Well, thank you for being here in the last day of the APA and welcome to our symposium about ketamine and psychotherapy. I'm very excited to introduce our panel here. So we have Dr. Jung, who is Associate Director of the Maginot Depression Clinical and Research Program, also Co-Medical Director of the South Cove Community Mental Health Center, and he has experience treating patients with ketamine-assisted psychotherapy. We have Fernando S. P. Forsen, who is Associate Professor at Mass General and works in inpatient psychiatry at Blake Eleven there. And then we have Dr. Altine, who is the Director of the LGBT Clinic at Cleveland Clinic, but also does research on treatment-resistant depression and neuromodulation, and is currently participating in a randomized controlled trial for a ketamine-assisted therapy. And I'm Tatiana Falcone, Child Psychiatrist at Cleveland Clinic, and also currently doing a randomized controlled trial for youth who had suicidal thoughts with ketamine and therapy. Hello everyone. Good morning. Thanks for coming to this session. And before I go into talking about ketamine-assisted psychotherapy, I would like to do a survey. Who are clinicians doing ketamine-assisted psychotherapy here? Can you raise your hand? One, two, three. Okay. And this overlaps with the earlier question, who have learned and heard about ketamine-assisted psychotherapy? So most of you. So there is not much I can tell you. So as you know, that ketamine-assisted psychotherapy is under the framework or the umbrella of psychedelic-assisted psychotherapy. So I'll first talk about psychedelics, and then psychedelic-assisted psychotherapy as an introduction, and then talk a little bit about ketamine as the agent for ketamine-assisted psychotherapy. No disclosures. So psychedelics, what are psychedelics? Psychedelics are mind-manifesting drugs that induce alterations in consciousness states. And in the past, people would call it hallucinogenic agents or hallucinogenic drugs. But not all hallucinogenic drugs are psychedelics. Psychedelics are a subclass of hallucinogenic drugs that can cause specific visual and auditory distortions and complex closed-eye visions. People can close their eyes with an eye shade, and they can still see a lot of things when they are on psychedelics. Psychedelics can induce profound changes in emotions, in mood, and heightened sensitivity to internal as well as external context. Psychedelics can cause a temporary change in a patient's perspective of the world, self-reflection that brings new insight, and that new insight can have a long-lasting effect. The classic psychedelics include mescaline, which is found in South America, Ketet, including the well-known peyote, and also it includes psilocybin, which the street name is magic mushrooms, and LSD, and DMT. And in South America, shamans mix DMT with monoamine oxidase inhibitors to make ayahuasca, which is well-known to induce spiritual journeys. So this is from a patient who went through a psychedelic experience. They drew what they saw during the journey, a lot of colors, a lot of patterns, meticulous. And this is from another patient who went through a ketamine journey, and then they drew this picture, less formed, still equally colorful, and some kind of shape that is obvious like a human person's face or head, and others are less obvious. So it is up for interpretation what this means to the patient, and the patient will need to make sense of what it means to them. So when we talk about psychedelics, when we talk about ketamine, people will first challenge you, are you kidding? This is drug, partying drugs. So are we going to get high? Are we going to get wild? And of course, there are a lot of young people who use psychedelics, who use ketamine for to have fun, and just to do whatever they want. So yes, people do that. But unfortunately, there was a study trying to look into, so what were they taking? And in fact, they were not, those kind of drugs are fairly contaminated. They may not have a lot of those, what they are seeking, what they call, oh, I bought some ketamine. It may not have a lot of ketamine inside that powder that they purchased. So psychedelic-assisted psychotherapy can be a serious medical surface. If you look at this setting, it is not going to get wild or to have fun, fairly serious kind of psychotherapy setting, as well as approach. We'll talk more about this in a while. So talking about psychedelics, psychedelics is not new to the world, and LSD was first synthesized in 1938 by the Swiss chemist Albert Hoffman. And at that time, he worked at Sandoz, and now it is called Novartis. It is based in basal Switzerland. LSD was found to be useful to elicit release of repressed materials and provide mental relaxation, and also to help clinicians to understand what's going on in the brain and to understand what changes can induce psychosis or psychotic symptoms. By the end, by the middle of 1960s, over 40,000 patients had taken LSD in psychedelic research and produced over 1,000 scientific papers and many books, as well as several international conferences. LSD was considered a candidate or a model to understand psychosis, and it was used for the treatment of alcoholism, neurosis, and pain. And in late 1960s, there were studies questioning whether LSD is harmful or not harmful, and there were studies suggesting that LSD can lead to chromosomal changes, cancer, teratogenesis, psychosis, and even suicide. And at that time, it was 1960s, during the Vietnam War, LSDs were used profusely by hippies, people who were counterculture, people who stood up against the Vietnam War, and then they were considered anti-authoritarian, and Washington, D.C. did not like that. In 1965, medical use of psychedelic drugs started to be restricted, and soon afterwards, all psychedelic research was discontinued. By the 1970s, many of the reports regarding psychedelics' safety were shown to be not true or misleading. Scientific evidence began to emerge supporting that psychedelics could be used safely with supervision, not during partying, with supervision. In the end, psychedelics were found to be no more risky than other forms of treatment. So how do psychedelics work? So, classic psychedelics are serotonin 2A receptor agonists. They could trigger deeply profound, potentially life-changing experience. And the effects of serotonin 2A receptor usually focus, concentrate at the cortex, which leads to change in consciousness. Psychedelics can induce increased global functional integration. What it means is that it affects the whole psychology of the person, leading to ego dissolution. And what does it mean? It means that you lose yourself. You become not yourself. You don't know who self is, forgoing of self or your identity. You don't feel much about your body, and you feel differently about the concept of space, of time, bodily sensation. And a lot of things come up. Memories, emotions come up during these psychedelic journeys. And change of consciousness and ego dissolution, they are intimately related to so-called, what they call the unitive experience, which is when people, when they undergo psychedelic experience, or people who are trained to do deep meditation, they can have this kind of unitive experience, which is a profound sense of personal, interpersonal, existential oneness. You feel that you are connected to the universe. You are no longer an individual, and you are actually part of the universe, what they call interconnectedness. The unitive experience is considered the core component of mystic experience, and which have been found or shown to predict positive mental health outcomes. So Bill Richards, a pioneer in this area, he summarized what happens during this mystic experience. So we talk about unity, or unitive experience, oneness with the universe. And transcendence of time and space. And you feel that you know something, which is by intuition, not by reasoning. And you feel that, yes, I know something. And also a sense of feeling connected to the sacred, to the divine. And deeply felt positive emotions and mood. And ineffable. The experience is hard to be explained, communicated through words or language. You just feel it. So this is one of the core characteristics during these journeys. So talking about how the SSRIs work, and how the psychedelics work, in the upper row, talking about SSRIs, SSRIs increase the postsynaptic serotonin 1A receptor signaling, and decrease limbic responsivity. And functionally, you see that the patient receiving SSRIs, they have less stress, less impulsive, less aggressive, and less anxiety. And at the end, they feel more resilient and more emotional blunting. Some patients like it, say that I'm less sensitive, I'm less moody, less labile. Other people, other patients do not like it. Say that I lost my sense of feeling. I'm not alive. But at the end, we do see that people taking SSRIs have improvement in depression as well as increase in well-being. For psychedelics, it increases the serotonin 2A receptor signaling and increased cortical entropy, the freedom of the cortex in relating, connecting to other areas of the brain. And the outcome you see is a reduction in rigidity, being more flexible. And you see the patient is more sensitive to the environment, and you see a lot of emotional release. During psychedelic journeys, you see patients have emotional expression, crying, feeling very painful. I had a patient who said that, I don't feel sad, but she was crying profusely. So a lot of emotional expression and release. And psychedelics also have been shown to be related to decrease in depression and increase in well-being. So what is psychedelic-assisted psychotherapy? It is the use of psychedelics to modify the brain's function and offer them, put them in a change in the consciousness. And then during that time, you offer psychotherapy. And after that time, you see the patient for integration, to talk with them, what the experience was, what kind of subconscious materials have been uncovered, and then how to integrate that materials back into their life so that they can be balanced. And patients, they go through deeply meaningful experiences and elicit positive emotional, cognitive, and behavioral changes. And we do know that. We talk about partying and being wild. And the outcomes of psychedelic-assisted psychotherapy is highly influenced by set and setting. What does it mean by set and setting? Set is the mindset, the mindset that the patients bring to the treatment. That we spend an hour, at least sometimes two hours, to prepare the patient what they can anticipate when they receive ketamine or psychedelics, that they may feel a sense of difference, a change in their consciousness. You feel that you have no control. And then what you want to do is to bring your intention to the therapy, to the session, that there are things you want to resolve, things that are bothering you, that are troubling you in life. And then you want to resolve that. And this is intention. Of course, sometimes during the journey, the experience has nothing to do with what the patient came in with, the intention that they came in with. But still, this is the motivation, this is the belief, and the attitude that patients come in for psychedelic-assisted psychotherapy. And the setting is the environment, including, we just saw the picture, it is more like a home environment rather than a hospital environment, which is like no feeling, sterile feeling. And also, part of the environment is the therapist. Usually there are two therapists, a male and a female, representing like parenting figure, parental figure. And then the relationship between the patient and the clinician is part of this setting as well. The patient has to trust the therapist, they know that their therapist is supportive and have their best interest in mind. So this is the setting that we showed. Patients usually are given, it is like a Freudian couch. Patients are doing therapy with their altered consciousness. They wear eye shades so that they can focus inward, and then we play music to help them to go into different emotional tone. And patients can talk to you. And during ketamine, a lot of time patients are silent, but they do communicate to you from time to time. Sometimes they'll say that, I'm afraid I can't hold my hands, and so on. So you are ready there to offer your support. So can we trust psychedelics? So there are more and more well-designed studies using good scientifically sound designs, what they call the second