Ketamine is a controlled substance and should only be used under medical supervision in a controlled environment. Unapproved or unmonitored recreational use can be lethal.
In 1970, ketamine was approved for human consumption by the US-FDA and administered as a battlefield anesthetic during the Vietnam War. In sub-anesthetic doses, ketamine can induce dissociative experiences similar to the psychedelic effects of ingesting psilocybin or LSD; however, unlike psilocybin or LSD, ketamine tends to be lighter on the visual hallucinations and heavier on the out-of-body experiences.
On ketamine, you may experience a sense of relief like a relaxing dream, you may experience that sense of oneness felt on psilocybin, and you may also – and perhaps most acutely – experience the 30,000 mile view, the chance to separate yourself from the rut you’re in and see a new path forward.
In 2019, the FDA approved a version of ketamine – esketamine – as an effective tool for treatment-resistant depression. Treatment-resistant depression requires having an inadequate response to two antidepressants. To learn more about ketamine and its evolution from battlefield anesthetic to antidepressant, I spoke with Renata Sasson, board-certified psychiatric mental health nurse practitioner, and owner and founder of PVD Ketamine & Wellness.
Meg Coss (Motif): Why has ketamine proven effective where other antidepressants failed?
Renata Sasson (RS): Ketamine works on a different neurotransmitter than SSRIs. It’s working on the glutamate system and targeting the NMDA receptor. By doing that, it causes an increase in BDNF – brain-derived neurotrophic factor. That is something that helps the brain create new neurons and create new connections between neurons; that’s called neuroplasticity. Literally, it’s helping to grow new brain cells.
[Ketamine] helps to break out of old patterns of thinking. Think of skiing in fresh snow: you get those lines, it’s easy to follow the lines, and hard to go in the deep snow. So you end up in these ruts with chronic symptoms. Ketamine and BDNF can be thought of as a fresh coat of snow – suddenly everything is a possibility, and you can blaze a new trail to break out of those patterns.
Motif: I’ve read ketamine can help with alcohol abuse, anorexia, PTSD, anxiety, and chronic pain. There seems to be consensus that it’s an effective tool for depression but not so much in other areas. Can you speak to that?
RS: The majority of the research has been with depression, so it’s well established that it’s a very effective treatment for depression. It has also been noted to be effective for a variety of other conditions, but the research isn’t as extensive. There’s just so much variation in how each research study is conducted that it’s hard to compare. But there is broad agreement it can be helpful for other conditions, specifically with PTSD. It can be helpful with anxiety, and I’ve seen a lot of people with alcohol use disorder find it helpful there as well, the research just isn’t as robust for non-depression conditions.
Motif: What should someone interested in ketamine look for in a provider?
RS: That they have training in ketamine therapy. It’s great if they participate in a ketamine-specific professional organization. Ask them how many years experience they have providing ketamine treatment. Ask how patients are observed during their session, what type of room are they going to be in – is it a private room? Is it a bunch of people in a room with curtains? Know the set and setting. Ask how patients are monitored between treatments. It’s also good to ask about their treatment philosophy.
A lot of IV clinics are medically focused. So you’ll go there and receive this medication through infusion and that’s kind of the end of it, not much importance is given to what happens during the session.
Providers with more of a psychedelic-informed approach can really hold space for the psychedelic effects and make that an important part of the treatment.
A big one to avoid are clinics that offer unrelated psychiatric services, like vitamin infusions or Botox. You want to be sure that it is a psychiatric-focused practice.
Last of all, check their website to see if they acknowledge ketamine isn’t a magical treatment – it’s a treatment and it can require maintenance. Check to see if they set realistic expectations rather than making wild claims of a miracle cure.
Motif: Can you discuss the efficacy and onset time?
RS: There’s a lot of hype about ketamine, that you feel better within two hours. Some people may feel that level of rapid relief, but certainly not the majority. A lot of people feel lighter with some symptom relief after one session. Usually, it’s within 24 hours after the session.
It’s more of a cumulative effect. It’s important to do an induction series, and that’s going to be six ketamine sessions close together within a period of 2 to 6 weeks, generally, that’ll allow for things to stick in a way they otherwise wouldn’t when doing one treatment here and there.
Once people have done the full six sessions, it looks different for everyone. The majority of people who’ve had chronic, lifelong symptoms, those people will generally need a regular maintenance protocol tailored to the individual. Sometimes we’ll increase to two weeks between treatments, then three weeks, just a gradual increase. Other times, people wait to see how long the results last and continue monitoring with mood scores and symptom questionnaires, and then come back for a booster.
