic alternatives.A rational use of antidepressants that incorporates all potential benefits and harms consists in targeting their application only to the most severe and persistent cases of depression, limiting their use to the shortest possible time. Since behavioral toxicity appears to be related to the dosages of antidepressant drugs, the lowest dose of these agents that seems to be both effective and well tolerated should be employed [2]. Augmenting strategies (i.e., adding new psychotropic drugs to the regimen) need to be carefully weighed, if not avoided, because of their strong link with behavioral toxicity [2].Antidepressant drugs were developed and found to be effective in the treatment of severe depression, but the better tolerability of newer antidepressant drugs has stretched their original indications. Their use has been prolonged to maintenance and prevention of relapse of depression, under the unfortunate assumption that what made the patient better could keep him/her well, without proper consideration of behavioral toxicity. The sequential use of two different pharmacological strategies (for treatment of the acute episode and for maintenance) has not attracted adequate attention.The authors have no conflicts of interest to declare.No funding sources are to declare.The authors equally contributed.
Psychotherapy (i.e., cognitive behavioral therapy, interpersonal therapy, behavioral activation, problem solving) may yield comparable results [4]. However, compared to pharmacotherapy, it may present a few disadvantages (patients need motivation for psychotherapy; competent psychotherapists may not be available; remission from depression tends to be slower than with pharmacotherapy) [4, 5]. Combined treatment, in particular pharmacotherapy and psychotherapy, may offer slight advantages compared to each of the treatments alone in the average case of depression. The benefits are, however, clearcut in chronic forms of mood disorders and double depression [4].

If a patient suffers from severe depression there is little doubt that pharmacotherapy may yield substantial benefits, even though, of course, response may vary from patient to patient, and meta-analyses have challenged the notion that the magnitude of benefit compared with placebo increases with severity of depression [6]. However, if symptoms of mild or moderate intensity are present, clinical trials indicate that benefits may be minimal or nonexistent [7].



Antidepressant drugs offer a number of advantages in specific clinical situations: they are readily available, they can be administered by nonpsychiatric physicians without specialized training, they act in a few weeks.

A chemical imbalance doesn’t explain depression. So what does?
The causes of depression are much more complex than the serotonin hypothesis suggests

Medicine-assisted psychotherapy is supported by more than 100 years of research. In this approach, a medicine intended to have a change in your mental health, regardless of what that medicine is, is not presumed to fix, cure, or give your life meaning just because you ingested it into your body. Working concurrently with a licensed mental health counselor or a licensed marriage and family therapist who is specially trained in medicine approaches, such as ketamine-assisted psychotherapy, supports what the drug is doing in your brain and body, and sets you up for transformation and lasting change, something experienced in your mind. While the time your therapists sit with you under the medicine may or may not be covered by insurance, the preparation before you do this medicine, and the integration of your experience afterwards, can absolutely be covered by insurance using a medical structure that exists more or less around the world without the need to invent new licenses. In the United States, that insurance will UNDERPAY your therapist, in most cases, so many psychotherapists prefer to charge a sliding scale, or offer a superbill to submit to the client's insurance plan to help with some sort of financial reimbursement to the client. Decriminalizing access to medicine so that trained clinicians can support the personal decision to access this approach is essential across the range of medicines that have such effects on the human experience.

Licensed psychotherapists are some of the many types of people and professions who may support you in your experience of being alive on the planet which include teachers, ministers, yogi, death doulas, elder care assistants, nurses, hospice care workers, tripsitters, life coaches, couples counselors, sex therapists, massage and physical therapists, ministers, physicians– to name but a few. Some of these specialists are licensed professionals, and others require no such license. Licensed certified professionals have a minimum standard of training and professional authority within their local communities (at the state level, for example). Any further invention of new licenses of "psychedelic facilitators" adds to the acceptance and recognition of a variety of people and pathways that may help support psychedelic practice.

Psychedelic-assisted psychotherapy is a specific modality of accessing a medicine, while working with a medical provider, a mental health clinician, and in some studies, a second trained psychedelic practitioner in the room, all of whom have to have been licensed as well as specially trained to do this work, in addition to a specially certified pharmacist. This may be in person, or at home, with individual clinicians offering the services they provide under their scopes of practice and competency.

