While researchers continue to study ketamine, practitioners such as Lapidus have already begun to provide it to patients. The Ketamine Advocacy Network lists 17 providers and clinics around the country. Anesthesiologist Enrique Abreu, DO, runs the Portland Ketamine Clinic in Portland, OR. He works with a mental health specialist — Marilyn Sears, LCSW and clinic co-founder — and gives IV ketamine infusions. Most of his patients are self-referrals. “These people are suffering, and they find us online,” says Abreu, who estimates that he has treated 30 people since he opened his clinic 15 months ago. He says he has no mental health background, but he’s got 15 years’ experience using ketamine as an anesthetic. In fact, many clinic operators are anesthesiologists rather than mental health specialists. “It’s a weird gray area,” Abreu says. “Who’s going to help these people and do it safely?” Before Abreu treats someone, he consults with their psychiatrist or primary care doctor. Treatment then consists of six infusions over 12 days.
Each infusion lasts about 45 minutes. Side effects, which often include confusion, lucid daydreaming, and fuzzy vision, clear up quickly. Patients are watched closely and must have pre-arranged transport home. They’re barred from driving or using heavy machinery for 24 hours. Abreu says in his experience, the side effects “go away as soon as the infusion is over, and patients don’t have hallucinations.” Abreu says about three quarters of his patients aged 15 to 55 benefit from ketamine. Older patients have a lower response rate. The initial six infusions cost $3,800, the beneficial effects of which last anywhere from 3 to 5 weeks for some patients, and up to 12 weeks for others. Patients return as needed for single boosters, which cost $600. Because the FDA has not approved ketamine for this use, insurance doesn’t cover it. Lapidus says his clinic will mainly use a nasal spray form of ketamine, a method that he and his former colleagues at Mount Sinai’s Icahn School of Medicine found effective.
They published the results of their research in April. Manevitz, who has also used ketamine in his practice, says we don’t know anything yet about ketamine’s potential as a long-term treatment for depression. “The problem is maintaining the gain, prolonging the effect,” he says. Lapidus agrees: “How to maintain benefits: This is an area that needs a lot more research. Most of the studies published have involved only a single treatment.” A mind-altering drug called ketamine is changing the way some doctors treat depression. Encouraged by research showing that ketamine can relieve even the worst depression in a matter of hours, these doctors are giving the drug to some of their toughest patients.
And they’re doing this even though ketamine lacks approval from the Food and Drug Administration for treating depression. “It became clear to me that the future of psychiatry was going to include ketamine or derivatives of ketamine,” says David Feifel, a professor of psychiatry at the University of California, San Diego, who began administering the drug to patients in 2010. Ketamine was developed as an anesthetic and received FDA approval for this use in 1970. Decades later, it became popular as a psychedelic club drug. And in 2006, a team from the National Institute of Mental Health published a landmark study showing that a single intravenous dose of ketamine produced “robust and rapid antidepressant effects” within a couple of hours. Since then, thousands of depressed patients have received “off-label” treatment with ketamine.
One of those patients is Paul, 36, who lives in San Diego and is a patient of Dr. Feifel. We’re not using his last name to protect his medical privacy. Paul’s depression began with anxiety. “I was an extremely anxious child,” he says. “I would always make choices based on fear. My life was really directed by what was the least fearful thing that I could do.” As Paul grew up, his extreme anxiety led to major depression, which could leave him unable to get out of bed for days. “I lived in pain,” he says.
Paul managed to get through college and a stint in the Peace Corps. But most days were a struggle. And Paul has spent much of his adult life searching for a treatment that would give him some relief. He tried just about every drug used for depression, as well as cognitive behavioral therapy, acupuncture, and even electroconvulsive therapy, which induces a brief seizure. But nothing worked — at least not for very long. Paul says he was increasingly haunted by “this comforting thought of pressing a cold gun against my forehead where I felt the pain the most.” Then one day, while investigating depression on the Internet, Paul discovered the research on ketamine. “It was clear to me that this was real,” he says. Ordinarily, there would have been no legal way for Paul to get ketamine. He didn’t qualify for most research studies because of his suicidal thoughts.