There’s a subset of people who only need treatment every couple of months. There’s a small percentage of people who come to me for an acute event – like difficulty with grief and really getting stuck, and being unable to move past it like a divorce or an event that can be pinpointed. People that haven’t had decades of depression prior, with the combination of talk therapy, may not need ketamine again. They may do the six sessions, get the insights they need to participate in therapy in a different way, and see with a new perspective.
Improvement isn’t linear. Depending on what people are coming to heal, things can get worse before they get better. If someone really suppresses things, like a box of old traumas, those need to come to the surface, like lancing an infected wound – it needs to come to the surface to be healed. Things can get more difficult before they get better, and that’s why therapy is so important alongside this.
For somebody who has chronic depression who’s suddenly free from it there can be what are called the therapeutic bends. People who come up quickly out of their depression can be overwhelmed by looking around and grieving what they’ve lost from being depressed for so long. It can be a rapid change that can be disorienting. That’s something to look for in a ketamine provider, somebody who’s familiar with that and can support people through.
This interview has been edited for length and clarity. Read the full transcript below.
To learn more about PVD Ketamine & Wellness, visit pvdketamineandwellness.com.
Full Transcript
Meg Coss (Motif): Could you state your medical credentials and what makes you qualified to administer ketamine?
Renata Sasson: I’m a board certified psychiatric nurse practitioner and I’ve also had specialized training in ketamine therapy. There’s not a national certifying body for ketamine practitioners, so it’s really based on experience practicing within your scope of practice, whether medical or psychiatric, and doing one of the training programs out there.
Motif: What does training entail?
RS: There’s a number of different programs. The association of ketamine practitioners offers a program, as well as The Ketamine Training Center Fluence and Polaris Insight Center, those are some of the big ones. The kind of training center and what they entail includes a didactic portion and an experiential portion, that’s when the trainees experience the medicine. And basically do treatment on and with each other.
Motif: Would you mind talking about that? Your experiences trying ketamine as therapy?
RS: I started my own ketamine treatment about a year ago and it’s been extremely impactful for depression in a way I’ve never experienced before with a medication for my symptoms. I’ve tried so many different medications. But what ketamine has given me that nothing else has, has been rapid relief. Now I know I have something that I can rely on if I do end up sliding into a depression and I know I can get back on my feet within a couple of days. It’s giving me a lot of insights and has helped me to move through my depression by being able to stick with healthy routines and healthy habits. It’s made it much easier to prevent a depressive episode from happening in the first place, by having all these systems in place, that before ketamine, I was never able to be consistent with.
Motif: Can you talk about the onset time and explain how that works?
RS: There’s a lot of hype about ketamine, that you feel better within two hours. Some people may feel that level of rapid release, Certainly not the majority of people. A lot of people feel a little bit lighter, with some symptom relief after one session. Usually, it’s within 24 hours after the session is my experience. After a single infusion or oral treatment or injection or what have you, after just one treatment, assuming the person has never had ketamine before, it’s not going to last for very long. It’s more of a cumulative effect. So it’s important to do an induction series, and that’s going to be six ketamine sessions close together within a period of 2 to 6 weeks, generally, that’s going to allow things to really stick in a way that they won’t by just doing one treatment here and there. Once people have done the full six sessions, then it looks different for everyone, as far as maintenance treatment. The majority of people that have had chronic symptoms, lifelong symptoms, those people will generally need some sort of regular maintenance protocol, and that’s tailored to the individual. Sometimes we’ll increase to two weeks between treatments. Three weeks, four weeks, just a gradual increase. Other times, people want to wait, see how long the results last and just continue monitoring with mood scores and symptom periodic questionnaires, and then come back for a booster. There’s a subset of people that will only need a treatment every couple of months. There’s a small percentage of people who are coming to me for an acute event – difficulty with grief, unable to move past that extreme difficulty with a divorce or other major life stressors that can be pinpointed. People that haven’t had decades of depression prior, those people, with the combination of talk therapy, may not need ketamine again. They may do the six sessions, get what they need, get the insights they need to be able to participate in therapy in a different way, see with a new perspective, and that’s what they need to move on from that single event.
Motif: What defines treatment-resistant depression?
RS: The definition of treatment-resistant depression is kind of funny to me. It’s technically trying two different antidepressants of different classes for an adequate amount of dose and time. What that looks like is maxing out the dose of the antidepressant and taking it for 6 to 8 weeks at minimum. Many people who end up in my office have tried 10 or more medications. So I personally wouldn’t consider two medications failing as treatment resistant, but the technical research definition is that.