wave. More recent, better designed psychedelic research, and the population, the patients can be having obsessive compulsive disorder, anxiety, depression, tobacco smoking, or alcohol dependence, treatment resistant depression, and major depressive disorder. The drugs being studied include psilocybin, LSD, and ayahuasca. And the outcomes are fairly promising. If you look at the right side column, the main outcomes for obsessive compulsive all improved in 24 hours of treatment. And then anxiety, depression, the second row, improved in anxiety in three months, and then depression in six months, follow up. So all the right side outcomes show that patients responded fairly well, fairly well. Ketamine, we know that there is the S-positive, S-negative enantiomers of ketamine. S-positive ketamine is FDA approved as a nasally applied antidepressant for in-office use. And apart from the nasally applied ketamine, it can be given to patients through IV infusion, intramuscularly, or sublingual, or even rectal delivery. And the antidepressant effect of ketamine is believed to come from its antagonism of the NMDA receptor of the glutamate neurotransmitter system. And having said that, it is believed that downstream effects on other neurotransmitter system may occur, including the cholinergic, monoaminergic, kappa OPI, as well as the GABAergic system. And animal models show that ketamine-induced synaptic potentiation and proliferation may play a role in having good treatment effects for depression, or antidepressant effects. Is it safe? Ketamine has been used for more than five decades, usually in the emergency room or in the operation room as an anesthetic. And there are common side effects that we see, including nausea, dizziness, feeling unstable on your feet, derealization, drowsiness, elevated blood pressure. There has been no report of persistent neuropsychiatric sequelae, medical effects, or increased substance abuse in clinical practice, again, in clinical practice. People who do it in their own home, in varying doses, and sometimes not sure what they are taking, that can be dangerous. And chronic abusive use of ketamine with high dose could lead to cystitis. And this is a very painful situation. Patients will need to be rushed to the ER. So in ketamine-assisted psychotherapy, we give varying doses, of course, starting from a low dose so that we know that it is safe for the patient. Everyone responds differently. Everyone's dosing is different. Usually we start with sublingual low dose, like it could be 50, 100, sometimes 200. And then you will see that the patient have a kind of a time out from the patient's ordinary usual mind. They have a relief from negativity. And they are more open, open to their own experience, open to talking about the experience, open to expressing their mood and ventilate. And they are able to access difficult materials with less fear. And they have a relief from obsessive and depressive concerns. They feel a sense of healing, a sense of newness. And in higher dose, we're talking about 50, 60 milligram IM, or sometimes use up to 100. People use sometimes 120. But the higher the dose, the higher the risk of side effect. And patient would have an out-of-body experience. They feel a reduction of their bodily sensation. And they have auditory hallucinations. They can see things that are not there. They can hear things. And there is a form of ego reduction. They feel that the self is lost, which people who do meditation know that this is a wonderful thing. The loss of self can bring a lot of bliss, that a lot of the pain for human life comes from that kind of self, ego, desire, and greed, and so on. And this is like a list for the ketamine signature, which we covered in earlier slides, some of them, like ego dissolution and feeling cosmic cautiousness. You feel that you are connected to the universe, cosmic consciousness. And you feel connected. You feel the sense of love. This is a slide showing that ketamine in this paper has been applied to people with various psychiatric diagnosis. And then side effect, mostly nausea, vomiting, some agitation, not that often. And then one brief case report, patient was a 30-year-old white female, a graduate student married with two children. First visit, she said, I'm depressed all my life, hopeless, and also frequent bad dreams, always sad, and reports history of childhood neglect, childhood trauma. She had been treated with various antidepressants, mood stabilizers, stimulants, no significant improvements. She came in with persistent suicidal thoughts, and she said, you're my last hope. People who work with ketamine frequently see patients who come in saying that you're my last hope. So it's a lot of responsibility. And then during ketamine treatment, as well as post-treatment, psychotherapy, or integrative sessions, she talked about the memories about her abusive, angry father when she grew up, her neglectful working mother when she was a child, and also being a victim of sexual violence in college. A lot of crying during the session, a lot of crying after the session during integrative psychotherapy session, which could be several days after the ketamine treatment. And four months later, after seven ketamine treatment sessions, she wrote this to me. I can now process things in life in the past it would have been repressed. I have an anxious attachment style, afraid of joy and love, fear of losing it, fear of abandonment. So more insight about her own personality. Overall, I would say my suicidal thought has been eliminated. It is a huge improvement, but I can still feel the depression creeping back. But they are less intense, and I'm more objective about it now. So conclusion, psychedelic-assisted psychotherapy is an innovative treatment model, which is gaining in popularity among clinicians, among patients. Ketamine is currently the only medication we can prescribe for psychedelic-assisted psychotherapy. Ketamine has a strong safety record. It has been used as an aesthetic in the past five decades. There is some initial data showing that ketamine-assisted psychotherapy could be effective for a wide variety of clinical conditions. However, experience is still limited. And also, well-designed studies with data supporting the treatment of specific conditions like suicidality, bipolar disorder, depression, or whatever that you can think of, or PTSD, it needs to be shown to be proven. More research is needed. Thank you. I lost my, let's click, let's click, I guess. I don't know, the little arrow. Oh, it's here, it's like a virtual thing that goes from here, now I see it, okay. So this extends from the screen to the computer, apparently it's the same screen, and I had to go from there to here. It was like science fiction to me. Okay, so where's my talk, here, slide show. Well thank you, thank you Albert for your presentation on ketamine, psychedelics in general and ketamine. Which is a dissociative psychedelic, and I think now in psychiatry, we live in this divisive realm, that shouldn't be divisive, where ketamine came out as a neuromodulation agent for suicidal ideation. And we're talking about suicidal risk here today in the talk. But it was proposed by NIMH as a neuromodulation agent that can help suicidal ideation, sleep patterns, etc. But the effects of ketamine were seen as side effects, like the mind effects, like there could be side effects. It can cause dissociation, you should ignore those effects of ketamine. Whereas in the realm of psychedelics, from the 1960s, 70s, 1960s when ketamine was discovered by Carl Stevens here in the US for the Vietnam War combats. We saw in the 70s with John Lilly and other people that ketamine actually is a powerful psychedelic. And John Lilly, which people who are familiar with the history of psychedelics was the person who created the floating tank and who was doing ketamine with LSD. And he said ketamine can really enhance the psychedelic experience. So in the psychedelic realm, actually those side effects are actually what you can utilize in psychotherapy. So, and I think both worlds work synergistically together. So when patients have a severe depression that is not improving on three or four psychopharmacological agents, sometimes a high dose ketamine can be very helpful and the patients are able to not be suicidal at least for a week. I mean, the main problem that people face is the relapse of depression that can happen within a week sometimes. In the psychedelic psychotherapy model, we normally don't see these patients. When you take ketamine high dose, probably because it antagonizes the NMDA receptors, it affects memory. So patients won't be able to retrieve memories and they won't be able to utilize their ketamine experience. I would say over 130 milligrams IV or IM, it's very hard to retrieve memories. But patients show a response, an antidepressant effect, and sometimes even superior because the dose is higher than the lower doses. When you're using lower doses like 25 to 80 milligrams IV or 25 to 100 milligrams IV, you are able to retrieve information. The lower the dose, actually, the more information you're able to retrieve. This information can be powerful, it can be psychedelic. And in that model, I think it would be better to do it together with psychotherapy. Like if you remove psychotherapy there, it can be scary for the patients. They say, that was scary, I don't know what I went through, I don't know if I didn't like it. And many patients actually stop the ketamine treatment because they didn't like the psychedelic effects because they thought, well, if this is a side effect, I don't like it. So together we can work. I mean, we don't have to compete with the neuromodulation. People who don't believe in psychotherapy, they use higher doses, it's fine. You can be without psychotherapy, but if you're gonna use lower doses, psychotherapy can be effective, and also it's safer if you do it together with psychotherapy, or at least with some education about the power of this treatment. So I must say myself, I got trained in ketamine-assisted psychotherapy in Boston. And I also got trained in psychedelic psychotherapy recently for a study on Irritable Bowel Syndrome. And I work with Albert, but also Tatiana has been my mentoring in another research study that is part of Cleveland Clinic, part MGH. And she's the PI of that research study with ketamine and psychotherapy. I know more about it because I did my training in Cleveland, and I met everybody in Cleveland, and now I'm in Boston. But today, I work right now in the inpatient unit. Working in the inpatient unit, I was thinking for myself, why not are we doing ketamine in the inpatient unit? I mean, like half of the patients, or 40% of the patients, they are admitted for suicidal ideation. The most effective treatments for suicidal ideation are psychotherapy. I don't know how often they have it in the inpatient unit, but not all the time. Electro-compulsive therapy and ketamine. Sometimes you could argue benzodiazepines, you wanna decrease the acute anxiety or whatever, but. So why in a unit that cost usually $4,000 a day to be there, we cannot offer ketamine, which is the most effective treatment to go with electro-compulsive therapy. Many inpatient units nowadays, they don't even offer electro-compulsive therapy, nor ketamine. Because they don't have medical, the ability to do an IV. They don't wanna do an IM, because they don't wanna monitor the blood pressure and things like that. So most inpatient units in the United States don't offer neither ketamine, neither electro-compulsive therapy, but ketamine even less. In our unit, we started, which is shocking to an extent, because you're like, man, most of the patients we have here, they have suicidal thoughts. And the treatment that we do in the inpatient unit is, we start an antipsychotic, or start an SSRI, or increase the dose of the SSRI, or add Depakote, or whatever. And in one week, if they are no longer suicidal, we discharge them, when we know in research that you need two to four weeks to evaluate the response to the treatment. So this is the number of days that you get by your insurance and everything don't match the practice that we're doing. We don't have any evidence for the practice that we do in inpatient psychiatry. Other than the patient told me, I'm no longer suicidal. So I'm no longer suicidal might mean many things. It might mean, I'm actually no longer suicidal. I'm not suicidal here, because here I feel safe. But maybe I go back and I feel