And doctors usually won’t prescribe a mind-altering club drug to someone with a mental illness. But the studies of ketamine have produced results so dramatic that some doctors, including Feifel, are bypassing the usual protocols. By the time Feifel began hearing about ketamine, he had become frustrated with existing depression drugs. Too often, he says, they just weren’t helping his patients. David Feifel, a psychiatrist at the University of California, San Diego, has treated about 100 people with ketamine. A major study on antidepressant medication published in 2008 seemed to confirm his suspicions. It found that current antidepressants really aren’t much better than a placebo.
Many psychiatrists criticized that study. But not Feifel. “I was kind of like, I’m not surprised,” he says. “These really don’t seem like powerful tools.” Feifel remembers feeling “professionally embarrassed” that psychiatrists didn’t have something better to offer their depressed patients. Something like ketamine. He knew the drug had risks. It could be abused. It could produce hallucinations. And it didn’t have the FDA’s OK for treating depression. But he also knew that doctors had a lot of experience with ketamine. It’s been used for decades as an anesthetic that can rapidly stop pain without affecting vital functions like breathing. And ketamine’s safety record is so good that it’s often the painkiller of choice for children who arrive in the emergency room with a broken bone.
So in 2010, Feifel decided he wanted to offer low doses of the drug to some patients. The decision put him at odds with some prominent psychiatrists, including Tom Insel, director of the National Institute of Mental Health. “While the science is promising, ketamine is not ready for broad use in the clinic,” Insel wrote in his blog a few months ago. “There are a lot of pundits who remain skeptical or feel we need to research this ad infinitum before it’s ready, which doesn’t make sense to me,” Feifel says.
It’s hard to take the wait-and-see approach when you’re treating patients who are desperate for help, he adds. Paul was one of those desperate patients when he was referred to Feifel in March of 2014. The referral was from a local psychiatrist who had run out of ideas, Feifel says. And Paul jumped at the chance to try ketamine. “If there was even a 1 percent chance that this worked, it would have been worth it to me,” he says. “My life was hanging in the balance.” And for Paul, the benefits of ketamine became obvious soon after one of his early injections. “I remember I was in my bathroom and I literally fell to my knees crying because I had no anxiety, I had no depression,” he says. For the past year, Paul has been getting ketamine every four to six weeks. He feels an altered sense of reality for an hour or two after getting the drug. The effect on depression and anxiety, though, lasts more than a month. Ketamine doesn’t always work that well, Feifel says.
After treating more than 100 patients, he’s beginning to understand the drug’s limitations. One is that its ability to keep depression at bay can fade pretty quickly. Feifel recalls one patient whose depression would disappear like magic after a dose of ketamine. But “we could never get it to sustain beyond maybe a day,” he says. Shots – Health News Depression Treatments Inspired By Club Drug Move Ahead In Tests Also, ketamine treatment is expensive because patients need to be monitored so closely. Feifel charges about $500 for each injection and $1,000 for an intravenous infusion, which takes effect more quickly. Insurers don’t cover the cost because the treatment is still considered experimental. FROM KETAMINE PATIENT ADVOCACY NETWORK
Ketamine is “…the most important breakthrough in antidepressant treatment in decades” Thomas Insel, Director, National Institute of Mental Health What is ketamine? Can it relieve depression? Bipolar Disorder? PTSD? Anxiety? OCD? Migraines? About 70% of patients with treatment-resistant depression (including bipolar patients) experience rapid relief after a low-dose ketamine infusion. Similar success rates have been seen in returning combat veterans suffering from PTSD. These patients’ cases are the worst of the worst, lasting years or even decades, and which have not responded to any other treatments. Many have hovered on the verge of suicide for years, many have actually attempted suicide, and all have endured a very poor quality of life. Before ketamine therapy, there was virtually no way to substantially improve the condition of patients like these. The fact that ketamine works rapidly on 70% of them is astonishing, and its discovery has profoundly changed depression research, and our understanding of the very nature of depression.
It’s important to keep in mind, however, that the degree of relief can vary among patients. Some sufferers get only partial relief, some do not get relief until a second or third infusion, and some do not respond to ketamine at all. And some patients have additional medical conditions in addition to depression that can reduce its effectiveness. “The sense of wellbeing sneaked up on me. Instead of coming directly from the infusions like I expected, it came from doing all these new things that ketamine has freed me to do.” R.S., 30-year sufferer Ketamine patient since 2013 Is this real medical treatment, or just quackery? It’s real.
