What They Didn’t Tell Me About Ketamine
Considering the limitations of ketamine for depression
Clearly, I’m not a medical professional. This isn’t medical advice. I am a writer and lab rat exploring alternative mental health therapies in self-interest and for survival.
If you’re like me (roughly 50% of the population who responds positively), you’ll find that ketamine truly is a miracle molecule for the treatment of chronic depression. Especially compared with things like SSRIs, benzos, and therapy alone, it’s remarkable how rapidly the stuff works. When I take it, I notice about a 90% total reduction of symptoms for my bipolar depression and roughly a 75% elimination of my anxiety, including the social variety.
However, like most approaches to better mental health, it’s an imperfect solution on its own. Ketamine gave me a major kickstart into the healing process, but it’s not quite the all-purpose salve I hoped it’d be.
After almost two years of experience and research on ketamine therapy, here are some notes I’d like to send to my younger, more depressed self. Seeing past the glossy social media ads and glowing media coverage, I take a sober look at some of the cold realities of using this very ancient drug in such a novel way.
It is wildly, inconceivably confusing.
Despite all the short and long-term benefits of therapeutic ketamine, the dissociative experience itself often leaves me deeply unsure and ungrounded. As human beings, we like to wrap things up in meaning, a tidy unit of knowledge to nibble and reflect on. And the ketamine trip unravels any concept of self, leaving an illusive, unsure concept of is–let alone you. The thirty thousand feet perspective shifts, the psychic breakthroughs alluded to by advertisers and hawkers, are often elusive.
Yet when I wake up the next morning, I’m unconcerned with making sense of the previous day’s effects. Everything doesn’t have to mean anything. I think this is a fundamental aspect of dissociative therapy: things aren’t always going to make symbolic sense, and that’s alright.
Moderate doses of traditional psychedelics like LSD and psilocybin, while sometimes unpredictable, usually leave me feeling grounded and fully in my body. And I’m able to apply concrete lessons from the experience to my life in a comparatively deliberate fashion. Ketamine isn’t so introspective.
While the intensity is mitigated by ensuring you have someone with you during the treatments (I suspect self-association is reinforced when socializing before and during the sessions, preventing full dissociation), I wish I had known just how confusing ketamine can be. The feeling usually wears off after a few hours, but the bafflement is profound. In the hours after I come down, sometimes I feel there’s something wrong with me.
I should be resting in peaceful contemplation! I think, reorienting myself to collective reality. Instead, I just see a familiar world in pure, cold neutrality. I recognize this feeling as progress, this newfound ability of my observing mind to notice and recognize patterns, sensations, and phenomena as a non-reactive observer. But it’s an oddly jarring sensation, so accustomed to my monkey mind sitting at the wheel, now an emotionless surveyor of the road ahead.
There’s an ongoing debate on the relationship between dissociation and its efficacy in treating chronic depression. Most research suggests dissociation is not integral for treatment success, often even labeling it a side effect to be avoided. Indeed, most of the scientific literature reveals little correlation between the dissociative experience and depressive remission. They see ketamine’s method of action as largely pharmacological.
On the other hand, most clinicians of ketamine therapy seem compelled to trip the patient, prescribing doses high enough to induce hallucinations. According to physicians I’ve spoken with, and some suggestive scientific literature, the dissociative experience of ketamine can have profound therapeutic benefits. Considering racemic ketamine hydrochloride is dirt-cheap and long-ago-made generic, the financial motives for pushing dissociation aren’t clear (though indeed worth noting this highly-cited study was partly funded by a medical company developing patentable protocols for ketamine therapy).
I’ve wrestled with this for some time now because I wanted to know if I could get the benefits of ketamine without the multiple-hour process of going through a K hole. (Because I’m poor, I take lozenges prescribed to me for at-home use, a longer, more digestive process than IV infusions.) But I’m fairly convinced the dissociative aspect of ketamine is integral to the rapid relief I found from my depression. Even if it isn’t always gentle, it jumpstarts a process resembling experiential psychotherapy. Again, clinicians seem to agree that dissociation is directly correlated to depressive remission.
It’s very important to note that while sometimes frightfully confusing, my ketamine sessions haven’t (re)traumatized me. That’s a genuine concern, and it’s probably something the psychedelic community (industry?) needs to be more honest about. Sure, the experience can be psychically challenging, but I’m of the school of thought that it’s part of the therapy. We’re working with deeply subconscious material here, and trauma manifests and dissipates in mysterious, often unknowable ways.
Progress isn’t always linear.
As depressed people, it’s easy to feel excited by the sense of relief any successful treatment provides, and hope is a finicky thing for the chronically ill. Hope gives us energy, clarity, and a willingness to say, “Maybe I’m wrong; maybe things can get better.”
