Eye of the Beholder: Understanding The Subjective Experience of Acute Ketamine Treatment

Over the past 20 years, ketamine’s therapeutic potential for combating multiple psychiatric disorders has grown. In both the US and Europe, esketamine (Spravato; Johnson & Johnson) is approved by regulatory bodies to treat both resistant depression and acute suicidality depression.

Image credit: Darwin Brandis | stock.adobe.com

Research on ketamine primarily focuses on the clinical and physiological effects of the drug. However, researchers from the Medical University of Vienna recently attempted to shift the focus to the subjective experience of individuals who receive ketamine treatment. The research team conducted a systematic literature search and a thematic meta-synthesis to assess 24 qualitative studies on the first-person ketamine treatment experience and identified 3 main themes.

Firstly, the ketamine treatment experience can be understood as a 3-stage journey: the pre-treatment phase, acute treatment phase, and post-treatment phase. Patients often start the pre-treatment phase with feelings of frustration, hopefulness, and nervousness. Many paths lead to ketamine for the treatment of a mental disorder, most involving multiple previous ineffective interventions. Some individuals see this treatment as a last chance for clinical improvement.

Set (the patient’s personality and experiences) and setting (the session’s environment) dominate the acute treatment phase. A perceived safe, trustworthy, and pleasant environment can promote a positive experience. It is worth mentioning that simultaneous psychological therapy is extensively reported to act synergistically with ketamine.

The post-treatment phase spans from the ending of ketamine treatment onward. Positive reports highlight the speed and impact of experienced improvements, although these effects can vary from hours to months. Significant feelings of disappointment and despair arise with negative or short-lived positive experiences of ketamine.

Secondly, the researchers noted that the subjective experience of acute ketamine treatment is multifaceted and complex. Ketamine-induced mental phenomena exist on a spectrum of varying intensity. Study participants’ reports span from a vague sensation that something has changed to dream-like sequences with severe distortions of space and time. Changes in spatial awareness of one’s body is a common sensation, but it too differs dramatically.

Positive emotional effects reported in acute ketamine treatment are often described as the feeling of a weight being lifted. In some cases, individuals associate ego dissolution (complete loss of subjective self-identity) with feelings of spirituality or finality.

Negative emotional effects include feelings of extreme panic, anxiety, distress, and loss of control. The experience of ego dissolution is also described at times as frightening, and potentially traumatic. In some participants, negative experiences were still reported as a net positive clinical benefit.

Finally, the researchers acknowledged that ketamine can have positive outcomes, but questions what happens if it doesn’t work. Due to ketamine treatment's rapid impact, study participants often report an immediate improvement of depressive symptoms. Sustaining this uptick in mood, however, varies substantially among individuals. Participants in included studies reported the fast effect of ketamine as a reset or rewiring of their brain, hopefully as a spark to realize that their mental health problem is not terminal. However, some individuals reported no benefit from treatment or described the beneficial effects as fleeting. This can result in frustration and increased hopelessness from baseline having failed another interventional trial.

There is still limited research on the first-person experience of acute ketamine therapy in mental disorders. Studies thus far have demonstrated promise, but are not without some concerns. When considering the 3-stage framework, perhaps a greater emphasis on pre-treatment phase research could help identify some of the more individual traits used to better predict patient outcomes.

Reference

Trimmel M, Renner A, Kaltenboeck A. How do people who undergo ketamine treatment for a psychiatric problem subjectively experience this intervention? A meta-synthesis of qualitative studies. Int J Ment Health Nurs. 2024. doi:10.1111/inm.13425