Ketamine treatment is an intravenous infusion procedure performed in a specially-equipped medical office by an MD, usually an anesthesiologist. It’s not hype. The National Institutes of Health has been studying ketamine’s affect on depression for more than ten years. There is serious scholarly research behind this treatment, which means controlled, double-blind, peer-reviewed studies at major institutions. Researchers at Yale pioneered this research nearly 20 years ago and published the first major study in 2000. Since then, dozens more ketamine studies have been conducted at Yale and other major institutions including NIH, The VA, Harvard, Johns Hopkins, Mt. Sinai Medical School, Oxford University, and many more around the world. What does relief feel like? The answer to that question is different for every patient.
The effects don’t always manifest themselves in the way you might expect. A lot of the ketamine buzz makes it seem like relief is instantaneous and total. But it’s important to keep realistic expectations based on facts, not hype. Yes, the relief is fast and it can be life-changing. But “fast” doesn’t always mean “instant”. Sometimes it takes several days to appear, and it might take multiple infusions. It might seem intermittent at first. Even if it takes several days, that is still warp-speed, comparatively. And the relief can be extremely subtle at first, building gradually instead of instantly overwhelming you. We’ll explain it by drawing on actual ketamine infusion patients.
This page is based on the experiences of real people, not hypothetical examples. Our ages range from 19 to 72. All of us all suffered extreme, treatment resistant depression (or bipolar or PTSD) lasting between 5 and 60 years. We include two university professors, a disabled US veteran, a PhD advisor to school districts, a small business owner, a retired programmer, a PhD neuroscientist, a corporate President/CEO, two college undergraduates, two single moms, and several people on Social Security disability due to their condition.
Nearly all of us experienced prolonged exposure to intense stress during childhood, or extreme trauma at some point in our lives. Our stories include combinations of physical abuse, emotional abuse, sexual abuse, neglect, the murder of a loved one, having an alcoholic or addicted parent, being in violent military combat, having an imprisoned parent, and much more.
All of us tried the usual meds and therapies for years. We were mostly unable to function normally, causing many of us to lose nearly everything we held dear: marriages, family relationship, jobs, homes, friendships, a sense of belonging, etc. About half of us had attempted suicide resulting in hospitalization; and in some cases multiple attempts. Each of us was acutely miserable immediately prior to our first infusion. Our symptoms were typical for patients like us: anhedonia, anxiety, dysphoria, irritability, insomnia, fatigue, social phobia, cognitive impairment, etc. Some of us responded immediately, and felt relief within hours. Others didn’t feel anything until a few days later, or until after the second or third infusion. In one case, it took four infusions, but then the relief was solid. Some described their relief as total, others partial. Keep in mind that to someone who is in acute agony, even partial relief can be life-changing. Also keep in mind that some patients do not respond to ketamine, and here we are only talking about those who do.
We ask many successful patients “If you could travel back in time to before your infusion, how would you explain the relief in terms your depressed self could understand?” Most say it’s impossible. They say the explanation would be incomprehensible to their depressed self, and the only way to understand it is to experience it.
We’ll try to explain it anyway… Relief of Symptoms You might not think of your depression/bipolar/PSTD as a collection of symptoms. To you it might simply feel like the way you interact with the universe, like it’s part of your very identity.
But how many of these typical symptoms apply to you? •anhedonia •anxiety •fatigue •irritability •feelings of sadness, emptiness •insomnia, or excessive sleep •difficulty concentrating and making decisions •feelings of guilt or worthlessness •social avoidance •thoughts of suicide
If those symptoms were relieved, would you still be depressed? In the simplest terms, ketamine relieves symptoms. It doesn’t add something new to your personality that causes instant happiness. It just takes away some horrible symptoms. You think you’d notice immediately when these symptoms vanish. Not always. The sensation can be incredibly subtle. There is no jolt of giddiness that instantly courses through your system. The sensation is deeper than that, and gentler. When symptoms are relieved, patients can quickly gain new abilities that were previously impossible.
Like casually picking up the phone to call a friend. Or suddenly breaking out of persistent negative thought loops or behaviors. Or simply being able to get out of bed and stay productive throughout the day.
Let’s go a little deeper… Mood vs. Function When we talk about ketamine relief, keep in mind the difference between your mood versus your function. It’s important. Most of us think of depression/bipolar/PTSD as something that makes us feel horrible, where our mood is bleak. But the impact is in how it prevents us from functioning normally.
