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The Biomedical Model vs Psychedelic Model in IV Ketamine Treatment
Ben Medrano, MD, medical director, Field Trip Health, Toronto, Canada, and Michael J Verbora, MD, MBA, medical director, Field Trip Health, discuss the pros and cons of the biomedical model and the psychedelic model in intravenous (IV) ketamine treatment. Dr Medrano and Dr Verbora, who is also the chief medical officer at Aleafie Health, and assistant professor at Seneca College, Ontario, Canada, also explore the ketamine-assisted therapy (KAP) approach and the efficiency ketamine offers over psilocybin or 3,4-Methylenedioxymethamphetamine (MDMA).
This discussion took place at the 2021 Psych Congress in San Antonio, Texas.
Read the transcript:
Dr Verbora: There's so many IV ketamine clinics out there. How do you compare and contrast the strategy with IV ketamine, which might have a little bit more evidence for depression, but has a very different approach? What are the pros and cons of these 2 different models?
Dr Medrano: We frame them as the biomedical model versus the psychedelic model. I'm a little reticent when I hear some psychedelically-minded practitioners look down their nose at the biomedical model, because I have had clients, prior to working with Field Trip, really benefit from that approach.
There is an attitude in the biomedical model that I think is one of a missed opportunity, I would say, because the focus is on weight-based dosing with this hope that you might be able to minimize the so-called unpleasant side effects of ketamine.
I say so-called because a lot of what they're trying to minimize is the psychedelic effect. As we just said, the psychedelic effects could be one of the most therapeutic aspects of one's experience. That's why I find myself working with it more within the psychedelic model.
Also, what is it that I hear? The one thing that I hear the most concern about IV ketamine centers points to some foundational aspects of psychedelic work, and that is set and setting. It's important to touch on those topics.
Set, we talked about a little bit when we talked about preparation therapy where we're trying to get people into the mind state of how to make use of these experiences. Setting actually has to do with the physical setting. What is it like? What is the treatment room like? How is it decorated? What is the treatment staff trained to do?
In a IV Center, you'll find that there's rarely any mental healthcare providers on staff. It's rare that they're even run by psychiatrists at all. The vast majority of them are run by emergency doctors or anesthesiologists. This is not meant to be a criticism per se, it's you had a missed opportunity.
If you are somebody with a mental health training, you might catch things within the dialogue between you and your client that maybe an anesthesiologist wouldn't catch. There's a great deal of opportunity in the moment of the psychedelic experience to affirm someone's experience as being meaningful.
That's why we believe in having a therapist present in the psychedelic model. Those are the key hallmarks of the differences between IV and psychedelic.
Dr Verbora: Such a fascinating and exciting time with this potential paradigm shift in how we approach mental health. You hear the word cure in the literature now coming out with some of these psychedelics, which offers a lot of hope. You see a lot of psychotherapists, psychiatrists, and others who are looking to get involved in this field.
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Dr Mike Verbora: It's going to be interesting because it's going to evolve. The first thing we need to do is compare and contrast in the literature, produce literature about, is ketamine-assisted psychotherapy the best model?
What are the outcomes that we see in IV clinics versus this [Ketamine Assisted Therapy] KAP approach? What patients might do good in an IV clinic, and which patients might do really well with KAP? We've got to tease that out, so we can recommend the best approach for patients.
The other question that comes up a lot is, "Is ketamine going to still be around when psilocybin's out or MDMA is out?" and the answer is yes, because ketamine is, one, it's relatively gentle compared to the other psychedelics. Two, it's very short-lived, so it's nice from a perspective of being able to treat a greater population. You can be a little bit more efficient with ketamine than you can with something like psilocybin or MDMA, where the resources are quite intense for one client or one patient.
Then the other thing that a lot of people forget is that ketamine can be used while you're on SSRIs. That's the big one because very few people come through our doors who aren't already on an [selective serotonin reuptake inhibitor] SSRI therapy, and to have to figure out how we're going to taper these patients to give them psilocybin or MDMA is going to be interesting because there's that risk of destabilization.
That's something else we're going to have to figure out over the next 35 years as all these drugs come to market is, what's the best drug for these patients? How do we get them in a state that they can use it in a safe manner?
Dr Medrano: I've heard you present about that before. It's some of your ideas of maybe one day having a menu of treatment options for people, and say, MDMA for trauma, and psilocybin for end of life anxiety or something to that extent, because that's what we have research on. It's a very exciting future.
