A Cohort-Based Case Report: The Impact of Ketamine-Assisted Therapy Embedded in a Community of Practice Framework for Healthcare Providers With PTSD and Depression

The impetus for embedding ketamine-assisted therapy (KaT) within a group-oriented community of practice (CoP) revolves around the growing mental health crises in Canada, with healthcare providers (HCP) disproportionately impacted (1). Due to high stimulus and trauma-laden work environments, they are at a higher risk for mental health challenges (2). Even before the pandemic, 40–60% of HCPs were experiencing burnout at some point in their career (3), and the addition of COVID-19 is causing a devastating impact on morale, absenteeism, retention and patient care (1). Given HCP training and lived experience, their input helps identify occupational health and safety gaps and options for remediation.

Modern psychiatry was strongly influenced by the emergence of so-called Biological Psychiatry and the Decade of the Brain (1990's). The belief at the time was that we were on the threshold of a new psychiatry, where we could reduce mental illness to defined perturbations of neuroreceptors, trusting that our novel antidepressants and antipsychotics would provide definitive treatment.

By any standard, this has been a failed experiment. Despite an exponential increase in prescribing over the recent decades, even before the pandemic, the costs of mental health disability were higher than ever before and steadily rising (4), with depression as the leading cause (5). Treatment wise, it is common knowledge that the placebo response to antidepressants is equal to, or greater than the effect of the medication (6). Further, among those who respond, many are left with subsyndromal symptoms, with only a minority realizing full remission. Not surprisingly, there is a growing cohort of treatment resistant patients. Perhaps our patients are not treatment resistant at all, perhaps we are simply using the wrong treatments.

Modern psychiatry is failing to get to the source of the distress that is a product of living in an increasingly frenetic and disconnected world. Instead, we label distress as disorder, failing to recognize that many of our disorders are simply an adaptation to increasingly hostile and toxic environments. The failure of frontline therapies for a growing number of people is accelerating the re-emergence of psychedelic-assisted therapies.

An interdisciplinary and multi-agency team innovated by combining KaT, using ketamine as a psychedelic-like agent, with an evidence-informed CoP program, serves HCPs facing depression and PTSD. The program was a registered quality improvement project. The community based, evidence and equity informed framework is designed to minimize safety risks and to support and maintain recovery. The team's guiding principles include holistic, trauma-informed care, inclusivity, cultural/personal safety and constant quality improvement. Aligned with Canada's Strategy for Patient-Oriented Research led by the Canadian Institutes of Health Research our program is about engaging HCPs in the research process. This engagement helps to ensure that studies focus on HCP-identified priorities, which ultimately lead to better treatments and patient outcomes. The treatment program is 12-weeks in length (2 h each week, three, 4-h sessions for KaT; ~40 h in total) and runs through Vancouver Island University.

The team includes medical doctors, researchers, HCPs with lived experience of depression and PTSD, nurses, clinical counselors, spiritual health practitioners, Indigenous Elders and Knowledge Holders, Somatic Energy Practitioners, Functional Medicine Experts, Sleep Experts, Aromatherapy experts, and Physical Movement Experts. This style of team is rare in the Western Medical Model, necessitating apprenticeship/mentoring to build the team and orient new members.

Alongside Indigenous knowledge holders and cultural safety experts, the team engages in ongoing training and practices that promote equity and trauma informed care. The team models the program's guiding principles, including the adoption of shared intentions and agreements. These include, honesty, authenticity, vulnerability, and the mirroring of unconditional positive regard. The realization of these practices and principles bring forth a remarkable real humanity and palpable caring within the team. This, in turn, creates an environment of safety and trust that is often espoused, but rarely realized in mainstream health care settings.

Those wishing to join the team are encouraged to first go through the program as participants in the CoP program, and if eligible, in the KaT portion as well. Once participants transition to alumni, they can apply to be a mentee on the team, working closely with a mentor before they become a full facilitating team member.

HCPs with depression and PTSD were the priority population. Prior to acceptance into the program, participants first undergo a thorough three step intake process. The initial intake is completed by a registered psychiatric nurse who introduces participants to the program concepts through regulation practices, inner attunement, and authentic expression. For instance, the intake begins with a breathing technique that promotes relaxation, encouraging them to listen to what is arising in their physical awareness, and to speak to their fears and hopes of the process.

