Unlocking the Power of Ketamine With Sandhya Prashad, MD

While ketamine and esketamine have been heralded as one of most significant breakthroughs in depression treatment, treatment success depends on finding the optimal application for each individual patient.

Psych Congress Network connected with Sandhya Prashad, MD, president, American Society of Ketamine Physicians, Psychotherapists, and Practitioners; ahead of her session on this topic at the 2024 Psych Congress Elevate meeting in Las Vegas, Nevada. In this Q&A, Dr Prashad explains how ketamine differs from traditional pharmacological treatments, dispels common misconceptions, and contemplates what the future holds for this novel treatment.

For more insights direct from the 2024 Psych Congress Elevate, check out our newsroom here on Psych Congress Network.

For more information about Elevate, visit the meeting website.

Psych Congress Network: Could you walk us through why ketamine and esketamine are “one of the greatest breakthroughs” in depression treatment? How does it compare to traditional psychopharmacological treatment approaches?

Sandhya Prashad, MD: Ketamine and esketamine are considered major breakthroughs in depression treatment due to their high response rate, even among treatment-resistant populations, and their rapid action. Suicidal thoughts often diminish immediately or within the first few treatments. Patients may experience a life-changing shift from severe depression to full remission within a few weeks.

Additionally, a higher percentage of patients achieve remission compared to other psychopharmacological treatments. The response quality is also distinct; instead of a "blunting" effect, many patients report accessing a broader range of emotions while maintaining resilience. This enhances the effectiveness of psychotherapy and helps patients learn new coping mechanisms.

Ketamine also has a different side effect profile, not causing weight gain or sexual side effects, common with traditional medications.

Psych Congress Network: In your session at Psych Congress Elevate, you emphasized the importance of personalizing ketamine treatment to individual patients’ diagnosis and symptom severity. Which factors do you consider before recommending ketamine treatment to a patient?

Dr Prashad: The key factors I consider are the presence of suicidality, trauma history, and the severity of anxiety. Benefiting from ketamine requires an element of "letting go," similar to meditation. High anxiety can make this challenging, but careful preparation and dose titration can mitigate these barriers. Patients with trauma histories can experience significant improvements and processing with ketamine, although additional support and preparation may be necessary. For those with acute suicidality, I often adjust the timing of infusions.

Psych Congress Network: Which misconceptions about ketamine for depression treatment would you like to clarify for our readers?

Dr Prashad: A common misconception is that ketamine is only for patients who are completely non-functional due to depression. Research shows that after two unsuccessful trials of oral antidepressants, the likelihood of achieving remission drops to about 14%. Residual symptoms despite treatment increase morbidity and affect quality of life. Striving for remission is crucial for all patients with depression.

Another misconception is that psychotherapy is always needed with ketamine. Significant increases in neuronal connectivity and improvements in suicidality and depression symptoms can occur without psychotherapy. Patients often continue to improve with their usual therapist, and "ketamine-assisted psychotherapy" may not be necessary for all.

An individualized approach is key.

Psych Congress Network: What do you think the next 10 to 20 years holds in store for ketamine as a treatment within the psychiatric space? Any new potential applications that clinicians should keep an eye out for? 

Dr Prashad: Combining ketamine with psychedelic treatment to support patients as they navigate challenging psychotherapy work will be an interesting and unique way to support patients. Since medication adjustments will likely be needed to pursue treatment with psychedelics, ketamine may be helpful in weaning patients of medications that are contraindicated. Also, I foresee developing more targeted psychotherapy models in conjunction with ketamine in order to focus on certain behaviors, akin to the research on motivational enhancement therapy and alcohol use disorder. More work between couples and group settings will likely also be implemented. Lastly, I think these new treatments will blur the boundary between treating a disease state and simply human enhancement. For example, people may seek treatment to improve their leadership and business skills. The ethics around this will likely be challenging. 

Sandhya Prashad, MD, is a board-certified psychiatrist specializing in interventional modalities for treatment resistant disorders with a particular interest and expertise in ketamine therapy. She completed both medical school and psychiatry residency at Baylor College of Medicine. She has been in private practice in the Houston area since 2011 and has been utilizing intravenous ketamine since 2016. She is the founder and medical director of The Houston Center for Advanced Psychiatric Treatment, Houston Ketamine Therapeutics, and Houston TMS Therapeutics. She is a founder and the current president of the American Society of Ketamine Physicians, Psychotherapists and Practitioners (ASKP3, www.ASKP.org), a non-profit medical society dedicated to the safe and effective clinical use of ketamine.