suicidal. Or actually, I'm ready to go home, which is another reason. I'm ready to go home, therefore, I'm no longer suicidal. So these are things that we face in the clinical practice. So why ketamine is not available in the inpatient unit? It was always very intriguing to me. And I think it's the system, the bureaucratic aspects of it, how they're gonna implement. And people say, we don't do ketamine. And sometimes the answer that I get is like, we never do that. We've never done it, so we're not gonna do it, period. So that's the answer that we get. So I've been working for three years in an inpatient unit. And now, I've been able to refer some patients to the ketamine clinic. But it's not like an electroconvulsive therapy. In electroconvulsive therapy, I get a consult. And most of the times, they agree to send the patient downstairs and do electroconvulsive therapy. We have a ketamine clinic at MGH, they get to choose. They say, well, I don't think it's a good candidate for our clinic. As if it was an outpatient consult, they get to choose. So many of the patients that I think they should benefit from ketamine, I cannot refer them for ketamine downstairs. So I started a protocol to see if we can do it in the unit. So far, we are waiting for that. But I must say, two months ago, I said, where is this thing with ketamine-assisted psychotherapy? And I was referring some patients. And I was doing some psychedelic support psychotherapy with the patients I was referring to the unit. But then I decided to go myself in ketamine-assisted psychotherapy training. So I found a group in Boston called Psychedelic Therapy Boston. And they gave me two sessions. I was able to see there for two, I had a partner, so I was be the see there or the therapist, and also they gave me the ketamine. So when I do the ketamine, I didn't know what to expect. You hear all these things. But when I do the ketamine, it's so different for every person. It doesn't matter what they tell you. Even if they describe to you the ketamine experience or the psychedelic experience that I understand probably many of the people here, because nowadays many people have had a psychedelic experience. Even if they explain it to you, it's so emotional that you cannot describe it. You have to experience the emotions of it, the disintegration. Like I said, you experience disintegration. Either you go through that or you don't go through that. You cannot just imagine what it is to have a psychedelic experience. So I think to do this kind of therapies, it's very important to have a personal experience. So what I felt when I took like 400 ketamine sublingual, like Albert was describing, and I had a sitter with me. And the sitter normally is giving you support, like you see they can give you your hand and help you. I thought I wasn't gonna need my sitter. I thought I was gonna go in my mind and just. I started going through different rooms, and I could see architecture spaces. And then I was going very far, like so far that I didn't know where I was. I didn't know if I was on ketamine or LSD or MDMA. I didn't know where I was. I mean, I was just like very far away. Then I was holding the hand of my therapist, and she allowed me to go even farther, and I have a universal experience of love. And I could really feel a lot of love, and that's something that I felt so good to feel that. After that, we were a group of 30 people, and we were able to discuss our experience. And we felt that we bonded there. So in a group therapy model, I think this can be very powerful. I understand some people have a lot of trauma experiences, and it can be difficult. And I saw people there who had traumatic experiences that they were able to revisit. And they felt so pleased and so gracious that they were able to share that with us in a safe place, knowing that we had gone through that as well. And there were therapies there, there were supervising therapies. And some people, maybe they just have very severe depression, they don't want to do therapy, and they just want a high-dose neuromodulation, and they get better for a week or two. But I think having these experiences, when people have mild or moderate depression, it can be so healing that you may not need ketamine after that. Because many of the people that I see that take ketamine, after a week or two, they want more ketamine. Because you may feel a little bit of a crash when the ketamine is no longer working, and you feel great on the ketamine. It may last for three to seven days or eight days for some people, two weeks. But then you feel a little crash, you say, okay, I had my therapy experience, that that was the healing part. It was not taking ketamine, it was the therapy experience. So you carry that with you. So it can be very powerful that way to the extent that I don't feel, I didn't have severe depression, but I didn't feel I needed more ketamine after that. When I had the second experience, after three days, I must say, I didn't want to do ketamine again. I had taken ketamine one time, and I was like, man, I'm done with this. It was very powerful, I don't need to feel this again. But it was part of the workshop, so I had to go through it. So I said, okay, let's go for it. I took a shot of IM ketamine, 80 milligrams. They gave it to me, I said, low dose, because the other one was too powerful. So man, you need to decrease the dose, I cannot take so much of that. And then I could retrieve even more memories. I had been on a trip to Mexico recently, and I was down in the underworld. And I could see pyramids, and I could see guttural faces. And I was in the underworld, I could hear things like, rarr, rarr, rarr. I was like, wow, I was curious about it. Then after that, I grabbed the hand of my therapist, and my therapist skyrocketed me to a red room with Flemish Renaissance windows. And I could feel love, and then I felt again a universal feeling of love. I love everyone, I love everything. I remember I yelled, I love you all. I remember yelling that. I was with my eye mask, my eye shades, and covering myself. And somebody told me, I love you too, Fernando, we love you too. And I felt, my God, my message has settled here. And then after that, I went to a blue room with a light on the roof, and I felt that was like a near-death experience. And then I started going back from the trip, and I started unfolding. And then I started unpacking, and I said, hey, I told the therapist, I was with my eyes, because it can get very intense. I was like, I am an immigrant, and as an immigrant, I always try to survive by myself here in this country. But I want to rely on you, and I want to rely on other people, and that's why I want to hold your hand. And that was very powerful for me. And then I started hearing other songs that I could feel about relationships, like relationships that have failed in my life, and how I wanted to feel about my romantic relationships in the future. So that was very, very powerful, and we all could share our experiences. So I think ketamine, as a neuromodulation agent, a high dose, can be helpful. But if you're going to use lower doses, especially for people who have trauma or relationship difficulties, this can be very, very powerful if you do it with psychotherapy. So on that note, let me talk a little bit about my slides as well. I have no disclosures. How are we doing with time? We're good. So as we know, a physicalist approach, this would be the neuromodulation aspect. It was discovered by Carl Stevens for Vietnam combat. It's a derivative of PCP, actually, but it's just much milder than the PCP. And it has an action of several receptors. It's not only an antagonist of the NMDA receptor. Do people know what NMDA is? N-methyldiaspartate. It's like a toxic that they use for mice in mice models. It targets that receptor so that you can cause exotoxicity, causing exotoxicity of the neuron. And then you can kill the neurons in that area, and you can study what the lesion in that area of the brain can cause. So that's what the name NMDA comes from, that poison that you give to the mice in the neurons. And it gave the name to the receptor. But we know that the NMDA receptor also mediates glutamate and glycine. And you have the AMPA receptors, and it may help with memory. And I think blockage of those receptors may cause losing your memories. And that's why some people cannot retrieve enough memories after that. But also, it has an action of other receptors, like dopamine receptor, that could explain some of the antidepressant effects, nicotinic, muscarinic, estrogen receptors. It may enhance short-term. We don't know long-term, because a lot of people do ketamine. Ketamine, of all the psychedelics, might be the most addictive, if you may say, or the one that you can use more compulsively. So you see cases of people who start using it compulsively, something you wouldn't see on LSD, something you wouldn't see on psilocybin. It's interesting that, for me, ketamine is the one that we can prescribe the most. And the things that we can prescribe in psychiatry are the most addictive, like Adderall, Benzos, and ketamine, that is less addictive than the others, but still more addictive than LSD, or psilocybin, or DMT. But this is where we are now. So it has an action of all these receptors, of pain receptors. That's why we do it for pain, as well. So it has, we know all this. Phenomenologically, if you're taking ketamine, you can feel these experiences. I mean, I felt these experiences when I took ketamine. I was feeling calm. I had a feeling of peacefulness, euphoria, no negativity. I remember thinking I could have the most negative thought, and I was feeling OK with it, feeling love. And then when you're listening, you do it with music. I tell the patients, just grab a list on Spotify, ketamine assistive therapy playlist, and you can go through that playlist. Those playlists are very enhancing, and then you can tell all the notes, all the instruments, and be connected to the music. It can also help with feelings about interpersonal relationships, about how you want to relate to your coworkers, to your partner, to the people in the world in general. It can expand psychological insight. And also, you can have vivid dreams. You can see images. And these images can be interpreted symbolically as well, almost like in a Jungian way, like in archetypes as well. But you guys are familiar with dream interpretation, with Sigmund Freud and Carl Jung. I think this is a method that I have found helpful to do dream interpretation. So I found myself, after I started referring patients for ketamine in the inpatient unit, reading the books about the management of interpretation of dreams in clinical practice so that I can work with the patients on that. And I was like, ketamine, you may feel dreams, and we can do psychotherapy about it. We talked about this already, but one of the pros of doing ketamine with therapy is it can help prolong the time to relapse. We don't have research comparing ketamine alone with ketamine with psychotherapy, but I believe it can prolong the time to relapse. So people who take ketamine, they can relapse their depressive symptoms. They can relapse in a week, approximately, or in two weeks, depending on how severe their depression is. And depression is very severe. I have patients that they relapse in three days. Actually, I have a patient right now in the inpatient unit that was taking 200 milligrams of IV ketamine weekly, and he would relapse in the depression in two or three days after taking 200 milligrams, which is the highest dose I've ever seen. It can improve the quality of life. If you think that the study that they did with Cajar heart rates, with SSRIs compared to psilocybin for the treatment of depression, they found that they were equally effective, the SSRI. But with the psilocybin, you can do only two doses of psilocybin. Instead of taking the SSRI alone every day, that you have to take every day with two doses, you will have similar responses. But if you do the psilocybin versus the SSRI, the quality of life was better. So I don't know what's the difference between quality of life and depression, because these concepts are arbitrary and abstract. But in my opinion, quality of life and depression come in parallel together. I mean, I don't think you can not have quality of life, and it cannot affect your depression. So it can improve quality of life. And some people were telling me, well, it's going to improve quality of life, but it's not going to improve