Ketamine-assisted Therapy: A Collaborative Approach to Improve Multiple Health Outcomes in Underserved Minority Patients with HIV
Sharon Steckler LCSW (Presenter), Michelle Agnoli RN MSN, Stockton Mayer DO,
Agueda Corona Semrad LPC, Audrey Stillerman MD
Background
The goal of this clinical program was to pilot the use of ketamine-assisted therapy to treat trauma in BIPOC and LGBTQ+ people living with HIV. Many persons living with HIV experienced emotional trauma as children and/or as adults affecting their HIV outcomes, myriad other physical and mental health conditions, and social well-being. Therefore, healing trauma is an essential part of HIV care. Research shows that ketamine, the only legal psychedelic medicine in Illinois, is effective for treating trauma and its related conditions when paired with therapy. To date, ketamine-assisted therapy has rarely been used to improve care or health for persons with HIV. Moreover, this therapy is not readily available, especially to Blacks, People of Color, (BIPOC) and people who are poor.
Program Goals
Implement ketamine-assisted group therapy for people living with HIV in their primary care HIV clinic.
Increase representation of BIPOC and/or LBGTQ+ participants in ketamine-assisted therapy.
Explore the impact of group ketamine-assisted therapy (KAT) on mental and physical health conditions and social well-being associated with HIV.
Materials and Methods
Materials included eligible participants, medical and mental health clinical staff, ketamine troches, ondansetron rapidly dissolving tabs, ginger chews, floor mats, blankets, emesis bags, tissues, flight instructions, poems, curated playlists, writing and drawing materials, light snacks, and water. HIV clinic staff invited eligible patients to participate in the ketamine-assisted therapy (KAT) groups in spring and fall of 2024 for two total groups with a target of 5-6 participants per group. Eligibility included: 1) receiving health care in the HIV clinic; 2) 18 years of age or older; 3) able to speak and read English; 4) identify as BIPOC and/or LGBTQ+; 5) able to sit or lie on a mat on the floor for at least 90 minutes; 6) no history of moderate to severe ketamine allergy, severe sleep apnea, uncontrolled hypertension, traumatic brain injury in the preceding 12 months, current use of any contraindicated medications, active psychosis or any other condition or medication which would increase risk of harm beyond usual risk. After a chart prescreen, interested participants received medical and psychological intake visits. Those who maintained eligibility and interest participated in three virtual preparation sessions, three in-person medication sessions including in-person integration and snacks followed by another virtual integration session within 96 hours, and a final integration session one month after the last medication session. During the medication sessions, patients received sublingual ketamine between 100-400mg: 100-200 mg for Medication Session 1 and a tailored increase (25-50% depending on response and patient input) for Medication Sessions 2 and 3.
Participants were invited to complete the following clinical assessment questionnaires during the preparation sessions and last integration session: ACE (Preparation only), BEAQ-CAGE-AID, DES-II, HAM-A, PCL-5, PHQ-2, Mood, CAGE, and GAD-7. Results were collected both chart and session notes.
Results
Program staff completed a chart pre-screen on 20 interested patients receiving services in the HIV clinic. Those still eligible received a medical and mental health virtual intake visit. Five eligible patients joined each group. We offered two group treatment experiences (10 sessions/experience) of KAT to 10 participants living with HIV and multiple medical, mental health, and social issues. There were 5 participants per group with 8 unique participants; 2 participants engaged in both groups. 100% BIPOC or LGBTQ+ participants, 80% men, age range 29-61. Of participants completing assessments during preparation, 67% reported ACE score>4. 100% of participants attended 9/10 sessions with 100% of participants attended all 3 medication sessions. Of participants completing pre-and post-assessments. 100% reported symptom reduction on PCL-5 and PHQ-9. Program staff were 20% BIPOC and 80% female.
Additional examples of participant self-report include:
No liquor for 2 weeks since before my first medicine session. I noticed I had no anxiety since the first medicine session. I noticed my focus has improved.
When I started, I felt like I was chained in a room of darkness. I feel lighter and more liberated.
My arthritic shoulder pain has subsided.
My blood pressure is lower than it’s been in years.
No participants had adverse medical reactions to ketamine. One participant requested low doses (starting at 50 mg SL troches) because he had no prior experience with mind-altering substances and had anxiety around their use. Two participants had increased symptoms of depression and/or PTSD, which improved with additional mental health support and postponement of the third medication session. Both had symptom improvement after the third medication session. One participant had excellent resolution of anxiety after the second medication session beyond anything he had previously experienced with psychotherapy, psychotropic medication, or support groups. This lasted through the one-month follow-up, but his anxiety subsequently returned.
Challenges
Both groups went extremely well overall, and there were also challenges. First, changing pharmacies was necessary for Group 2 because the university pharmacy was unable to send medications via the mail to our patients, and the clinic is not set up to store medications, especially controlled substances. Second, we had no program assistant or coordinator to help follow-up on completion of assessment questionnaires, which were offered virtually only as part of our mental health partner’s behavioral health record. Third, some of the more vulnerable patients referred were unable to participate for social or psychological reasons either because of their schedules, where they live, or other challenges connecting. Finally, funding for this program lasted one year only, so implementation of groups in 2025 has not been possible so far.
Conclusion
The project team successfully implemented two KAT groups in the context of the longitudinal primary care provided in the HIV clinic. Both participants and clinicians were engaged with excellent retention and representation of the underserved minorities we are hoping to reach: BIPOC and LGBTQ+ persons. Providing KAT group therapy with a medical-mental health interprofessional team inside the HIV clinic was both feasible and acceptable to patients and staff. Participants and staff had overwhelmingly positive experiences supported by qualitative and some quantitative evidence.