It impairs us so we can just barely socialize, work, take care of ourselves, maintain relationships, keep our lives organized or our homes clean, etc. – and sometimes not at all. Our lack of function makes our mood even worse, which creates a vicious cycle. Most patients go into ketamine therapy focused on their mood. Understandably, they are desperate to feel better. They hope to be overwhelmed with an obvious, electrifying sense of relief.
They’ve heard that ketamine can create a miraculous feel-good sensation. One prospective patient said “I imagine the doctor pouring a quart of happiness into my veins, and I’ll be able to feel it coursing through my body afterward.” It doesn’t work that way. Most successful patients do not get an instant, obvious, smack-you-in-the-face sense of total recovery. Relief usually comes without the jolt. Sometimes it takes multiple infusions and several days (which is still incredibly fast, after years of suffering). Instead of an instant smack in the face, relief usually reveals itself in a different way – more subtle, yet still profound.
Here’s a typical expectation of a first-time patient: After the infusion I will instantly have an acute sense of relief. This will lift my spirits and make me feel happy. Then my new mood will make me function better and I’ll become productive. Here’s what the same patient might say after successful treatment, looking back after some time has passed: After the infusion I had trouble detecting instant changes. I didn’t get an obvious thunderbolt of happiness, so I thought the treatment failed. Then I started noticing I was functioning better, doing things that used to be terrifying or impossible, but surprisingly it didn’t seem like a big deal. The more I exercised these new abilities, the more I realized this was a huge improvement. I started to feel a deep satisfaction that I was functioning well, and that something at my core had truly improved. This made me feel healthy and happy. It’s very important to understand that function often improves before mood.
We’ve seen many first-time patients turn all their thoughts inward and search intensely for obvious feelings of happiness. If they don’t find it quickly, they can become despondent because they pinned so much hope on ketamine therapy, and now they think it failed. By focusing solely on their mood, they often don’t notice improvements in their function. In fact, friends and family often notice the function improvements before the patient does – this is very common. Once the patient finally recognizes they are functioning better, even just a little bit at first, it’s very likely to trigger strong improvements in mood – and they’ll get the sense of happiness they expected in the first place. But what do we mean by “improved function?” Here are some examples given by actual ketamine patients:
- Being able to genuinely feel positive emotions, without faking it
- Being able to socialize with friends and family, and truly enjoy it
- Stresses and obstacles roll off your back instead of reducing you to the fetal position
- Finding it easy to sleep right, shower every day, and take care of yourself
- Having enough physical energy to get through the day without constant exhaustion
- Finally finishing projects that have dragged on for months or years, like home repairs, housekeeping, organizing finances, etc.
- Interacting comfortably in big groups, or with strangers, without social anxiety
- Criticism and unkind words become things you can simply shake off, instead of causing deep wounds that won’t heal
- No more energy spent trying to block out certain memories or traumas; they’re just not terrifying anymore
- No longer intimidated by authority figures, bosses, etc.
- Suddenly “getting” what your therapist has been saying for years It seems like any of those improvements would hit you like a ton of bricks, and you’d recognize it immediately.
But fellow patients will tell you these changes can be incredibly subtle at first. They can sneak up on you. It’s counter-intuitive, but it’s just simply a fact of ketamine therapy. A couple of actual patient quotes summarize it nicely: Patient R.S., male, suffered 30 years: I can’t believe the huge difference these tiny gains have made in my life. I thought ketamine would give me an instant sense of wellbeing that I could feel in my gut, and then I would use it like a weapon to conquer the world and do the things I want. But it actually worked the other way around. Ketamine gave me the ability to do a bunch of small routine things that I could never do before, and together they’ve made my entire life easier. The sense of wellbeing sneaked up on me.
Instead of coming directly from the infusions like I expected, it came from doing all these new things that ketamine has freed me to do. Patient S.P., female, suffered 20 years: I thought I’d be blasted with relief. Like from a fire hose. I squinted my eyes and tensed up waiting for the blast. The longer I waited the more tense I got. It distracted me from the pool of relief that formed silently under my feet over the course of three infusions. I didn’t notice it until I was completely soaked from the bottom up. Frankly I was disappointed because I imagined the blast would be so awesome. But once I realized I was drenched in relief and was actually functioning and living life again, the blast seemed pointless. We know how hard it is to be patient after your first treatment – we’ve been there.
