Ketamine for Post-Traumatic Stress Disorder (PTSD)
Who does PTSD affect?
Post-traumatic stress disorder (PTSD) can affect anyone who has experienced trauma. It can occur when someone is exposed to a traumatic event such as a natural disaster, a serious accident, abuse, war, or being threatened with death, sexual violence, or serious injury. Certain risk factors like genetics, access to support, and previous exposure to trauma can increase the likelihood of experiencing symptoms.
Exposure does not have to be firsthand for trauma to manifest. For example, PTSD can occur from learning about the violent death of a close family or friend. It can also develop after repeated exposure to details of trauma, as in some police officers exposed to child abuse cases.
PTSD is currently diagnosed in 8.7% of the general U.S adult population (1 in 11 people) and does not happen to just combat veterans but can occur in all people at any age. Women are twice as likely as men to have PTSD. Rates of PTSD are also disproportionately high among Latinos, African Americans, and Native Americans. The highest rates are found among military veterans, firefighters, police officers, and emergency medical personnel.
Symptoms: What Does PTSD Look Like?
PTSD can occur months or even years after a traumatic event. When left untreated, it is unlikely to go away on its own.
PTSD creates recurrent, intense, and disturbing memories, nightmares, and flashbacks. These can be triggered by internal or external cues that somehow remind the person of the traumatic event. Individuals often attempt to avoid reminders of trauma by controlling their thoughts, memories, and emotions or by avoiding people, places, conversations, and situations. A person’s memory of events may change, and they may also develop symptoms of serious depression including negative beliefs and expectations, negative emotional states, anhedonia (inability to feel pleasure), and social withdrawal.Those suffering from PTSD often exhibit irritability, self-destructive behavior, hypervigilance, sleep disturbance, and lack of concentration.
PTSD is often disabling, making it difficult for an individual to maintain employment and social wellness. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 published by the American Psychiatric Association), in both community and veteran populations, PTSD is associated with poor social and family relationships, excessive absence from work, lower income, and lowered educational achievement. Individuals with PTSD are 80% more likely to have at least one other mental disorder. Conduct disorder, depression, anxiety, and substance use disorder are common.
Some studies have found a connection between those who have PTSD and their loved ones developing secondary symptoms of PTSD. The most common secondary symptoms were sleep disturbances, anxiety, and distress.
Treatment for PTSD
Antidepressants and cognitive-behavioral therapy are the most common treatments for PTSD but fail to work well for many patients.
The Veteran’s Administration/Department of Defense currently recommends treatment with the selective serotonin reuptake inhibitors (SSRIs) including Zoloft and Paxil. Other drugs may also be tried, for example, Effexor, tricyclic antidepressants, and monoamine oxidase inhibitors. These medications take weeks to work if at all and need to be used with caution as they carry their own risk for creating suicidal thoughts and violent behavior. One novel treatment not typically included in guidelines is ketamine.
Research suggests that PTSD damages how information moves through the brain (synaptic connectivity). The success seen from ketamine treatments comes from ketamine’s ability to repair and improve damaged connections at the same time as building new healthy connections (neuroplasticity). This repair and rebuild happens almost immediately reversing the effects of PTSD damage. However, if ketamine therapy is discontinued with no ongoing support strategies, PTSD damage may reappear over time.
Studies on Ketamine Therapy for PTSD
1. A double-blind, randomized, controlled trial studied the efficacy of ketamine for PTSD in 41 patients. Researchers found symptoms were significantly improved 24 hours post-infusion with multiple patients remaining significantly improved at 2 weeks. Additionally, ketamine was associated with a decrease in negative thinking and depression.
2. In one of several case reports a 26-year-old combat veteran with diagnoses of PTSD and major depressive disorder reported a complete reduction of anxiety and depression from day 1 to day 14 after a single ketamine infusion. At day 14 effects from the single infusion began to diminish.
3. A case report by D’Andrea and colleagues looked at a 23-year-old veteran who, following a 15-month deployment, experienced symptoms of PTSD for 6 months. He frequently sat ‘guarding’ his home and crashed his car twice in response to gunshots heard during hunting season. The patient had tried multiple antidepressants, hypnotics, and antipsychotics. He had been hospitalized three times, including at facilities with PTSD treatment programs. The patient achieved only partial short-term improvements. Following IV ketamine he showed an immediate, drastic decrease in PTSD symptoms which led to improved functioning, remission of anxiety and hyperarousal, improved mood, normalized sleep without the use of sedatives, and no nightmares. His improvement lessened 15 days after the treatment.
4. A case report followed a 7-year-old boy with a significant history of PTSD and frequent emotional and behavioral outbursts. He was treated with several medications with no significant improvement. After the patient received IV ketamine as anesthesia for a tonsillectomy, his caregivers noted a significant improvement in his symptoms, including decreased aggressive behaviors and improved ability to control his emotions and behavior. The child was also able to speak about his past trauma for the first time. After 13 days, his symptoms began to return. Following a second ketamine infusion, the patient again displayed improvements in behavior, which lessened after 8 days.
5. Another study aimed to examine the efficacy of oral ketamine therapy in an outpatient setting for PTSD and depression. It was found ketamine treatment reduced hospital admissions by approximately 70% per patient. There was a significant decrease in both the number of admissions and the length of stay in a psychiatric hospital for patients.
Existing data show little risk for routine significant side effects or drug-to-drug interactions related to the use of ketamine. It is recommended that patients be monitored closely during ketamine treatments. Side effects reported in the first 24 hours included blurred vision, dry mouth, restlessness, fatigue, nausea/vomiting, poor coordination, and headache. Ketamine can create a dose-dependent transient dissociative state (temporary disconnecting from one’s thoughts, feelings, memories, or sense of identity).
Overview: Ketamine for PTSD
PTSD is a problematic condition that can be difficult to treat. SSRIs are the standard first-line treatment but, oftentimes, PTSD can be found to be resistant to these treatments. Many patients who have participated in trials of SSRIs, as well as other psychoactive drugs, have not achieved remission. Atypical antipsychotics and benzodiazepines are sometimes used in an attempt to control symptoms but should be used with caution as individuals suffering from PTSD are at heightened risk for addiction. Supplementing these standard treatments with psychotherapy and hospitalization has not been demonstrated to significantly improve outcomes.
Based on randomized controlled trials, and case reports, ketamine has shown a near-complete resolution of PTSD symptoms over the short term. These clinical improvements are immediate and typically last a minimum of 1–2 weeks after a single treatment.