Motif: What about the conditions and disorders ketamine treats? I’ve read everything from anorexia to alcoholism, PTSD to chronic pain? There seems to be some agreement that it’s effective for depression but not so much in other areas. Can you speak to that?
RS: The majority of the research has been with depression, so it’s pretty well established that it’s a very effective treatment for depression. It has also been noted to be effective for a variety of other conditions, but the research is not as extensive. There’s just so much variation in how each research study is conducted that it’s really hard to compare. But there is broad agreement that it can be helpful for those other conditions. Specifically, with PTSD, it can be really, really helpful. It can be helpful with anxiety, and I’ve seen a lot of people with alcohol use disorder find that it can be helpful there as well. It’s helpful for all these things, but the research really isn’t as robust for the non-depression conditions.
Motif: Why is ketamine effective where other medications are not? What is it doing scientifically that SSRIS aren’t?
RS: Ketamine works on a different neurotransmitter than the SSRIs and other common antidepressant medications. It’s working on the glutamate system and targeting the NMDA receptor. By doing that, it causes an increase in what’s called BDNF – brain derived neurotrophic factor. That is something that helps the brain create new neurons and create new connections between neurons; that’s called neuroplasticity. So literally it’s helping to grow new brain cells. It’s been pretty well established that people, for instance, with chronic depression have a decrease in their brain volume, in their neurons, they’re not producing new neurons and connections. They’re kind of like, I want to say shriveling, shrinking back, kind of pruning down. [Ketamine] helps to literally break out of old patterns of thinking. Basically, if you think like you’re going in the snow and you ski in fresh snow, you got those those lines. It’s really easy to follow those lines, and it’s hard to go in the deep snow. So you end up in these ruts with chronic symptoms. Ketamine and BDNF can be thought of as a fresh coat of snow – suddenly everything is a possibility, and you can blaze a new trail to break out of those patterns.
Motif: What about the different methods of administration – nasal spray, sublingual, IV – can you speak to the efficacy of each one? Is one better than the other? Are there dangers or specific benefits of each?
RS: They have pretty nuanced differences. One big difference is the nasal spray that’s approved by the FDA, Spravato, that’s the only on-label use for ketamine. The ketamine that’s used in that is actually a bit different than the ketamine that’s used for all the other treatments like IV intramuscular, and oral/sublingual. All those are made with what’s called racemic ketamine, that’s made of two molecules called R-ketamine and S-ketamine. What Janssen Pharmaceuticals did was they isolated one of those molecules ketamine and rebranded it and patented it as Spravato. Recent studies coming out seem to suggest that Spravato may not actually be as effective as the racemic ketamine. The jury is still a little bit out on that one. As far as IV, one drawback would be the side effects and complications related to having the IV put in – such as infection or infiltration into the tissue rather than just going into the vein. You’re also going to be attached to a piece of tubing, so if you have a more active session that can be a problem. IM is the intramuscular injection. You have the benefit of not being attached to something, so you can do it in a therapy office like ketamine assisted psychotherapy. The one thing about that one that’s more unique is the way that it’s administered. You get an entire dose at once, and so you do get somewhat of a sharp spike in the effects in the beginning, and then it tapers down. It can be a little intense in the beginning for people, as compared to IV, which is basically keeping it at a constant drip rate that’s evenly distributed through the infusion over time. Sublingual is smoother, almost like a bell curve. The onset is a little more gentle because it’s slowly absorbing into the bloodstream through the oral tissues. It’s a gentler onset, which tends to be a little more comfortable for people, and then the come back down is also pretty gentle. The efficacy of all those different types, aside from what I mentioned about Spravato, is pretty comparable between all of them. Most of the studies have been done with IV. What we can run into specifically with sublingual is some people don’t absorb very readily through their oral tissues, so that is the one stumbling block with oral ketamine. So those people would be better served with IM or IV Ketamine.
Motif: Why were the molecules separated for Spravato?
RS: That’s a strategy pharmaceutical companies use to keep their patents going. When you have a medication, that’s brand name only, it’s very expensive. So the one that developed it gets all the money from that patent for 20 years. Generally, when it runs out, that’s when all the generics pop on the market and are much cheaper, which really cuts into the business of the initial company that made it. A common example is Celexa and Lexapro. Celexa is two molecules and the patent ran out, so they separated those out and made Lexapro, which is just one of the molecules.
