Treatment

Preparing for treatment

Psychological preparation

We recommend that you try to create a ‘peaceful mind’ before we start your infusion. But it is normal to feel a little anxious or unsure before your treatment. Using a breathing app on your phone or mindfulness techniques to focus on your breath and feeling calm can be helpful to do this (See Headphones and Music, below).

The effects of the infusion will feel strange. Staff will encourage you to ‘let go’. Allow yourself to feel strange. Be curious about it. Try not to ‘fight’ these effects. Turn towards any difficult experiences rather than trying to escape them. Focus on your inner experience rather than what’s going on in the clinic around you.  Do not look at electronic devices during the infusion.

Preparation groups

You may wish to take part in our optional, but recommended, Preparation groups.

Preparation Groups are designed for patients who are due to start ketamine treatment. Patients attend two sessions with up to three other people on two consecutive Tuesdays 2.30-4pm by Teams. The purpose is to come together and openly share information and expectations, and to consider:

• Information about ketamine and dosing
• Dissociation and psychedelic experiences
• The concept of “Set and Setting”
• Values and self-care
• Setting goals and intentions
• Cultivating curiosity and a capacity for change

Two staff from the clinic facilitate the groups, drawing on psychodynamic, attachment-based, cognitive-behavioural, and mindfulness-based psychotherapy.

Our clinic Preparation, Integration and Psychotherapy groups are described in detail here:

Headphones and music

We strongly suggest that you bring noise cancelling headphones to block out the inevitable noise in the clinic. There are three bays in the clinic, separated by curtains. We do not have any private rooms. Other people will be having their treatment at the same time as you. We aim to create a quiet clinical environment; however, you may hear noises around you, such as the phone ringing and conversations with other patients.

It is a good idea to practice listening to a ‘mindful’ track at home before you come, using the same smartphone and headphones that you will use later.

Avoid music which you know well, has words, or is likely to evoke any emotions. Unstructured music works best. The idea is that this should be a neutral background.  If you find it hard not to listen actively, then noises of nature (waves, wind, rain, woodland etc) may suit you better.

Here are some sources of tracks that others have found suitable:

• Wavepaths
• Kriya Institute on Spotify
• Sana Healing Collective on Spotify

Treatment

Before treatment

Look again at the section on Preparing for Treatment above.

Continue to complete True Colours mood monitoring daily throughout your treatment and follow up.

Preparation on the day of infusions

Treatment involves intravenous ketamine infusions and optional, but recommended, Integration groups.

Before every appointment, we will send you a link to a brief questionnaire. This asks for updates in your symptoms and medication and is also an opportunity for you to let us know about any changes in risk.

On the day of your treatment please keep your food intake within 4 hours of treatment to a minimum. Do not take benzodiazepines or alcohol the night before or on the day of your treatment as this may reduce the benefit.  If you are unable to do this, please let us know.

You should arrange for someone to escort you to your appointment and advise them that you will need to stay in the clinic with them for 1 hour after treatment.

Where this is not possible, and you attend treatment unescorted, you should stay in the clinic for a minimum of 2 hours after treatment before getting public transport home.

Under no circumstances are you permitted to drive away from the clinic after receiving ketamine treatment. After you have had any ketamine treatment, you should not drive until after a restful night’s sleep. We cannot continue to treat anyone who drives after a ketamine treatment.

What treatment involves

Ketamine infusion days

Ketamine infusions for the self-pay service happen on Mondays, Wednesdays, Thursdays. NHS ketamine (only for those from Oxon and Bucks) is on Tuesdays and Fridays.

You will arrive at the main reception of the Warneford Hospital.  The reception staff will point you to the Interventional Psychiatry Service at the end of the main corridor.

You will be greeted by a member of the treatment team and shown through to a treatment bay. We will normally show the person accompanying you to the recovery area where they can wait and have a drink. During covid-19 restrictions, the person accompanying you may not be allowed into the department but is welcome to make use of our cafe and hospital grounds.

Before your first treatment, we will

• take your blood pressure
• weigh you
• take a urine test
• take a blood test.  This is to establish whether any folate or B12 vitamin deficiencies may be contributing your depression, and to check your kidney, thyroid and liver function.  If you are able to provide us with this information separately, we do not need to do the test.

During the appointment we will put a needle into a vein on the back of your hand and then arrange a pump to gradually infuse a low dose of ketamine over 40 minutes.