But many patients before you have been through this, and you can benefit from their experience. Relief doesn’t always come as instant happiness. For many patients it comes as an improvement in function over several days, which in turn lifts your mood. Please take this to heart, and keep your expectations in check during your initial treatment phase. Lasting Benefits, Even After Relapse When a patient experiences relief like we’ve described, they can often make huge sudden leaps forward in their emotional healing. Some patients have spent their entire lives suppressing traumatic memories, or nurturing hatred towards an abuser. They may be wracked with guilt over lost relationships, or may be despondent from losing precious years of their lives. When relief lifts a patient’s function and mood, they can have a sudden profound shift in the way they view life itself, and how they fit into the universe.
A sudden positive shift in how you see things It’s hard to truly understand if you haven’t been through it. There’s a lot of variation among patients, of course, but there is a common theme. In their pre-ketamine suffering, many feel like a walking defect, an uninvited and unwanted guest wherever they go. But in their relief, this can be replaced by a sense of belonging, like they are a valued member of the human race, and that they are wanted. This can set the stage for sudden shifts in the way a patient views the world and his/her place in it. That might include social phobia giving way to a desire to interact with new people, or letting go of toxic hatred toward an abuser, or coming to terms with a horrible trauma so it stops being a constant source of terror.
It doesn’t mean they suddenly become happy about everything in their past. But it means they can suddenly understand and accept it in a way that was impossible before. They can make peace with traumas, failures, regrets, etc., that have hijacked their thoughts for years. In this state, many patients say they suddenly “get” what their therapists have been saying for years. If you have a competent therapist, this is the perfect time to tackle your emotional issues. By building on symptomatic relief, improved function, and newfound resilience, effective counseling at this stage can help you make deep, lasting gains. Some ketamine responders have told us they made more emotional progress in a few months of post-infusion counseling than all the years prior.
Patients who have these massive shifts often find they are permanent. Even if their individual symptoms return, many of these patients have lasting benefit from these shifts. Their improved, healthier thought patterns make them more resilient, and help them contend with the symptoms better than before. And some long-term infusion patients say that repeated cycles of relief/relapse help this resilience to increase over time. This is one of the best possible outcomes of successful ketamine therapy. It doesn’t happen for every patient. Many patients get tremendous relief even without this effect. If it happens for you, great – but it’s not a requirement for success.
A Metaphor for Ketamine Relief People with depression/bipolar/PTSD often feel trapped. Imagine you’re in a hedge maze where you can’t see over the hedges. All you can see are the leafy green walls surrounding you. How will you get out? The only thing you can do is wander aimlessly until you encounter a juncture. But then which path should you take? You still can’t see anything except what’s right in front of your nose, so you can’t make a plan that considers the big picture. All you can do is guess at the right direction.
Your odds of escaping are slim. You’ll be stuck in a never-ending loop: wander aimlessly, stumble across a juncture, pick a random direction, wander some more. But other people in the maze are tall enough to see over the hedges. They can see where the exit lies. They can see exactly how to get to the next juncture, and which way to turn when they get there. To them, it’s easy. You’ll be exhausted from wandering and backtracking. You’ll be embarrassed each time someone breezes past you. Trapped in the maze long enough, you’ll eventually forget you ever knew anything besides futility, hopelessness, shame.
When ketamine relieves depression it’s like suddenly being able to see over the hedges. Now you can see the exit. Now you can function like everyone else. It doesn’t matter how long you’ve been trapped or how hopeless you’ve become – once you get a birds eye view, charting your course out is straightforward. In this metaphor, your “symptom” was not being able to see over the hedges. Once that was relieved, you were able to function normally and get yourself out. No superpowers were needed, like being able to fly over the maze or blast your way through. Removing your symptom allowed you to do it in a matter-of-fact way, under your own power. Successful ketamine therapy is like that.
Some patients feel initial relief, but then have the sensation that it disappears suddenly after a day or two. This can be very upsetting. Relief makes you start to feel hopeful again, maybe for the first time in years, so imagine your sense of loss if it vanishes quickly. We have a suspicion as to why this occurs. We’re not doctors or researchers, and our suspicion isn’t science. It’s just an informed hunch based on our experiences as patients who collectively have been through dozens of infusions.
