Ketamine-assisted psychotherapy (KAP) is an emerging treatment for mental health conditions like depression, anxiety, and PTSD. Currently the strongest evidence for this treatment option relates to treatment-resistant depression (TRD) and suicidality.

While KAP shows promise in the alleviation of certain mental health difficulties, ethical considerations are crucial to ensure patient safety, well-being, and maximise the potential benefits of this innovative therapy option. A multidisciplinary team, including psychiatrists, therapists, nurses, and anaesthetists, working within a robust ethical framework can deliver KAP in a manner that respects patient autonomy, minimises risks, and promotes long-term mental health outcomes. While not exhaustive of all ethical concerns in this sphere, this post highlights what we at SIPSA believe are some of the key points that healthcare practitioners in this field should not compromise.  

Importance of Collaboration in the Multidisciplinary Team

To deliver the most effective KAP treatment possible, close collaboration between all the healthcare professionals involved is essential. This teamwork ensures a comprehensive understanding of the patient’s individual needs and sets the stage for the best possible outcomes. For example, both a qualified medical professional, such as a psychiatrist or anaesthetist, and a mental health professional should screen the patient. Each professional brings their area of expertise (physical/medical health vs. mental health) to the table. This collaboration is vital for appropriate preparation, dosage, and aftercare planning. By working together, the team can tailor each patient’s treatment plan to their unique circumstances, rather than following a one-size-fits-all approach. The therapist can provide a psychological assessment and mental health history, while the medical professional can assess the patient’s physical health and any potential medication interactions. Throughout treatment, the team should continue to communicate and monitor the patient’s progress and potential side effects. This collaborative approach ensures the patient receives the most effective and comprehensive KAP treatment possible.

Informed Consent and Patient Selection

KAP’s dissociative effects necessitate thorough informed consent. Patients must understand potential risks like psychological distress, transient hallucinations, and bladder issues. The team should meticulously screen for contraindications, like psychosis or uncontrolled hypertension. It’s further of utmost importance to set appropriate expectations for treatment outcomes, ensuring patients view KAP as a catalyst for change when paired with behaviour change in line with their desired outcomes, and not a miracle cure.

Training and Competence

KAP is a specialised treatment requiring KAP’s multidisciplinary team members to be trained adequately in its specific protocols, limitations and potential risks; this is to avoid unethical practice and compromised patient outcomes. The team should further remain well-informed on new and available research in order to adapt their practices in light of new evidence, as needed. SIPSA currently offers a course on KAP to aid professionals in their work using this treatment option.

Ethical Sourcing and Cost Considerations

Ketamine is a medication with a history of misuse. The team should ensure ethical sourcing practices and prioritise patient well-being above financial gain. KAP can be expensive, and ethical considerations extend to ensuring equitable access to this potentially life-changing treatment.

Touch During Ketamine-Assisted Psychotherapy

Due to the dissociative state during KAP, touch can be misconstrued. Therapists should establish clear boundaries and obtain explicit consent regarding the patient’s comfort levels with certain types of physical contact (for example, a consoling hug, a comforting hand on the shoulder, the squeeze of a hand) before any touch takes place. Physical contact can be a powerful tool in therapeutic settings to console or demonstrate care when a patient is in distress or experiencing difficulties during their process, but it’s crucial to ensure that it is used appropriately during KAP sessions. Therapists should discuss their touch policy with patients beforehand and obtain verbal consent each time touch is deemed necessary and appropriate.

Aftercare Planning for Ketamine-Assisted Psychotherapy

Integration therapy after KAP sessions is vital to solidify therapeutic gains. The team should ensure a clear aftercare plan is in place. After the dissociative effects of ketamine wear off, patients begin the process of integrating their experiences into their ongoing therapy. This integration allows them to translate the insights gained during KAP into sustainable coping mechanisms and behavioural changes. The aftercare plan should outline the frequency of therapy sessions, potential challenges, and strategies for managing them.

Avoiding Misuse of Ketamine-Assisted Psychotherapy

The team should prioritise long-term psychological well-being over dependence on any medicine. Therapists must work collaboratively with patients to develop sustainable coping mechanisms to reduce the risk of future episodes. KAP should be viewed as a tool to empower patients, not a replacement for ongoing therapy and self-management skills. Healthcare professionals should avoid overusing KAP and focus on equipping patients with the tools they need to manage their mental health in the long term.