During the infusion you will be lying on a bed. A nurse will be present in the clinic at all times. Before, during and after the infusion we will check how you are feeling and ask you to describe and record any symptoms or side effects which you may be experiencing.

You will remain on the bed until you are ready to get up.  Most people feel initially unsteady on their feet. We will show you to a recovery area where you will remain until the end of your recovery time.

In the recovery area there are facilities to make hot and cold drinks and biscuits. We recommend that you eat and drink something before leaving.

Filming, recording or photography of any kind is not permitted at any time.

Precautions after treatment

If you are going to be accompanied home by a responsible adult, you will stay on the unit for an hour after treatment.

If it is not possible for you to be accompanied, you will stay on the unit for at least two hours after the end of the infusion.

Between infusion days

Integration Groups

You may wish to take part in our optional, but recommended, Integration Groups.

Integration Groups are designed to help you maximise the benefit that you from your ketamine infusion by sharing their experiences with others.  Studies have shown that the best window for growth and change is between 1-7 days after an infusion. This might include

• Being more able to do things which help improve your mood
• Developing the capacity to think flexibly which can be difficult to do in depression
• Improving how you relate to yourself and others
• Reviewing unexpected or new ideas that come up during dissociation

Patients attend with up to seven other people on Fridays 2.30-4pm by Teams.  Two staff from the clinic facilitate the groups, drawing on psychodynamic, attachment-based, cognitive-behavioural, and mindfulness-based psychotherapy.

Details of the clinic Preparation, Integration and Psychotherapy groups are here:

Integration group details

F

What happens after the initial series of infusions?

There is usually a period of 3-4 weeks following the initial series of infusions when you will have no further treatment.

If you have responded to the ketamine, we expect you to relapse in this 3-4 week period because the average length of benefit of ketamine is 10 days.

The reasons we have this period are to help you and us work out:

• whether the ketamine is responsible for any benefit
• how big that benefit is
• how long the benefit lasts

If you have responded to the initial course of ketamine, you are very likely to respond when you are given it again after relapse.

Follow up

Initial follow up

After the initial series of treatments, a telephone or Teams follow-up appointment will be arranged to discuss your response and to discuss the options.  This appointment will be scheduled for about 4 weeks after your last infusion and will last up to 30 minutes.

Please continue to complete True Colours throughout this period.

The options at this point include:

• No further ketamine treatment for those who have not responded
• Further intermittent infusions every 4-8 weeks this is the most common initial pattern
• Further intermittent infusions every 4-8 weeks with oral ketamine taken once weekly in between infusions
• Further intermittent infusions as-and-when required

We do not offer treatment packages based only on oral ketamine.

The decision about these options will depend on a wide range of factors and will be discussed in the light of your response to ketamine.  We cannot discuss these ahead of an initial assessment.

We will then write to the doctor who referred you, copying in yourself and your GP unless you direct otherwise.  This will be a summary of your treatment and any suggestions for your ongoing care.

Further follow-up

All patients receiving ongoing ketamine treatment will be reviewed by a ketamine clinic psychiatrist at least annually.  Patients with an interval between infusions of less than monthly will be reviewed at least every 6 months.   This may be by phone, by Teams or, if you prefer, in person.

Follow-up appointments last 10-30 minutes.

Oral ketamine

The average duration of initial benefit of IV ketamine infusions is 10 days.

Attendance at the clinic for infusions every 10 days is not practical for most people or for the clinic.

Oral ketamine, taken at home, can help maintain the benefit of IV infusions

Therefore, if the benefit is short-lived, we may offer you our maintenance regime:

Intermittent (usually monthly) IV ketamine PLUS oral ketamine, taken at home, once a week on the weeks between each infusion.

If you are going to start this, you will come to the clinic for a single session during which you will take one or two test doses of oral ketamine.  This will help you to understand the very different experience with oral ketamine.  It also helps us to be confident that you are on the right dose.

Oral ketamine is supplied as a liquid so that the dose can be readily adjusted.

We do not supply this from the hospital. It is supplied through an external pharmacy (PCCA) who send it by courier to your home. You will need to sign to say you have received it.

You will need to pay PCCA directly for oral ketamine, not us.

We are not permitted to prescribe more than one month’s supply at a time.  This is typically 3 or 4 oral doses.

Each bottle can contain a maximum of 100ml of 10mg/ml oral ketamine.  However, you will be charged the same amount for each bottle irrespective of how much there is in it.  The cost of a bottle containing 20ml and one containing 100ml is the same.

By law, each new supply requires a fresh prescription.