Motif: Last October, the FDA issued a warning about the use of compound versions of ketamine. Is Spravato a compound? What’s meant by compound versions?
RS: Compounded means it’s made by a specialty pharmacy. Generally in small batches versus being mass produced like Spravato is through the pharmaceutical company. Spravato is not compounded, every other type of oral and nasal ketamine is compounded, and ketamine for injection or IV can be compounded but is also available as a non-compounded generic mass produced product. The important thing about compounding pharmacies is it’s important to vet them. Some compounding pharmacies are just tacking on compounded ketamine as a little side money maker, so it’s important to know and trust the pharmacist, make sure that they have experience and state of the art equipment, and that they’re testing their batches. For instance, it’s important to know that the dose that is in the tablets is going to be consistent from tablet to tablet. The specific warning that the FDA put out was actually related to compounded nasal spray, and later expanded to include other forms. Specifically, it was a case in Oregon where somebody was prescribed nasal spray and the dose was inconsistent between refills, and they ended up having a serious adverse reaction. That was one warning, but there’s also this inconsistency that can happen with some pharmacies.
Motif: What should someone interested in trying ketamine look for in a provider? What sort of questions should they ask?
RS: They should have training in ketamine therapy. It’s great if they are a member a ketamine-specific professional organization with a code of ethics. Ask them how many years of experience they have providing ketamine treatment. Ask how patients are observed during their session, what type of room are they going to be in – is it a private room? Is it several people in a room with curtains? Know the set and setting. Is the room comfortable? Is it cozy? All of these things that support the session. Ask how are patients monitored between treatments. It’s also good to ask about their treatment philosophy. There are different treatment philosophies, one is strictly the medical perspective. A lot of IV clinics are much more medically focused, that would be more similar to taking antidepressants. You’re going there and you’re receiving this medication through the infusion and that’s kind of the end of it, not much attention is given to what happens during the session. The psychedelic effect and all of that, that’s kind of seen as more of a side effect. On the flip side, providers that have more of a psychedelic-informed approach can really hold space for that and make the experience a really important part of the treatment. Setting an intention before the session and supporting the client during the session, whether that’s verbally or sitting and holding space, and then after the session, providing integration support to help make sense of what happened during the session and helping the person integrate that into their lives in a meaningful way, helping them change the way they’re interacting with the world, developing healthy habits, all of that. That’s something that strictly medical approaches don’t really see as part of the treatment, but this can be a good approach for some people nevertheless. So that’s an important thing to ask about, to make sure it’s a good match. Some people really resonate with the medical model and don’t want the other stuff and vice versa. Then also a big one is avoiding clinics that offer unrelated psychiatric services, like vitamin infusions or Botox. You want to be sure that it is a psychiatric-focused practice and last of all checking the website to see if it acknowledges that ketamine isn’t a magical treatment, it’s not a magical cure – it’s a treatment and it can require maintenance. Check to see if they set realistic expectations rather than making wild claims of a miracle cure.
Motif: Are the psychedelic effects what people refer to as dissociative effects?
RS: With the Spravato trials the dissociative effects were seen as side effects, which is pretty wild. In my personal opinion, I think that probably contributes to why Spravato may not be as effective as racemic ketamine. The jury is still out whether the dissociation correlates positively with therapeutic improvement or not, the research is still in its infancy, but reasoning tells me that putting therapy on top of a medical treatment is beneficial.
Dissociative effects can be experienced during the ketamine session as more emotional distance from thoughts, as well as physically feeling less connected to or even completely outside of one’s body. The emotional distance can be particularly helpful for people to gain a new perspective about old problems or traumas in the session without feeling as triggered by thinking about them
Motif: You also incorporate yoga and meditation and breathwork. Could you expand on what you do in your practice, like using ketamine not as a cure-all, but as part of a path toward wellness, and incorporating ketamine as a treatment strategy?