If determined a good fit by the participant-candidate and the team member, they proceed to meet with the team psychiatrist. If cleared by the team's psychiatrist, they then proceed to a meeting with a medical doctor who specializes in psychedelic-assisted therapy, ensuring no contraindications to ketamine use.

The CoP curriculum is informed by the literature, describing what humans need to thrive and maintain resilience amidst adversity (2). The concept of a CoP was coined by Lave and Wenger (19) and defined by (20) as “groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly (p. 1).” The program was developed from a research-informed resilience development framework (2) call Roots to Thrive, which focuses on the development of:

The context for developing these qualities favors a focus on the somatic nature of healing and present moment experience, within a CoP that mirrors unconditional positive regard (23) rather than sharing extended narratives and events of personal history. Aligning with Polyvagal Theory, when social relationships become a source of connection and security, they regulate the nervous system and encourage authentic ways of being (2, 24). The mechanisms of healing that are integrated into the CoP include:

Based on ongoing participant feedback, the most important healing components of the program revolve around the team's ability to model vulnerability themselves and to provide unconditional positive regard, which is quickly mirrored among participants.

The KaT component of the 12-week program brings CoP members together to receive ketamine in a group format, with a skilled therapist-clinician dyad per six participants. In addition, floating cultural and spiritual safety experts and knowledge holders, somatic energy practitioners, medical doctors, and a psychiatrist oversee all of the group administrations, attending where needed.

KaT is typically provided at week 4, 5, and 7. The short window of time between sessions provides a liminal space that magnifies the psychedelic mechanism, which could also be described as a loosening of the mind/ego structures that lead to the sense of stuckness that characterizes many mental health conditions.

KaT sessions include at least one or more one-to-one preparatory sessions. Participants plan for the ketamine sessions to take 4 h. Participants arrive at the healthcare center and are welcomed by the medical team for check-in and vital signs. They are then invited to settle into the room where the session will take place. Each room is set up with mats on the floor in a circular formation. A ceremonial process takes place, similar to the CoP structure, while also honoring local Indigenous and cultural traditions and participant preferences. Consent forms are collectively reviewed and signed. Ketamine is administered as either oral lozenges for the first session and intramuscularly for the second and third sessions. Participants are provided with eye coverings and synchronized headphones, ensuring that they are all listening to the same uniquely constructed, ketamine-specific playlist. When the effects of the ketamine begin to wane around the 90-min mark, the initial sharing begins. Upon completion and ceremonial close, vital signs are repeated, and participants are escorted to the person driving them home.

Post-KaT, to facilitate integration within the first 36 h where neuroplasticity is most pronounced (25), participants attend group sessions in addition to their weekly CoP. These additional post-KaT sessions promote further integration of insights and new ways of being in their day-to-day lives.

Over 1 year, three cohorts totaling 94 participants completed the 12-week treatment program. With each cohort, quality improvement results were directly translated to the frontline of care and to ongoing program development efforts. As illustrated in Figures 1, 2, mean aggregate results of those who screened positive for GAD, Depression, PTSD, or Life/Work Impairments were clinically significant, demonstrated by a shift in score of five or greater after the 12-week treatment program.

Access to ketamine assisted therapy is limited, the cost of treatment, and durability of results are common challenges. Using a group/CoP model reduces cost, enhances capacity and thereby access, accelerates recovery and may reduce relapse by providing ongoing integration support over the 12 weeks of the program and beyond. Based on the learnings and positive outcomes of this program, we anticipate that the demand for communities of practice as a treatment and supportive integration mechanism will become a gold standard in the delivery of psychedelic-assisted therapies. Finally, we would like to recognize the HCPs that courageously stepped forward to co-develop this program in the process of navigating their own healing journeys.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

The project was registered as a Quality Improvement Project with the local health authority, exempt from formal ethical review under TCPS 2 (2018), Article 2.5. The patients provided their written consent to participate in the program.

All authors provided substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data for the work, drafted the work or revising it critically for important intellectual content, provided approval for publication of the content, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The project was supported by Vancouver Island University, a Canadian Institutes of Health Research Knowledge Synthesis grant, a British Columbia Ministry of Health COVID-19 Research grant, the Regional Initiatives Fund, in-kind support from Island Health, the British Columbia Nurses Union, First Nations Health Authority, and philanthropic funds.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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