depression. I was like, what do you mean that somebody can have a better quality of life and cannot get better from their depression? So this is something to think about. It can help to prevent traumatic or negative psychedelic experiences as well, and also the remission rates. But if you take ketamine alone and nobody tells you anything about it, it can be traumatizing. If you go through your traumatic experiences again, and you don't have anybody there to support that, I don't know. I think that can be bad for the patient. The cons is the financial cost, the burden. People say, well, you had to prove that this is effective. You had to bring a therapist. How are you going to bill for three hours of therapy here? It's going to have to be cash-only patients sometimes. Insurance won't pay three hours. You're there three hours with the patient. So we were trying to start, Albert and I were trying to start a ketamine clinic at the depression center of NGH. They were saying, how are you going to bill three hours? Who's going to pay for that? How are you going to have two therapists there? Who is billing for you? So for now, it's going to become a treatment for the privileged that can pay out-of-pocket three hours, unless we do. I mean, yesterday, I was in a talk of sublingual ketamine online. Like, they just send the ketamine to the patient, and they watch the patient on the computer with the therapist. And the patient goes through the ketamine experience, check themselves, the blood pressure, and then wake up and go back to the computer to talk to the therapist. I don't know. The cost was much cheaper. It was like $200 a session. But I don't know. What are the risks of doing that, of giving ketamine to somebody through the computer, and the patient has to check their own blood pressure? OK, so does it matter to have a personal experience? I mean, I think I have a bias. I have a personal experience. And I think it was so powerful that I feel that now. Actually, I noticed that I have one patient on ketamine now. And I tend to have one patient on ketamine every other month or so, because it's hard to refer them. But we are still able to refer them for the inpatient unit. And what we do, actually, to diminish the cost is to do the psychotherapy integration the day after the ketamine. So I tell the patient, this is your eye shades. This is the music you're going to use. You can use your iPhone here. I send it downstairs. And I say, take notes. And the next day, we do the psychedelic integration psychotherapy. And it's part of the billing. So it doesn't add any cost to the patient, because I had to see the patient anyway on rounds. We do the psychedelic integration psychotherapy as well. So I think it matters, because right now, actually, I've been able to share with my patients, hey, you know, I'm training ketamine-assisted psychotherapy. And I went through that as well myself. And the patient now say, OK, now I understand that you understand what I'm going through. And I think the patient will have a hard time connecting with you or empathizing with you as a therapy provider if you never understand that, because the psychedelic experiences are so different from our regular experiences that some people say, well, I can treat schizophrenia without being schizophrenic. I can treat trauma without having trauma. In psychedelics, if you haven't experienced that altered state of consciousness, it's very hard for you to give support and advice, it's very hard. And you will know once you have your own psychedelic experience. In the inpatient unit, what I was saying before, finally, it's the most effective treatment that we have for suicidal ideation, and it's more pleasant than ECT. If you get to choose between ECT and ketamine, let's say you have treatment-resistant depression or you have suicidal ideation, you're in the inpatient unit and they offer you ketamine or ECT. You have tried already your combo, your SSRI, your Abilify, your whatever, and you're still feeling miserable, and they offer you ECT or ketamine, what would you take? I mean, I know what I would take. One study in Denmark shows that it's potentially ECT more effective in severe patients, but very slightly more effective. So I would go for ketamine first. It's a very pleasant experience. ECT is not necessarily – I've never – I do ECT with my patients all the time as well. I've never had a patient who said, oh, I love ECT. It was so pleasant. You cannot do psychotherapy if you do ECT. How are you going to do psychotherapy with ECT if they forget everything? So there is no psychotherapy with ketamine. You can add psychotherapy. But it continues to be a problem. I wonder why most inpatient – and we're in a med psych unit, so we can do IVs – but most inpatient psychiatry units, despite being in a hospital, you cannot do IV. So you cannot give this treatment, which is the most effective treatment for suicidal ideation. And there is bureaucratic resistance. People say, we're just not going to do it. Idiot. Protocol. This is a protocol I wrote when I was having such a hard time referring patients to the ketamine clinic that I wrote a protocol to do IM. And I said, I'm going to volunteer time myself to just give IM ketamine to the patients here. I'm going to do it in the bed of the patient, with the nurse. I will be present all the time. It won't add any cost to anybody or no time to anybody. And they said, yeah, write the protocol, and we'll consider. So far, it's been waiting six months. They are rejecting it because nobody has done it, so they're not going to do it. I have this protocol. We're doing assisted therapy at the inpatient unit. This is what we do with the patient. We prepare them the day before. We educate everything about ketamine. We do an education. You would do it in the outpatient setting as well. Education, preparation, using the music, the eyeshades. Unfortunately, I cannot be there with them holding their hands. I would love that. I've done it with a couple of patients. I volunteer because they do the infusions at night. So I went there at night to hold the hand of the patient and be there. But sometimes you need to have your private time as well. And then the next day, they journal. They write about it. And then we do the integration psychotherapy after that. What is psychotherapy on ketamine? There is one study that they use cognitive behavioral therapy with the theory that they don't care about the psychedelic aspects of ketamine. They say ketamine, as an NDA receptor antagonist, it may help memory despite the block's memory, but it may help learning. The same with the other. It was DCS, decycloserine, that you could learn more when you were doing psychotherapy, this antituberculosis treatment. So the same thing for ketamine. They say, well, it might help the CVT, and maybe it's better. So it's open-label study. So people just tolerate it. And then we have the other study that Albert mentioned, that you do the ketamine-assisted integration psychotherapy. You can do yoga at low doses. It might be helpful as well, because you feel this connection to your body. And meaning-centered psychotherapy is something I did with one of the patients, because I feel suicidal. Meaning-centered psychotherapy is based on Vitor Frankl's Man's Search for Meaning, and it's a therapy that they do in New York. And I got trained in that therapy when I did my fellowship there in Sloan Kettering in New York. And I got trained in that therapy, and I found it very helpful, because suicidal ideation can be an existential issue, like life is meaningless. So doing meaning-centered psychotherapy can help you find meaning, and it was helpful for the patient. Collaborative assessment and management of suicide is something that Murat is going to talk about next. And then integration psychotherapy. What is integration psychotherapy? This is a study that Murat is going to talk about, that they are doing between Cleveland Clinic and Mass General, but I will leave it for him to explain. But we have recruited five patients in our site, and they have recruited a number of patients too. And we're doing ketamine with psychotherapy, with collaborative assessment and management of suicide, and comparing the psychotherapy with or without ketamine, and we're going to try to see the outcome. And this is Dr. Falcone and Dr. Altina, and I can talk more about it. This is a research protocol that I wrote that I submitted, but I didn't have the green card at that time, and now I have the green card. But if you don't have the green card, then they cannot give you the money. I didn't know about that, so I submitted it, but then I got rejected because, well, maybe they didn't like it, but also I didn't have the green card, so I was not eligible. But the idea was to compare ketamine alone in the ketamine clinic, adding psychotherapy, does it matter to add psychotherapy, can improve quality of life, can improve time to relapse. So that was the research study when I came to MGH I was trying to do. I'm going to talk about a couple of patients. This one was a patient, a 37-year-old African-American patient who had four people in his family dying to suicide, and he witnessed two of these suicides directly. He was going to New Hampshire, where you can buy guns, to buy a gun when the daughter called him and convinced him to go to the ER. He had two suicidal attempts himself as well. He was opposed to electrocompulsive therapy. He said, you know, as an African-American we don't do that, we don't do electrocompulsive therapy. So it took me like a letter to say I'm not discharging this patient, I think this patient is going to commit suicide. I could feel it as a clinician. I was like I'm not discharging this patient. If the unit director wants to come here and discharge the patient, fine, but I don't want to discharge this patient because I really feel he's going to commit suicide. I don't want to discharge him if we haven't tried ketamine first. He can reject the ECT. So I wrote a letter to the ketamine clinic and I said, hey, for this patient we need to make an exception. And this was the first patient that we were able to refer to the ketamine clinic. So at that time I was so naive. I was like, okay, what do I do here? So I started reading about ketamine psychotherapy and I started using meaning-centered psychotherapy as well, and the patient started resonating. And in the middle of when we're doing half the sessions of meaning-centered psychotherapy, we could refer finally to ketamine, and then we started doing ketamine-assisted psychotherapy. So this is meaning-centered psychotherapy. So the goal of meaning-centered psychotherapy is to find meaning in life through exploring your legacy, your identity, the future goals. And what we saw in this patient is by the end of the treatment with the ketamine, the suicide scores on the collaborative assessment and management of suicide scale, they decreased to one. And we saw the patient after six months, and the patient was fine after six months. So it was two ketamine-assisted psychotherapy sessions that changed. And I said, what was the most helpful? And he said, the therapy, like going able to disintegrate. It was very random. The first dream was a dream about his uncle. He had shot his uncle as a teenager, and the uncle never reported him. And then he was able to call his uncle and reconcile with his uncle after that. And he said, I have forgot that dream, that idea since I was a teenager. So he felt that he could change the narrative in his family. Four people had committed suicide. He was going to commit suicide. He at that time confessed, I have written suicide letters for everyone during my stay here. And now I tore the letters, and instead he wrote thank you letters for everybody. We saw him six months after, and he was still fine, working as a cook in the Harvard School. This is another patient that had a trauma patient. And we, the same. I was able, this was the second patient I was able to put ketamine-assisted psychotherapy. And now we've been able to refer six, seven patients. And we're trying to publish a case series on that. But this patient was, she sold the tickets for United Airlines of the flight that went from Boston to, was going to LA, the second flight that crashed on the Twin Towers, on the World Trade Center. And she talked to the terrorists twice, and they bought the tickets twice. But that time there was no this awareness. So she thought that was very weird. And then when all these things came