First, it’s important to know that most patients who experience The Crash ultimately declare their treatment a success. At some point after The Crash, they feel relief again – maybe in a slightly different form. Here’s our hunch… For some patients, the symptomatic relief produces definite physical sensations. It’s not subtle. They feel an acute awareness that their anxiety is missing, for example. Or that their dysphoria is reduced. Sounds great, right? But for a subset of these patients, after a day or so, the acute symptomatic sensation fades. We suspect this fading is The Crash. But even after The Crash, most of these patients go through the exact same progression described above. First they’ll gradually notice that they’re functioning better, which in turn will lift their mood, and so on. We simply want you to be aware this phenomenon can occur. If it happens to you, keep in mind that many other patients have been through The Crash yet still ultimately achieved solid relief.
Conclusion: Consider relief to be a spectrum of results. The very best outcomes might include a rapid, obvious reduction of symptoms; increased function and productivity; significant improvement in mood; and a massive positive shift in the patient’s fundamental thinking that persists even after relapse. Not everyone will get this best-possible case. But to patients who’ve suffered years in acute agony, even partial relief can be miraculous and life-changing. Most first-time ketamine patients are desperately craving relief. They can’t help but pin all their hopes on this new option. It’s completely understandable for someone who’s suffered for years, maybe decades, where no treatment has ever helped. When the stakes are so high, expectations can run wild.
We want to be blasted with relief, instantly. We might fantasize that it will arrive in dramatic fashion, with an incredible electric sensation, and gasps from spectators. Relief rarely comes in that packaging. It’s usually much more subtle – but just as gratifying. Many patients get incredible, life-changing relief without pyrotechnics. Honestly, it’s hard to understand until you’ve been through it yourself. We’ve done our best to explain it, but if you want to make sure your expectations are realistic, ask a question in the discussion forums or talk to your ketamine provider. “I wish I could have tapped the wisdom of other patients before my first treatment but there just weren’t very many of us then. I could have prepared better if I knew then what I know now.” Dennis Hartman Founder/CEO, Ketamine Advocacy Network
Getting The Most Out Of Treatment If you’re going to spend serious money and pin your hopes on being a ketamine responder, you should do everything in your power to get the most out of the treatment. Here we’ll share some practical experience from a variety of patients. Between us, we’ve had many dozens of infusions, and have picked up some do’s and don’ts along the way. Some of us did not feel our treatment was successful at first, but later recognized solid improvement. There are things you can do before, during, and after treatment to maximize your chances of a good outcome. Keep in mind that some patients do not respond to ketamine, and here we are only talking about those who do.
Rest Up Try to be well-rested before the infusion. If you have a morning appointment and are worried about being able sleep the night before, ask your ketamine provider if it’s ok to take a sleep aid. Some patients feel their infusions are less effective when they are sleep-deprived.
Relax Empty your bladder The infusion only puts a few ounces of fluid into your body. But many patients feel like their bladder is full as soon as the infusion is over. Make sure it’s completely empty before the infusion starts, to buy yourself time at the end of the infusion before you have to make your way to the bathroom. We realize this is easier said than done for some patients, but try to be in a relaxed state before the infusion starts. Patients who are very tense when the treatment starts are more likely to have brief moments of unpleasantness during the infusion. If caffeine makes you jumpy, maybe skip your daily cappuccino or wait until after your appointment. Obviously, you may be pinning a lot of hopes on the treatment and that can make you anxious. Arming yourself with knowledge about the treatment and setting realistic expectations can help you relax when you get there. (Do not take a benzodiazepines to relax before your appointment! See below.)
Ask If Your Current Meds Will Interfere Make sure your ketamine provider is aware of every drug you are currently taking, whether it’s a psychotropic med, heart medication, cough syrup, an illegal substance, etc. Some substances can interact with ketamine or interfere with its action in the brain. For example, high doses of benzodiazepines seem to reduce ketamine’s antidepressant effect. If you are taking a daily high dose of benzodiazepines, your doctor might recommend reducing it before your treatment (he/she probably won’t ask you to stop taking it completely). Other meds that can impact ketamine’s efficacy include lamotrigine [Lamictal], memantine, and any drug that affects NMDA receptors. Don’t hold anything back from the doctor. There’s no point investing your money and hopes unless you’ve disclosed everything and your doctor is satisfied nothing will interfere with the ketamine.