The experience that may be elicited from medicines like MDMA or psilocybin can be 6-8 hours. These medicines are being tweaked, then patented and brought through an FDA approval process, requiring expensive, extensive quantitative research review by competing interests. Ketamine, on the other hand, elicits a predictable experience lasting from 1-3 hours, and has been prescribed in various forms in various out-of-clinic settings for decades. Racemic ketamine was FDA approved as an anesthetic, safe in high and low doses in humans and animals in 1970. Ongoing research on ketamine in humans and animals spans 60+ years. Recently...

It doesn't take long to get a prescription if you don't have the medical or psychiatric contraindications to be prescribed this medicine, and your medical provider is not attempting to see 20 patients per hour for 37 seconds at a time. Social media click-bait headlines warn of easy access to mental health care and medicine, as if this were a bad thing, and will, no doubt, move on to other hot takes on psychedelic practice about which to panic. It is important to consider medicine given with the right support can be prescribed just as quickly and easily as prescribing medicine without that support. Ketamine has been studied and prescribed off-label in conjunction with psychotherapy for treatment-resistant mood disorders ranging from anxiety to trauma. Proper screening and support requires prescribers to collaborate with certified psychedelic-assisted psychotherapy and/or psychedelic support specialists who have had documented experience with that particular medicine at the usual dosing range. "How long" it takes to get proper access to your medical provider and to some level of mental health support is a larger issue, and where the personal becomes "political", and requires advocacy from each of us to demand proper medical care and mental health care, which is accessible at home and in remote locations around the world. It's not about "easy access" to ketamine. It's about "proper access" to care, and the support needed to work towards healing.

While it may sound like media hype, when this approach is successful, clients do report profound changes that are sometimes described as mystical and lasting. Cultures around the world take various approaches to working with medicines and with the non-medicine approaches related to what has been coined "the psychedelic experience". The people within each culture, who work with these medicines and practices, are fulfilling the same aforementioned roles (medical, mental health, spiritual, or other type of care provider) generally recognized and accepted within the local community. Psychotherapists and medical providers are encouraged to have first-hand experience with the medicines they prescribe when not medically / psychiatrically contraindicated to truly begin to understand what a patient may experience in the process of psychedelic-assisted psychotherapy.


After psychedelic therapist training? Apprenticeship Model of Practicum & Clinical Supervision helps psychedelic therapists gain valuable experience
The Psychedelic Institute of Mental Health & Family Therapy offers Psychedelic Practicum, Supervision, Apprenticeship, Clinical Consultation in the Greater Palm Springs | Joshua Tree area and online in collaboration with an independent medical / psychiatric provider.

The Psychedelic Institute of Mental Health & Family Therapy offers an Introductory and Advanced Ketamine-Assisted Psychotherapy training and experiential and Psychedelic Practitioner Fellowship to accomplish this interdisciplinary collaboration. This program includes 12 ketamine experiences with the medicine, as well as the opportunity to sit 12 times with someone else who has taken the medicine. Integration and support is framed with a cognitive behavioral approach. Medical clearance is required in collaboration with a medical team, overseeing assessment and prescription. Upon completion, clinicians are offered further training, practice and clinical supervision opportunities as part of our Psychedelic Practitioner Fellowship. Clinical fellows are given the opportunities to work in psychedelic preparation, support and integration and receive ongoing supervision and support from the Institute and our affiliates.


On Advertising

Antidepressants and Advertising: Psychopharmaceuticals in Crisis
As the efficacy and science of psychopharmaceuticals has become increasingly uncertain, marketing of these drugs to both physicians and consumers continues to a central part of a multi-billion dollar per year industry in the United States. We explore…

Sample of Johnson & Johnson's advertising, top of search results. Only certified providers may prescribe this medicine, sold from certified clinics, which also exactly describes a pyramid scheme? Aren't the Spravato doctors who have a vested interest in prescribing one brand-name medicine over medicine they know exists at $12 a vial in its generic, racemic form? Isn't Johnson & Johnson hiring doctors to prescribe their drug which they sponsored the studies for? It's a problematic system that extends way beyond whether there is a new IV-ketamine clinician practicing or what new startup finds a tech-savvy way to provide accessible care. Neither Spravato clinics nor Mindbloom collaborate with mental health providers of cognitive behavioral therapy.

Direct to consumer advertising started with the Reagan administration in the 1980's.