Potential for Misuse by Providers

Pressuring or coercing patients into KAP for financial gain or due to a lack of familiarity with alternative treatments can have serious consequences for both the patient and the practice of KAP.

• Patient Consequences: A pressuring or coercive environment can make it difficult for patients to provide genuine informed consent. This can lead to unrealistic expectations about the benefits of KAP and potentially worsen a patient’s mental health if the treatment is not effective for them. Additionally, financial pressure might lead some providers to overlook contraindications, putting patients at physical and psychological risk.
• Impact on the Practice of KAP: Unethical practices by some providers can erode public trust in KAP as a legitimate treatment option. This could discourage patients who might benefit from KAP from seeking treatment and hinder further research into the efficacy of KAP. Furthermore, if financial gain becomes the primary motivator for some providers, it could lead to a decline in the quality of care and potential exploitation of vulnerable patients.

Ketamine-assisted psychotherapy (KAP) holds significant promise for a wider range of mental health conditions. However, navigating the ethical considerations surrounding this innovative treatment is crucial. By prioritising patient safety, well-being, and informed consent, a multidisciplinary team can deliver KAP ethically and effectively. This collaborative approach ensures patients receive the comprehensive, tailored care they deserve while safeguarding the future of KAP as a legitimate treatment option.

References

[1] National Institute for Health and Care Excellence (NICE) (https://www.nice.org.uk/guidance/ta854/documents/129-2)

[2] World Health Organization (WHO) (https://www.who.int/) (2019). Guidelines for the pharmacological and non-pharmacological treatment of depression in adults.

[3] American Psychological Association (APA) (https://www.apa.org/) (2017). Ethical principles of psychologists and code of conduct.

[4] American Psychiatric Association (APA) (https://www.psychiatry.org/) (2013). Principles of medical ethics with annotations regarding psychiatry.

[5] International Narcotics Control Board (INCB) (https://www.incb.org/) (2020). Report of the International Narcotics Control Board for 2019.

[6] The British Psychological Society (BPS) (https://www.bps.org.uk/) (2018). Ethical guidelines for psychologists.

[7] The Royal College of Psychiatrists (RCPsych) (https://www.rcpsych.ac.uk/) (2019). National clinical guideline for the use of ketamine in depression.

[8] American Society of Addiction Medicine (ASAM) (https://www.asam.org/) (2020). Definitions related to addiction and clinical recommendations for terminology in the DSM-5.

[9] National Institute for Health and Care Excellence (NICE) (https://www.nice.org.uk/): Ketamine for depression in adults.

[10] World Health Organization (WHO) (https://www.who.int/): (2019). Guidelines for the pharmacological and non-pharmacological treatment of depression in adults.

[11] American Psychological Association (APA) (https://www.apa.org/): (2017). Ethical principles of psychologists and code of conduct.

[12] American Psychiatric Association (APA) (Read Here): (2013). Principles of medical ethics with annotations regarding psychiatry.

[13] International Narcotics Control Board (INCB) (https://www.incb.org/): (2020). Report of the International Narcotics Control Board for 2019.

[14] The British Psychological Society (BPS) (https://www.bps.org.uk/): (2018). Ethical guidelines for psychologists.

[15] The Royal College of Psychiatrists (RCPsych) (https://www.rcpsych.ac.uk/): (2019). National clinical guideline for the use of ketamine in depression.

[16] American Society of Addiction Medicine (ASAM) (https://www.asam.org/): (2020). Definitions related to addiction and clinical recommendations for terminology in the DSM-5.

[17] National Center for Complementary and Integrative Health (NCCIH) (https://www.nccih.nih.gov/): Considerations for Ketamine Use in Mental Health Care

[18] Nature Journal (https://www.nature.com/): (2023) Ethical considerations in rapid and novel treatments in psychiatry

[19] The Hastings Center Report (https://www.thehastingscenter.org/category/bioethics/): (2017) Ethical Issues in Ketamine Treatment for Depression