out, if you see something, say something, all that was like, oh my God, it was my fault. It was my fault that I didn't catch it, I didn't alert anybody. And since then she had a severe trauma. She had a severe suicide attempt, taking like 140 pills. And she was admitted to, after 10 years. And she had sexual trauma also from early on in life. And she was able to, she went to McLean Hospital, and there they gave her 12 sessions of ECT. And she couldn't tolerate the ECT, and she was referred, because she was doing aspiration. And she was referred to our hospital, because we have a med psych unit, to continue ECT. And she was doing more ECT, and she was getting more and more depressed, because they said ECT is not doing anything to me. So I was able to write a letter to the academic clinic, and say, hey, you know, this person is part of, you know, is a 9-11 survivor. And they were able to approve the patient. And we did the, we started DREAMS. And she said, I have DREAMS. So that's when I started reading about DREAMS. I was like, oh, let's do DREAMS. So I started reading about DREAMS. And then I started reading Carl Jung's book of DREAMS. I started reading a book of the clinical management of DREAMS. I had read Freud's interpretation of DREAMS. So I offered the patient to the academic clinic. I offered a Freudian model versus a Jungian model. She resonated more with the Jungian model. I mean, I think I was a little biased myself when I was explaining it. But we started working in symbol and archetype. And she had a dream. The first dream on ketamine was that she was in a fireplace. And she was with a TV presenter from the 1970s, drinking a cocktail with her family. And she was feeling very good. And that night she felt not suicidal for the first time in 11 years. And she found that very pleasant. I said, what is fire for you? And she said, fire. And sometimes you have to hold a patient with a symbolic language a little bit if they don't have that ability at the beginning. So fire is seen sometimes as a transition. But also we interpreted fire as a calming place. Like you're in a fireplace. You are calm. You are peaceful. You can be OK again. You can be with your family again. And she felt very positive about it. And she accepted that interpretation. In a second dream on ketamine, the patient felt she was on a cruise with her family. And she saw her family on a cruise. And we interpreted the cruise as a place where you don't have to do anything. You don't have to worry. You don't have to plan. You can just be on the cruise with your family, enjoying the cruise. And at that time she felt she could work on her marriage. She was getting divorced. And she said, I think I can work this out. I think I can work out this marriage. On the third dream, she saw the faces of the terrorists of 9-11. But she didn't see them as threatening. Almost like an EMDR. And also she had an image of Bradley Cooper next to her. And I said, what is Bradley Cooper for you? I mean, he's hot. And I said, well, I agree. I mean, he's hot. And I said, OK, well, this can be that you can experience romance and lust again. And she said, wow. Yeah, actually, I feel that. I want to experience romance and lust again. In a fourth dream, her mother was her favorite person. And she had died years ago. And she could dream for the first time of her mother. And after that, she was able to dream about her mother without ketamine recurrently. Her CAMHS scores decreased significantly. And unfortunately, a patient was able to talk to the insurance to get ketamine outpatient. But the insurance approved it. But they didn't give enough money to the clinic. And they said, we won't take the patient. So the patient relapsed. And then she came back to the ER. And she said, I want more ketamine. This is what helps me. And instead, they sent her to McLean. But in McLean, they couldn't do ketamine inpatient. Because they don't do it there. And she spent three months at McLean, which is like $3,000, $4,000 a day. Three months there, when the ketamine is like $20, the treatment. Or if you do a ketamine infusion, it can be up to $500. It would have been much cheaper than keeping her in McLean for three months. So I've seen since then. This is my last slide. But since then, this last case I published in the Journal of Clinical Psychopharmacology. And the other case I published in the Journal of Palliative Care. And then we wrote, Albert and I, I think with you, with Maren, we wrote a couple of reviews on ketamine as well. And I think we're going to try to publish a case series of the six cases. But so far, I had two patients who didn't like it. And they stopped the treatment out of six in the inpatient unit. I had one patient that really liked it. And she was a 70-year-old woman, completely naive to psychedelics or ketamine or anything. And she really enjoyed the ketamine-assisted psychotherapy. She said, I could see. And she worked with the symbolics. She said, I could see Jesus. She was a Catholic Italian woman. She said, I could see Jesus in the front. No, angel. Angel, the saint, protecting me. Jesus in my back. I could have the Virgin Mary and Isis, like the eternal mother. And down, I had Mother Earth. And I felt the mothering experience. And mothering was the most important thing for her in her life. And she felt very good about it. And I have another patient that I'm seeing now. They were doing ketamine for a long time, one infusion a week, 200. And when I took the patient, because after three months, they transferred the patient to me to see if I want to continue with the patient. And when I took the patient, I talked to the ketamine clinic. Can you reduce the dose from 200 to 130 so that we can retrieve psychedelic material? And the patient liked it. And he said, the 200 was maybe a little bit better for depression, but I couldn't retrieve material. And it feels so good to talk about these psychedelic experiences with you that I want to stay at this dose to continue to do psychedelic-assisted therapy. And the patient that I have right now weighs 400 pounds. And because of the weight, he has static dermatitis and recurring infections. He has muscle atrophy. And he's bedridden, and we cannot discharge him anywhere. He's been for a year in the hospital. And he's depressed. And with the ketamine, he has dreams about food. The first dream was cupcakes. And cupcakes, I said, what is cupcakes for you? It's like, cupcakes is goofy, but it's like the bad food. It's like, cupcakes is a food that I don't want. I want to lose weight. And then the second dream was about being at the patient had a trauma because his father abused his mother, and the mother killed the father. So he lost the father. I mean, he lost both parents to homicide and to abuse. And then he grew up with his grandparents. So he could be with his grandparents where he was feeling safe with his grandparents. And then the mother was a beekeeper, and she could experience honey as the good food. And now that is changing his relationship with food. So we are exploring the relationship with food, like the same relationship you can have with your mother or your father, food as a relationship. And the patient now is meeting 80% of his goals that we are doing. So he's not losing much weight, but he's meeting 80% of the goals that we're establishing for him to be able to refer him to a nursing home. So that's all. This is my email if anybody wants to reach out. Thank you so much for your attention. All right, so the last talk, I will be talking about the therapy program that we have for one of our clinical trials. And one of the reasons why we're talking about CAMS is because in the particular clinical trial that was mentioned, we use CAMS as our therapeutic procedure for people who are actively suicidal. I don't have any disclosures. So I don't think I need to convince anyone in this audience about the risks and the seriousness of suicide. So in 2017, 800,000 people died by suicide. And in 2019, 20 times more people attempted worldwide. And SAMHSA's 2021 report shows that 20 million people have serious suicidal ideation. So traditionally, the understood and accepted treatment of suicide has always been diagnosing the patient, aggressively treating the situation and hope that suicidal ideation would go away. But that doesn't seem to be a very effective strategy. And in terms of therapeutic or psychotherapeutic, I should say approaches, DBT, brief cognitive behavioral therapy, cognitive therapy for suicide prevention and mindfulness were some of the traditional treatments for suicide. But again, in terms of efficacy, I think we have seen that these approaches are not as effective as some of our newer approaches for suicidal ideation. So essentially we need to prevent suicidal behavior, increased clinician confidence to work with suicidal patients, and also more tangible, adaptable, flexible, and trainable suicide prevention strategies need to be formed. Before we get there, I want to clarify a couple of things about suicidal behavior in general. So suicidal behavior or suicidality is not just one thing, right? So when we look at the behaviors, when we look at the ideation, there are multiple components to it. So there's the suicidal ideation, having the actual thought to kill, to want to kill oneself. There is a suicide plan where we actually have a plan as to how we would do it and the suicide attempt, the actions that take us there. But there's also the deliberate self-harm without the intention to kill. There is the non-suicidal self-injury, which again goes into that category. And suicidal intent is also very important, our desire, our willingness to actually go through with it. And of course suicidal threat or gesture, usually without an intent to die but to get some help. So what is CAMS? So CAMS is developed by David Jobes in 2016. It is a suicide-specific preventative therapeutic network. It's a roadmap emphasizing five, four components of collaborative clinical care. It's usually 10 to 12 sessions, so it takes about three months to complete. And it is technically a clinician and a patient partnership. So in doing CAMS, when you do it in person, you actually sit with the patient side by side, and you together form a therapeutic alliance and also a technique and framework to address suicidal ideation. And the key to CAMS success in general is to cooperate with the patient, so there's no hierarchy in terms of helping the patient, and there's full transparency focused on suicidal ideation and suicidal behavior. It is primarily an outpatient-oriented therapeutic process, but it can also be done inpatient as well. All right, so we can divide CAMS into three phases. The first phase is the initial session, where you conceptualize and understand the drivers of suicidality. You come up with a stabilization plan with the patient, and then you also understand patient's drivers and also barriers between the patient and suicide. Then from there, you move on to the interim sessions, where you keep going back to the initial session, assessing the drivers, looking to see if there are new drivers, and then come up with alternative plans to suicide. And then lastly, the outcome and disposition session, where you end everything. So let's look and see what some of these components are. I'm sorry, it might be a bit difficult to read because the screen is a bit small. But at the beginning of the session, you look at the suicidal risk of the patient in that session, and I'll go into a little bit of detail of that. Then after you do that, you come up with a treatment plan with the patient in terms of how we're going to prevent the patient from actually acting on some of these suicidal thoughts. As I said earlier, we try to understand patient's suicidal drivers, the bridges and barriers of suicide, and then specific interventions according to that patient's reality, and then also developing some reasons for living, again, for that particular patient. So this happens, the collaborative assessment of suicidal risk happens at the beginning of every CAMS session. So you ask the patient about the psychological pain, the stress level, the agitation, hopelessness, self-hate, and overall risk of suicide at the beginning of every session, and you rate it from one to five, five being the highest risk. And the patients answer these questions depending on how they're feeling at that moment, not past week, not yesterday, but in the moment when you are sitting with the patient. And then after you're done with that, you