Over 60 years of research has shown the predictable and replicable effects of ketamine in humans, and there are proven mental health benefits that are maximized by work with mental health specialists and support. With no contraindications, and meeting the criteria to work with this medicine, we can reframe the concern for how quickly someone can be prescribed ketamine to being concerned about making this lifesaving medicine more accessible, with proper support, to as many people as possible. The standards of practice are dictated by each provider's local license as a medical provider allowing the prescription of ketamine (or other medicines that may have effects on your thoughts/feelings/behaviors). Licensed psychotherapists specialize in medicines that assist psychotherapy, ensuring both a standard for practice (by being licensed mental health providers) and competency (by specialized training with each medicine approach). Important context for the next headline that includes something about the Wild West of ketamine. In working towards healing, any approach comes with risks that should be reasonably weighed, and not ignored, whether working with a synthetic medicine like Prozac or Zoloft... or ketamine, or a traditional plant medicine like ayahausca or psilocybin mushrooms. Now let's talk about the problems of quick access and impulsive/compulsive use of alcohol, nicotine, botox, testosterone, CBD, THC, Viagra, sugar...



See also: Psychedelic Cognitive Behavioral Therapy : On Ketamine, Context and Competencies in "Assisted-Psychotherapy” (DeMarco, 2024)



THE SEQUENTIAL INTEGRATION OF PHARMACOTHERAPY AND PSYCHOTHERAPY IN THE TREATMENT OF MAJOR DEPRESSIVE DISORDER: A META-ANALYSIS OF THE SEQUENTIAL MODEL AND A CRITICAL REVIEW OF THE LITERATURE (GUIDI, ET AL, 2015)

COGNITIVE BEHAVIORAL THERAPY TO SUSTAIN THE ANTIDEPRESSANT EFFECTS OF KETAMINE IN TREATMENT-RESISTANT DEPRESSION: A RANDOMIZED CLINICAL TRIAL (WILKONSON, ET AL, 2021)

EFFECTIVENESS OF COGNITIVE-BEHAVIOURAL THERAPY PLUS PHARMACOTHERAPY IN INPATIENT TREATMENT OF DEPRESSIVE DISORDERS (KÖHLER, ET AL, 2011)

 

NON-PARENTERAL KETAMINE FOR DEPRESSION: A PRACTICAL DISCUSSION ON ADDICTION POTENTIAL AND RECOMMENDATIONS FOR JUDICIOUS PRESCRIBING (2022)Feb 23, 2023ADVERSE EFFECTS OF KETAMINEFeb 23, 2023PSYCHEDELICS: ALTERNATIVE AND POTENTIAL THERAPEUTIC OPTIONS FOR TREATING MOOD AND ANXIETY DISORDERSFeb 23, 2023

Additional Harm Reduction Resources:

Fireside Project
Real-time support - for when time doesn’t seem real. The world’s first real-time psychedelic peer support line is here. Call or text 623-473-7433 for free and confidential emotional support during and after your psychedelic experiences. Open everyday 3:00pm-3:00am PT.

Ketamine Harm Reduction
Ketamine prescribed off label is a legal possibility for some use cases. Your medical provider and pharmacist will discuss the various indications and risks involved. Talk to your independent medical provider to see if you might be a candidate for medicine in conjunction with psychotherapy.


Ketamine Psychedelic Therapy Telehealth | CA, NY, UT, VT | Palm Springs | Joshua Tree

Ketamine psychedelic therapy via telehealth for residents of CA, NY, UT and VT. In person / on location / home visits available | Palm Springs psychotherapist collaboration with a medical provider of your choice or by referral.

Psychedelic medicines assist psychotherapy, especially evidence-based methods such as cognitive behavioral therapy in individuals, families or groups.

PlanetMedicines (@PsychedelicInstitute@toad.social)
2.22K Posts, 66 Following, 176 Followers · Psychedelic Institute of Mental Health & Family Therapy | Telehealth therapy | CA, NY, UT, VT | Palm Springs | Joshua Tree | By Referral | “#Psychedelic”: a made-up word from the mid-20th Century for states of consciousness arising from #ketamine #mdma #dmt #lsd #ibogaine #psilocybin, & non-medicine practices. #Psychedelicresearch spans 100+ years, suggests least harm, most good with #cognitivebehavioraltherapy #psychotherapy to prepare, support & integrate the #psychedelicexperience

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