Then, maybe days, weeks, or months later, the rumination starts seeping in through the vents, a vapor without odor, the sinking sense of regression. The spiraling act, in turn, reinforces the anxiety fortress; the vertigo hits, and I surrender to gravity, the essence of my illness. Familiar friend: tepid puddle of consciousness.
A depressive relapse is devastating after getting a taste of freedom (hands uncuffed, rubbing wrists in relief). In the hours and days following my first sessions, I would achieve what could be described as remission, but relief sometimes seemed to fade out just as quickly as the brightness came.
After completing my first six treatments, it took about three weeks to see sustained mood improvement. Indeed, sometimes with ketamine therapy, things get worse before they get better. But when I found sustained relief, some cool stuff happened, including an instinct to taper off my psych meds after roughly ten years of Wellbutrin, Prozac, and the perennial Klonopin prescription. I became more productive at work and took better care of my physical health and diet. I lost the taste for binge drinking and even revisited hobbies I’d all but written off years ago while exploring some new ones.
Energy, clarity, a willingness to accept that I was wrong, that things really could get better. But the fact remains: quotidian life still presents existential challenges for me daily.
It can be boring.
In some ways, this is my least favorite aspect of ketamine therapy. With all the psychophysical bafflement of the dissociative drug experience, at least it’s interesting. Yet after, when I reemerge from the dark center of the universe, reatomizing and reorienting to collective reality, it can feel a bit anticlimactic. Again, the mountaintop perspective changes, the rich symbolism and afterglow of the stereotypical psychedelic trip are elusive on the ketamine journey.
As someone who has tried many of them, I can’t overstate how unpredictable ketamine is as a drug. Because of the unique methods of action, the subjective effects of the exact same dose of ketamine can vary drastically, depending on factors ranging from mood to metabolic to environmental. I’d say roughly half the time I disassociate, the other half it feels like I’m in a hospital waiting to be discharged.
I’ll probably have to take it for the rest of my life.
You might’ve noticed in the intro I said ‘when I take ketamine” and not “when I took ketamine.” That’s because, after two years, I’ve yet to achieve full remission from depression. After my first six treatments in the summer of 2022, I noticed relief for a solid two or three months. But I relapsed in a bad way, spending almost a year swinging wildly between debilitating bouts of rumination and manic sprees of money, drugs, and sex.
My last swing back from mania into depression left me feeling especially dreadful, perhaps a new personal low. I realized I was putting so much energy into killing myself (the slow way) but that I actually didn’t want to die. In fact, I wanted to reconnect to the world I so stubbornly eschewed so entirely; I felt like I was disappearing, slipping away. In truth, I had swapped my schlubby frame for a malnourished husk of a human body, ribs plucking pale skin.
So I did what I should’ve and called my mom. And I went back on ketamine, something I knew worked for me, this time with a different protocol (300 mg oral every three days), and stuck with it for a month. I was unemployed and had the time. But such frequency wasn’t sustainable once my life got busier, with work, friends, new classes, and hobbies (!).
I decided to try once a week, which I didn’t stick to for long, as life became even more full of commitments and social engagements. Then, at about two weeks, I noticed some major malfunctions, the rumination seeping in once again. I’m sure the winter plunge of seasonal affective disorder didn’t help. Inexplicably, the Great Mystery of my life, that stubborn asshole, my depression, had hijacked the plane, broke into the embassy, whatever. Fuck.
My medicine was still sitting in the cupboard waiting for me, so I dragged myself to the task, and when I took it, I felt cleansed. Like pouring acid through gunky pipes, consciousness again streamed at full resolution. That’s when I realized that, yeah, ketamine is amazing, but it’s not permanent. At least not under my current material and social conditions. So I’m sticking to once a week, ten days max between sessions. That’s when I notice things start to spin out of control.
My hunch is that as I maintain stability, integrate more into the world, grow roots as they say, I should be able to stretch my treatments to every two, then three, to four weeks. That’s the good news. The bad news is, at least for my particularly stubborn form of depression, that might be the cut-off, meaning I’ll need a ketamine treatment every 28 days or so.
Truthfully, it is disappointing to think I may have to rely on a medication (indeed, on the challenging experiences that accompany it) in perpetuity. But when I look at where I was two years ago, I’m undeniably far better off overall. Like I said earlier, I lost my pudgy COVID-era physique, as well as my manic underfed one, and am currently at a happy weight. I never returned to Wellbutrin or Prozac, and I’m no longer dependent on benzos. No more panic attacks, either. I’ve cut my drinking and cannabis intake way back, and these days, I take a comparatively reasonable approach to controlled substances (especially in the Fentanyl Age).
I long ago made peace with the idea I may need medication for the rest of my life. I’ve been dealing with this mind plague for over twenty years now, and as I creep into my forties, I would be very okay with a once-a-month protocol to keep my dendritic soil fertile. There are likely many other benefits, neurologically speaking, and I think experiencing total ego death once in a while, an afternoon in eternity–monthly–probably keeps me humble, spiritually speaking.