move on to the collaborative assessment of suicidal risk in terms of you rank these, so you rate them and then you rank them in terms of which driver is the most important to the patient at the time. And then you also identify the barriers in suicidal thinking and behavior and you also come up with some ideas in terms of the one thing that it would help me to no longer feel suicidal would be XYZ. Then you come up with a treatment plan with the patient. So the first item in terms of the problem, objectives and interventions is always the self-harm potential. So the first problem you're gonna put in there will be the self-harm potential, the goal will be safety and stability and then the intervention will be the stabilization plan that you're gonna work with the patient after. But then you move on to, so that first item will be the same for everyone, but for the item, the second and third items for the problem, goals and objectives and interventions will be patient specific. Like for instance, I'm having explosive fights with my mom, the goals would be to minimize the fights and then the interventions will be every time we are approaching a fight, I will do XYZ to prevent that fight. So those items will be specific per patient. The other helpful tool, which is not, you don't have to do this, but I find it extremely helpful to use the CAMS therapeutic worksheet because then you have a much deeper understanding of the patient and you also understand what certain suicidal thoughts or behaviors mean to that particular patient. So you take a personal history of that patient's suicidal ideation. Why am I feeling suicidal? What is my relationship to suicide? Is it escapism? Is it because I've learned to feel that way automatically over the past several years? So what does suicide mean to me, to the patient? Then the drivers of suicide. What is driving me to suicidal thoughts, specific thoughts? What are the feelings that lead me to suicidal thinking? What are my specific behaviors? What are the themes in my life that lead me to suicidal thinking? So that becomes again an important tool for us to understand the patient. And then you also conceptualize suicidal ideation with the patient. What are the bridges that lead to suicidal thinking and behaviors and what are the barriers that will stop that patient from going there? So that is also a good way to again understand a particular patient's drivers and barriers in terms of how they reach to that thought and behavior and what prevents them from going there. So this is an example of the stabilization plan and that's very specific. Again, this is something you fill out with the patient specifically. So what are some of the lethal ways that I am using to get to suicidal behavior or thinking? How can I cope differently? Who can I call when I feel that I'm out of sorts? And of course, is the patient attending the treatment as scheduled? Are they identifying their potential barriers? Are they trying on solutions? So this is something that you start, you fill this out in the beginning session but then you keep updating it as the patient goes through the CAMS process. In addition to filling all of this out with the patient, the other thing that you do as a clinician at the end is to fill out the clinician section of CAMS which essentially is a psychiatric assessment form where you record the frequency of suicidal ideation, suicide plan if there is one, and all the other areas that you see here which talks about patient's impulsivity, physical health, barriers, all of the things that you discussed during that session. And then you also, again, do a mental status exam and rate the patient's risk for suicide at that visit. So these clinician forms are the forms that you fill out during every CAMS session. So let's look at some of the CAMS research in terms of how effective it is. So there has been and still are several randomized controlled trials looking at CAMS efficacy in treating suicide. This is a summary of most of them. But I wanna talk about the meta-analysis that looked at CAMS. So this was, I believe, published in, for some reason I don't know how to date, but I think it is 2021 or two. 1,000 articles were reviewed, nine included in the final analysis which included information of 749 patients. And primarily these studies compared CAMS to treatment as usual or CAMS to DBT. And again, by treatment as usual we mean hospitalization of the patient, treatment of the underlying diagnosis and hoping that that will help with suicidal ideation. The results, CAMS significantly outperformed other interventions, lowered hopelessness significantly, had higher treatment satisfaction overall. There was no difference in terms of self-harm and cost effectiveness. Another new development, so usually CAMS obviously is done individually with one-on-one with a patient, but in 2020 there was a pilot study done on 30 veterans to do CAMS in a group setting and they titled it as CAMS-G. And that was also found to be pretty effective with good satisfaction and creating a sense of cohesion among members. So as mentioned a couple of times during this talk, one of the reasons why we're talking about all of this is because we have a new clinical trial at the Cleveland Clinic where we treat young, so MGH, it does the adult portion of that study and at the Cleveland Clinic we have the pediatric portion of the study where we give IV ketamine infusions to youth who attempted suicide and who are inpatient between the ages of 15 and 24. They're randomized to ketamine or normal saline, which is infused over 40 minutes, 0.5 milligram per kilogram. They get ketamine infusions until they're no longer suicidal or if they are discharged from the hospital. So a ketamine portion of the study ends there and as soon as they're done with that, then we start weekly CAMS treatment to help that patient and they continue with the CAMS until they're no longer suicidal or once we complete 12 sessions of CAMS. And as I said earlier, so usually CAMS is primarily an outpatient focused treatment but it can definitely be used inpatient as well and as you can see here, it can be applied in all of these settings very easily. Here are my references and I think that's all we have. Thank you. Thank you, and I'm going to be super short so we have time for questions. So I wanted to kind of like summarize. So yes, we're doing this study, but it's NIMH funded. So Dr. Altenay kind of disclosed, discussed a little bit about how CAMHS really engages the patient and can be in our studies and additive effects. So the patient is admitted to a hospital after a suicide attempt. The psychiatrist in the unit pick whatever treatment they want, and if the patient decide to participate in the study, it's an add-on treatment. So they'll get ketamine or placebo, and then everybody will get CAMHS. And I can tell you, as a psychiatrist, in the last 20 years, from all the different things I have learned, CAMHS is probably in the top three of the tools as a psychiatrist that you can learn. It takes two days to go through all the theory of CAMHS, and then it takes one day of practice, and then one month, once a week, one hour. And I felt like it gives you so many tools to treat your patients who are suicidal. And it's a short-term intervention. So the mean effectiveness is 6 to 8. In our study, we're going up to 12 if the patient need it. And it's focused on the collaboration with the patient and identifying the reasons for leaving. Then Dr. Spieforsen give us a personal account of his experience with ketamine, and also discussed the potential of using ketamine in the inpatient unit, like the pros and cons, but most important, the barriers. I can tell you that even just trying to get our trial off the ground, the fact that in most of the psychiatric units, we can use IB was a major barrier. So for our study, we have to move the patient from the child psychiatric unit to the PITS unit, and then readmitted back to psychiatry because we couldn't come up with an agreement that it was safe to do the IBs in the unit. And I think it was really interesting to also hear all the other kinds of therapy and how you are exploring these in the inpatient unit. And then Dr. Jung give us a journey through the different psychedelic studies in the past century, some of the clinical trials in psychedelic psychiatry, how the dose of the ketamine can have an effect in the trance and transformation, and how the psychedelics can have an impact on the patient journey and experience, right, and how that can be used for psychotherapy. So I think what we learned is like the effects of ketamine can rapidly improve some of the symptoms, and as we heard, in different conditions like depression, treatment-resistant depression, suicidal thoughts, and I think there are many others that are being studied right now like OCD, PTSD, that we don't have enough data to see the effectiveness, but I think the studies are coming. The potential use for inpatient psychiatry, some of the barriers and limitations, you know, inpatient and outpatient, right? I also have to mention there's some concerns about like the widespread use with not enough supervision, right? And I think what is very unique about ketamine is that, yes, we know it helps the mood symptoms. We know it helps the suicidal thoughts. The problem is like the patients continue to have like improved for some time, and then they come back. So what we don't know yet is like what is the effective dose? Like do patients need six infusions? Do patients need three infusions? And like also a range of the dose. So I think some of the new randomized controlled trials are going to help answer those questions. Also we learned about CAMS as an evidence-based practice to treat suicidal patients, and other really engaging forms of psychotherapy. So what are some of the unresolved questions? Like what is the right dose of ketamine? And I mean how many numbers of infusions and treatments, does dose matter? What is the difference between the people who have one infusion versus three infusions versus one infusion once a month? What is the safety profile of the ketamine for some other psychiatric conditions? And I think, as I said, some of the other randomized controlled trials are going to help us with that. And as Fernando was telling us about all these other really exciting therapies, but therapy models and how hard it is to get the insurance to approve three hours of psychotherapy that could be really meaningful for the patient. And what patients are good candidates for this treatment versus what patients should not be getting this treatment. And I know this one will have an article that, I'm not part of the article, but it's coming up today on a multicenter study of ketamine and ECT and the effects of that. And with that, I want to hear comments, questions, thoughts. And thank you for being here. Yes. Hi. Thank you for this talk. I'm Shira. I'm from New Zealand and I work in an intensive psychotherapy service for treating trauma and personality disorders. We had recently experience with two patients who self-referred themselves to a ketamine psychotherapy treatment and both of them didn't have very good outcomes. One had, actually it didn't help him. And the second one was actually worsening. And that made me think about the fact that I'm assuming that some of the patients who present with depression and suicidality, they have at least, you know, some of them, they might have a person, underlying person, borderline personality organization. And I wonder about two things. First of all, if you're doing a psychodynamic formulation to the clients, which we know is a process that might take time and skills for the assessor, for the clinician. And the other thing is how do patients with identity diffusion, which is, you know, one of the characteristics of borderline personality organizations, how would they experience the ego dissolution experience of this ketamine treatment, if you have any thoughts or experience? I can start and then I'm going to pass it to you. So I can tell you that in our study, because we knew there was not enough data on the effect for patients with borderline personality disorders, we decided to exclude them for the study for that reason. Nevertheless, I can tell you that patients who had some borderline traits struggle a lot in the therapy part. And I will say that the therapy was definitely longer than just your regular. And what we ended up doing with this one particular patient who felt like