RS: Ketamine is a tool. It’s one tool and it should be part of a comprehensive treatment plan. Using ketamine as the one and only mental health treatment someone is receiving is really not that helpful. Ketamine is going to help everything else work better. It’s almost like a fertilizer because of that neuroplasticity, it’s going to help the other interventions stick more and help people be more open to other interventions. The embodiment of practices like yoga and breathwork can be really helpful in helping people to connect and be present in their lives. And, that’s a great pairing with ketamine. With ketamine, it’s kind of doing the opposite of that during the session. It can really separate people from their bodies so they get that 30,000 mile view. Then it’s important to really get into the body, which can help people foster healthy habits. Breathwork specifically can be really helpful to prepare for a session or to integrate into a session. I offer breath techniques, and conscious connected breathwork, which is its own medicine in a way that can also have psychedelic effects. It can be helpful for somebody to prepare and experience that non-ordinary state of consciousness before taking any medicine, it gives people control. They can stop with the breathing pattern at any time and come back to themselves. It can also be really helpful for integration of ketamine experiences because it puts people in that non-ordinary state again in a different way, and that can help them connect with things that came up in their ketamine journey and help them digest other insights about it. There’s a study that shows that really experienced meditators, who are deep in their meditation, where their brain is in an MRI it looks very similar to somebody receiving a psychedelic treatment, which is fascinating. Meditation can help people be more present, be more grounded, and increase gratitude. All of which can help support healing. Last of all, there is still a place for psych meds, as part of treatment. I want to make sure to touch upon that as well. A lot of people think that they can come and do ketamine treatment and stop taking all their psych meds. But there is a place for regular psych meds as well. Some people can come off of some of them, maybe lower their doses, things like that. A small percentage of people are able to get off of them entirely and do well. But, you know, that’s another tool that is important to acknowledge.
Motif: I’ve never taken ketamine, but I’ve taken other psychedelics. When you were talking about that wider view, that’s kind of how I feel on mushrooms or acid, there’s a certain clarity – I see more, I feel more connected, like I can see the spirit of everything. Then when it’s over, I’m left with the imprint of it, which I can never unsee. Is it a similar sort of experience?
RS: That experience of oneness, that experience of connection can certainly happen in ketamine sessions. Once you see it, you can’t unsee it. That’s definitely the case with ketamine as well. But it is in many ways quite different than classic psychedelics, like mushrooms or LSD. For a lot of people, it’s less heavy on the visuals and it’s less of an embodied experience. Mushrooms tend to be a very embodied experience. Whereas on ketamine people can feel like they’re floating above their body and traveling through another world, that’s one side of the spectrum. On the other side, it can just be a really relaxing dream, like a trance-like state where their thoughts might be more interesting, insights might percolate through. It can be quite different. I always tell people who are coming from experience with classical psychedelics to really approach it with an open mind because it is a different kind of medicine. Each session is very different and it can give different things at different times.
Motif: When people say it has the ability to rewire the brain, is that the neuroplasticity you’re talking about?
RS: Yes, exactly.
Motif: People say it’s non-addictive, but it just made me think of what would happen if treatment stopped. Would you crave something?
RS: The non-addictive piece, that’s a bit more nuanced. Definitely there is ketamine use disorder, so people can have a problem with ketamine when they’re using it recreationally and they can develop a psychological dependence on it and use it as a way to escape their reality and dissociate in that way. So people can develop an addiction to ketamine, but as far as people developing an addiction to ketamine during medically-supervised ketamine treatment, that is exceedingly rare. We’re always monitoring that as people go through their treatment. So asking about cravings for ketamine, asking about wanting to do a session in order to escape from their lives, rather than to get to the root of things and heal. Monitoring for any issues is important as far as if treatment stops, but this is because of risk recurrence of symptoms rather than any concern for withdrawal. It’s given so infrequently, not more than twice a week, and even that’s just in the beginning, after that it’s less frequent. The frequency isn’t what you would see in somebody who’s abusing ketamine potentially multiple times a day. Also the setting is really important. You’re associating this medicine with healing with being a therapy, and that context is really important. It can even be possible to treat people that have had ketamine addiction in the distant past in very specific cases, but that speaks to the importance of the set and setting – the intention setting, the space where it’s being held – it’s just a completely different experience than taking it recreationally at a party or by yourself.
Motif: If someone has a history of recreational use, are they less likely to benefit from using ketamine as treatment? Or is that too nuanced to comment on?
RS: It’s a little bit nuanced, because I think the main concern would be to re-trigger the addictive behavior, so most clinics will screen out for that. If it’s a remote history, if they’ve been sober for a long time that’s a different story. But that would be the danger – re-triggering.
Motif: Can you explain the difference between ketamine clinics and teletherapy?