the ketamine was helpful and participated in CAMHS for 12 sessions, at the end of the 12 sessions, we refer her for DVT. But please. You know, of the six patients I had, I think only one had a possible borderline. We thought it could be borderline, but we were not sure. The patient was very negative. And that patient didn't like the treatment, didn't respond, and that's one of the patients who didn't like the treatment. In the study, normally when we have patients with borderline personality, they want ketamine in the inpatient unit. They are like, I want ketamine, I heard this is the best treatment, and TMS, and ECT. So we see a lot of that. But I try not to, because I know there are some psychological mechanisms, and I don't want to use the resources for that, because I think there is not much evidence other than I like it, sometimes, unless we find more better treatments. But in the research study, we exclude borderline personality disorder. So people with the diagnosis, we exclude. But we were like, what do we do with the borderline personality traits? Because that happens very often. So we're including those patients, and they get more excited, my feeling, with participating in the study, and more engaged with the therapy aspect. So I think a mild borderline might be helpful. So not at the psychedelic level, but at the 0.5 milligram per kilogram level. So we completed a study where we compared ketamine and ECT head to head. And it was a naturalistic study, so we didn't necessarily exclude people with personality patterns. So my anecdotal, and the actual results will be published today, later today, so I cannot really talk about the results. But anecdotally, what I can say about people with borderline personality traits is that they were good responders in the beginning, but they were not able to sustain the response because of the, I think, personality patterns that started becoming an issue and got in the way of their persistent response after the acute series of ketamine infusions were completed. But I cannot talk about the ego dissolution part, because we did not study that. Yeah, I just want to address the question about ego dissolution, and we don't have data to support or to disprove. I told my patients that the good news is that we do not know how this works. We do not know whether ego dissolution is important or not important. We use the framework for meditation and Buddhism as a way to look into what possibly is going on during these psychedelic journeys, and then try to make some kind of comparison. So we don't know how important this is. Thank you for your question. Thank you. Well, thank you so much, first of all. Fernando, I think that you referred in the middle of the conversation around a ketamine treatment of around $200. I believe that happens to be my company, so thank you for giving the reference. The company is called WonderMed, and for anybody that is interested in learning a little bit more, we're taking a lot of criticism, which we like a lot. We want to learn as much as possible how we can limit the risks. But this is a question for you guys. When we've been treating patients, and now I believe that it's over 1,200 patients that have gone through a clinical study, we notice how, even though we're treating anxiety or depression or PTSD, there are other aspects of their mental health state that also improve, even if that wasn't the initial intention. We've seen, for example, even instances of Parkinson's disease, and having seen very drastic improvements on the patient. I would love to hear a little bit from you guys of those kind of exoteric forms of diagnosis that were not primarily intentional to get improving with ketamine, but that potential psychoactive experience maybe allowed them to improve in that as well. Yeah, I mean, in our clinical trials, we don't usually include people with those kinds of medical problems, so I cannot speak for that. But yes, I do agree with you that there are so many peripheral effects of improvement that we don't initially expect other than the depression itself. But for other medical diagnoses, I can't really speak for in terms of our own, in my personal experience. Same here. Yeah, I have experience with like whether ketamine can be helpful, not helpful, for patients with some kind of medical conditions. I think, to be honest, we have limited experience with ketamine-assisted psychotherapy. This is interesting. We're trained to do that. We are trying to gain more and more experience, but the experience is still limited. We have a, one of the psych residents wants to start a trial for people with chronic pain. And I think it can be very helpful in people with chronic pain potentially, but there's no research. But yeah, thank you. I don't know if I saw you yesterday at the talk. It was my colleague. Oh, your colleague. Yeah, I went to that talk because I was very interested in, I tried myself to start some private practice, ketamine, and trying to take insurance. I couldn't bill the insurance. I said, this is gonna be a cash practice where only very rich people are gonna be able to afford it. And I learned about your company through a friend who was from Uruguay who said, hey, you know, I can get ketamine for $200. I was like, wow, how can you do that? Then I saw, oh, wow, that model, that made a model to make it more democratic and available for other people. So ideally, everybody gets two therapies for three hours, MDs, PhDs. But when we're, Albert and I, we're trying to start a practice at MGH. They were like, how are you gonna pay for that? Nobody's gonna pay for that. Are you gonna bring, you're gonna bring the privileged people here, so you wanna do a cash practice, go for it. But so, you know, we don't have a model that everybody likes, but this is what it is, what we have. I agree. Thank you so much. Thank you. Next question. A question and a comment. The question is, is there a peer-reviewed resource which outlines the expected standards for psychoactive psychotherapy, or psychotherapy that's assisted by psychoactive drugs? You mean like a guideline? Yeah. Well, Albert can comment more on that, but there are several... There are several modalities, right, yes. There are several modalities. Like is there a peer-reviewed reference? So I think, well... Consensus of what it is and what it means. The most common is MAPS, Multiple Association of Psychedelic Studies. You can see a research protocol, and then there are other modalities of training, but Albert can comment more on that. I think we're not there yet. So recently, we have the MAPS doing studies using MDMA, and then we have studies using psilocybin to treat depression, but they're only at this stage two. So we are not there yet. FDA has not approved using any of those psychedelics for treatment of depression or for any clinical condition except ketamine. So I think we don't have a guideline, and then we're still not there yet. But it seems a lot of the clinical studies show that there is promise, but I do not feel that we can say that, yes, this is definitely work, and this is a guideline to use this for that condition. Got it. Got it. The training, there are multiple agencies that you have the California Institute for Integration Studies, all that, but the guidelines, no. Okay. Another observation is we have an insurance-based practice and a number of providers who've gone through those trainings here in the Bay Area, a large cohort of esketamine. Some of the providers do psychotherapy along with the esketamine. Some don't. So we leave it optional depending on the physician's training. These are on barely treatment-resistant patients, patients who have failed TMS in our depression care pathway. We offer esketamine after TMS because of some of the durability differences. And we published a poster at Psych Congress, and we did not find any improved durability with the psychotherapy-assisted esketamine. Most patients have remained on esketamine once a week. So that's been our observation. I think that's a very good point, and it would be interesting to publish that data. My feeling is severe depression, the esketamine is going to make you feel good. And for a week, you're going to feel good. Like, it's very antidepressant, but it lasts for a week or so. So many of these patients are going to have to stay chronically on esketamine or ketamine. But the question is for how long, because if you take too much ketamine, you start having cognitive problems, the opposite to synaptogenesis. For people with mild, moderate depression, it sounds like the psychotherapy experience can be very powerful to the extent that you might not be able to go through that, but you have to create the right set and setting for that as well, not like just take the ketamine and we might do psychotherapy or not. So that's my feeling. Yeah, we have actually a very well-built-out clinic with wooden panels and nice furniture, so I don't think it's a set-and-setting issue at our clinics. Maybe the level of treatment resistance, I guess, is what I'm... More severe patients, if they have very severe depression, they tend to realize, regardless of doing ketamine or high-dose or low-dose or psychotherapy, and when they stay on ketamine, in some patients, one that I see now, it tends to last less and less, the effect of the ketamine. Thank you for your comment. Hi. Thank you for your talk. I came from Mexico. I've been doing ketamine for about seven years, almost 200 patients right now in our university. I am concerned about what you're saying, Fernando, about it is recommended for being a ketamine-assisted psychotherapy to have the experience of ketamine. I mean, I think that's too risky to say because in our 200 patients, I've never been in ketamine, and I think I understand the ketamine experience of our patients. But that's your personal opinion. I think the opposite. I have a colleague of mine, a psychiatrist, that were doing ketamine with me, that he died by suicide with ketamine. So I am very respectful about ketamine. And I was trying to say just two things. I think it's too risky to have a borderline personality disorder in ketamine procedure because we don't know what's happening in the mechanism of this patient. So in our protocol in Mexico, we try not to get ketamine in borderline personality disorders. But if we do, we try not to do these interpretations because we really don't know what's happening with them. And I think that the point that you mentioned is that we don't know. We actually don't know what's happening with these patients. If it's also the therapy, is the mechanism of action, I think that ketamine is only biased time in order to improve our treatment. And that's it. It's my comment. Thank you. I don't know what you think. I will respond first since you mentioned. I think in the medical model, and psychiatry is right now in the medical model. You take the pill for the condition that you need to have. And I think that's fine, especially if you're using ketamine as a neuromodulation agent. But the problem is, if you don't do psychotherapy, that the patients who have trauma may find traumatizing to go through ketamine. And I think the dropout could be related to that that you see in ketamine. In the psychedelic model, that is not necessarily the medical model, you need to have the psychedelic experience in order to be trained, especially if you want to be a therapist. And it follows more the psychoanalytic model. So you cannot be an analyst if you haven't been psychoanalyzed. So you cannot be a psychedelic therapist if you haven't had a psychedelic experience. But this, I understand, is different from the medical model. Many psychiatrists just are restrained to the medical model. Your friend committed suicide on ketamine. Ketamine is technically anti-suicidal, but I think to have the ketamine experience can really help you understand what the patient can go through. But this is up to every person, the way we practice. I know in Latin America, because I gave this talk last year about psychedelics in the Latin American Association, and many people came to me, some people were frustrated, I even got pushed by somebody. But the thing is, this is the way we believe is the way in the psychedelic realm to practice this. It's not something like, it's my opinion. And I think it would be very hard, as somebody who has had a psychedelic experience, to talk about my psychedelic experience with somebody who has never had a psychedelic experience. So they can prescribe it to me with safety and things like that, but not to do the psychotherapy. But this is, I think, different opinions is completely okay here, because we don't know. The truth is, in psychiatry, sometimes we have a problem that when we don't know something, we come with a hypothesis, and we just repeat the hypothesis a hundred times, and we just make the hypothesis the reality. But in psychiatry, we need to be humble. Many of the things we do, we don't know. Thank you guys for the talk. Great talk. I think for both types of therapies, I have one question for each and a comment. So by disclosure, I do have trust issues. So when it comes to doing ketamine-assisted psychotherapy, the study you presented, we talked about from yesterday's talk, they were very clear that they were not claiming it to be ketamine-assisted psychotherapy. But we all know there are companies out there who want to prescribe sublingual ketamine virtually, some therapists are sitting virtually, or there are therapists who are looking for providers to prescribe ketamine, and they would be providing the ketamine-assisted psychotherapy. So what qualifications or what credentials are we looking for in the therapist as a competency to be able to provide ketamine-assisted psychotherapy? That's a long first question. Second question is for people who got ketamine in an antidepressant dose and were followed by CAM. If the patient's suicidal ideation had resolved by the antidepressant dose, did they still get the CAM? And the third comment was just to add to Fernando. I think MUSC is doing IM ketamine because they're not allowed to do IV ketamine. So that's a referral source. In terms of the CAM's question, it's an ongoing study and that hasn't happened yet, right? So nobody got completely resolved suicidal ideation in the inpatient phase? So we are doing the CAMs to everybody, everybody in the study is receiving CAMs. What we're randomizing is ketamine versus placebo, that is normal saline. And then after they are leaving the hospital and they're no longer reporting active suicidal ideations, they continue the CAMs weekly for around six to eight, up to 12 sessions. So they can get CAMs without being suicidal if they had suicidal ideation resolved by ketamine or placebo, they would still get CAMs. So what happened with ketamine, right? And I think we have been talking about this also, is the effect of being in the hospital, right? So if you admit someone to a hospital because they're suicidal, like in our experience, like all the kids from the day one, they are saying, I'm no longer suicidal because they want to be discharged from the hospital, right? So they receive ketamine and we see some changes acutely on the suicidal thoughts. You know, after a couple of infusions, they leave the hospital. And I can tell you that four days after they come back to be suicidal, right? Because you see like the chronicity of the suicidality, right? And your first question. In order to do CAMs, somebody doesn't have to have an active plan and acutely suicidal. So you can still work on all of the framework and all of the other areas of CAMs without, you know, the active, active suicidal, acutely suicidal thinking. Thank you. I think this is a, you asked about, say, who is qualified to provide ketamine or psychedelic assisted psychotherapy, particularly ketamine. I'm not qualified to answer that question. I think the question belongs to the regulatory board of the state. They need to have a law to decide who can do that, who cannot do that. At this point, people are doing it with their own judgment and at their own risk. So personally, I'm not prescribing for other people because I don't feel comfortable to do that. And I do not know that. So it is, again, there is no law granting the authority to do that or forbidding people to do that at this point, as far as I know, it depends on the state that you're in. So more will come and then people will have a consensus and hopefully by then the law will come out and people feel more comfortable if they are not an MD, whether they're able to do that with a, working with a prescriber. I think, I will add in therapy, like sometimes we are not certified in something and we can use the techniques as well. So I'm not a psychoanalyst, but I can use psychodynamic techniques with the patients. I'm not a certified CBT therapist, but I can do a thought record with a patient and work with a patient. So, you know, if you are looking for a therapist and the patient is already on ketamine, getting infusions and they want to look for a therapist, the way I would look for a therapist is by saying somebody who has experience working with patients who are taking ketamine and is a therapist and is a qualified therapist in general. So I think that would be the way to go. There are some trainings that you can do, like ketamine assisted therapy training, Fluence, Polaris, there are a lot of trainings online, but there are no official qualifications for that yet. Yes. Thank you. Question. Hi. Marianne Shepard, California. And I think I'm one of those psychiatrists that have, as a therapist, a DBT certified as well as all the others. And I do a lot of therapy with my patients, but I have been really hard on a couple of my patients who have been doing ketamine on their own outside of me with an anesthesiologist stating for pain. And I have not been, I know I've not been helpful to them. So this whole meeting, I've been going to meetings to learn. And I'm wondering now, how, what do I, what can I ask? I'm not actually prescribing the ketamine, but what can I do to inform myself with the anesthesiologist who's willing to talk with me about what he's doing? But also, what time frame from her infusions until I see her can I wait? I mean, should we make our sessions closer? So those are my questions. And I really appreciated your talk, all of yours, and the CAM in particular, having done pretty intensive DBT therapy, I saw a lot of interesting things in your therapy that could be helpful. Thank you. I mean, thank you for the CAMs. I think your question is, what should be the time difference between the ketamine infusions and therapy that you're providing? So I guess maybe that's more of a... I think you can do it on the next day, on the day of the infusion. Sometimes I've done like a, you can do a preparation. You want to do relaxation or preparation. But the day after the infusion will be a day, like they can take some notes or draw a picture. Then they can bring that to the therapy and you can do some therapy. Is it just to be, if you are a therapist, your patient is getting infusions for pain, but ultimately you can use that treatment already to help the patient, the psychotherapy aspect. And would it be wise to know the amount, if it's a high dose, low dose? Yes, it would be nice. And the patient can tell you, they can say, hey, can you tell me which dose they use? Because if the dose is very high, the patient might not be able to remember much. The patient, if the dose is low, normally they use a dose of 0.5 to 1.2. So most of them can retrieve material. But the higher you go on the dose, the less, it becomes more dreamlike or don't remember anything. Also, I think one thing to take into consideration is that, and I have such patients too who go to ketamine for anesthesia for pain management. So because set and setting and the reason for the infusion is important, so that also needs to be taken into consideration because it sounds like your patients are not going to these ketamine clinics for the antidepressant effect, right? So they're going for chronic pain management, which is a completely different ballgame. But just to consider that as well. My understanding is that most patients who receive ketamine or ketamine infusion do not receive therapy. So this is the biological model. People may not believe in therapy may be necessary. However, people who have done this, I feel that if the patient can process with their psychiatrists, their psychologists about the experience, they can greatly benefit from that. And what about the duration? Duration, my experience is that three, four days could be fine. Patient would have time to process it on their own and then make notes and then sometimes a lot of emotional upheavals. And after that three, four days, they may calm down a little bit and then we process it with them. They like it. And they will ask for help if they need more sooner appointment from you. I can't handle it. Can I see you sooner? Something like that. But they will benefit greatly. Thank you. Hello. Thanks for putting this on. This has been really interesting to me. My name is Steve Manlove. I have clinics in South Dakota and Minnesota. And we do about 50 ketamine treatments a day between the two clinics. And we have been doing this for three or four years. And the model that we've developed is one in which we prepare people by having them do a sort of a mindfulness training, because at least that's a model that we think allows people to lean into the ketamine experience a little bit, prepare themselves to dissociate and to observe their dissociation, to be part of that process. We provide a safe environment, but we don't do therapy during ketamine treatment. And then we do psychotherapy afterwards, as you guys have been describing. One of the questions that I've had is, is there a value to doing treatment during therapy? We have not done that intentionally, but I'm seeing some models where people are doing that. I don't know if anybody's got any thoughts about that. And the other thing that I would say is, we think we've tried pretty hard with psychotherapy and ketamine. We don't see ketamine curing depression. I mean, successions, psychotherapy, and they don't have depression again. I wish that were the case, and it would be wonderful if somebody's got a way to do it. But you know, there's really nothing in psychiatry that cures depression. So it would be really a surprise if it did. But anyways, I'm curious what your thoughts are about the notion of doing ketamine, doing treatment psychotherapy during ketamine versus afterwards. I think that psychotherapy can definitely improve the quality of the experience. So if you don't do any psychotherapy with a patient, I mean, what's the cons of giving psychotherapy? What is the contraindication of adding a psychotherapy component to the treatment? I mean, it distracts them is my concern. I want them to have their ketamine experience without me directing their thoughts or even me affecting their experience. And then I would prefer to address it afterwards. The question is, during the ketamine infusion, doing therapy while they're getting infused or while they're under the influence? That's the question. While they are getting infusion, what we were doing when I was being trained on this is you are a viable for support, for holding hand, and for help the patient with experience. And then after the patient wakes up, the patient can start talking about their thoughts and their experience. So that's how we were doing it. But then what I do in the unit is, the day after the infusion is when I integrate the session. So I think you could do both. I just think from a practical perspective, I can train a reasonably bright, reasonably well-educated person to do the comforting piece, to be there with them, to support them, to save the psychotherapist for after, when we're really actually able to do psychotherapy. Just as a practical thought, it's expensive to pay a psychotherapist, especially two. I think the most practical is to, if you want to send a bill, it's the next day. To do the one-hour session the next day after. Thank you so much for being here. Sorry. My last comment is that during the session, during the academy session or the infusion or the IM, sublingual session, we encourage patients to be internally focused during the session. So we don't jump in a lot to do therapy. And that's the model. It seems sort of like interrupting somebody when they're meditating, in a sense. That doesn't make sense, right? I agree. Exactly. Thank you very much. Thank you so much. Thank you very much. Appreciate it. Thank you.

ketamine therapy

psychotherapy integration

NMDA receptor antagonist

dissociative psychedelic

antidepressant effects

trauma management

dosing standards

insurance limitations

Collaborative Assessment and Management of Suicidality

suicidal ideation

depressive symptoms

regulatory hurdles

inpatient settings

psychedelic-assisted therapy

research protocols