RS: In a clinic, you’re receiving ketamine under the supervision of a therapist with medical screening by a medical or psychiatric provider. That piece is really important. A professional has eyes on the patient for the duration of the session. With telehealth ketamine, there is a very wide range of how providers operate with varying levels of engaging patients and providing that integration and preparation support. Some clinics will have a 30-minute appointment and give people a month’s supply of ketamine, and say, “See you in a month.” I do not recommend that. Other companies have a more structured approach. They may assign patients a designated psychedelic guide or life coach that specializes in psychedelics to help with integration and preparation. There might be supporting materials to guide them through each session. To my knowledge, there isn’t a telehealth company that offers eyes on the patient during ketamine sessions. There’s a requirement to have a safety sitter present – a responsible, sober adult who’s there and checking in periodically every 10 – 15 minutes. But there’s no oversight of whether that’s happening, so it can be a little dicey. It can be helpful, but it can also be really dicey.
Motif: When did you open PVD Ketamine and Wellness and what led you to make that decision?
RS: It opened almost a year ago, in January of 2023. What led me to open it was a couple of things. First my personal experience of ketamine and the fact that I had to leave Rhode Island in order to access it because nobody was doing it here at that time. I definitely saw a need for that, and I wanted to be part of enabling my community to access that in a more meaningful way. I actually started working at a telehealth company, but I wanted to be part of the whole treatment journey and support people in their sessions, and be able to tailor the treatment to each person, which I was not able to do within their treatment model. I love the part of holding space for people and helping support them in a more hands on way, which I was already doing as a breathworker. I wanted to tailor it to people, to be there and support them from start to finish with their whole treatment.
Motif: Are there programs or services for folks who might not have the finances to afford the therapy?
RS: I’ve actually partnered very recently with an organization called Thank You Life, and they are a psychedelic nonprofit that gives scholarships for people to access ketamine therapy who ordinarily wouldn’t have been able to because of the cost. I’m hoping to be able to start offering that next year, because it is an expensive type of therapy and it’s important to have ways to help people access it. Sliding scale is another way but those scholarships from Thank You Life are really an impactful way to help people. Tangentially to that, group ketamine therapy can also be another way to reduce the cost. The group energy can be really, really therapeutic, it can actually be an enhanced therapeutic experience while also being less expensive.
Motif: Do you offer sliding scale and group therapy?
RS: I offer sliding scale and I’m working on obtaining a space to do group ketamine therapy, hopefully that will be coming in 2024.
Motif: Thank you, Renata. This has been really enlightening. Is there anything you’d like to mention or expand upon?
RS: Earlier you had asked the question about k-holes. Did you want me to address that?
Motif: Sure.
RS: There are a lot of fears that come up, so to kind of define what a k-hole is: a k-hole would be a high dose of ketamine where somebody becomes severely impaired – unable to walk, talk, move – someone who really, entirely, loses touch with reality. Internally they’re having visions, hallucinations, out-of-body or near death experiences. This most commonly happens in a recreational setting and can come on unexpectedly. As far as set and setting it’s a recipe for a really challenging experience and can be very frightening. This is something that really does not happen at all in a therapeutic setting. People can certainly have very intense experiences with ketamine and experience things like out-of-body experiences and even near death experiences. But it makes all the difference with the space that’s being held, knowing that they’re in a safe place, and having that preparation and support after. We don’t refer to it as a k-hole in the therapeutic world, but a lot of people come in with fears they’re going to fall into a k-hole, and it’s gonna be horrible. With sublingual specifically, it’s hard to achieve that. Set and setting is everything, and knowing the dose you’re taking, and having that medical supervision.
Motif: Thank you. Anything else?
RS: One thing I forgot to mention when we were talking about how quickly relief happens. I wanted to mention improvement isn’t linear. Depending on what people are coming to heal, things can actually get a little bit worse before they get better. If they really suppress things, really push things down, like a box full of old traumas, those need to come to the surface. It’s like lancing an infected wound – it needs to come to the surface and be healed. Things can get more difficult before they get better, and that’s why therapy is so important alongside this. Even when it’s consistent improvement with somebody who has chronic depression who’s suddenly free from depression there can be what are called the therapeutic bends. If you’re familiar with the bends from scuba diving, if you come up too quickly from the depth you have this horrible medical condition called the bends. So people who come up quickly out of their depression can be overwhelmed by looking around and grieving what they’ve lost from being depressed for so long. It can also affect their relationships and everything, because it can be a rapid change that can be disorienting to people. That’s something to look for in a ketamine provider, somebody who’s familiar with that and can support people through, because that can get people stuck and get people to leave ketamine treatment. Sort of like “I was getting better for my depression and then I got depressed all over again.” Without knowing that’s actually what’s at play, and once once that’s brought to light for people that’s a game changer and they’re back on track.