> EMDR

I’ve been undergoing EMDR treatment for PTSD and it is quite amazing how well it works. You wouldn’t expect that just watching something move back and forth in front of your face (or having an electric pulse alternate between your hands) in between talking about a traumatic experience would do much, but for me it’s been the most effective thing so far after trying many different kinds of therapy and medication.

I think what a lot of people need when it comes to depression/anxiety/trauma is not simply to feel better in short bursts, but rather to reframe and reprocess thoughts, feelings, and memories in such a way that they become easier to “hold” even if they don’t go away. A lot of our treatments focus on elimination rather than acceptance and reprocessing.

I think of it like short-term dieting vs lifestyle changes. The former may provide a quick fix, but the latter will usually be longer lasting, healthier, and easier to sustain after the initial push.

> not simply to feel better in short bursts, but rather to reframe and reprocess thoughts, feelings, and memories in such a way that they become easier to “hold” even if they don’t go away

This is absolutely the gist of it. Anything that helps you do something along these lines is worth pursuing. It's about building up scaffolding around a disaster area-- not to cut off access, but to put up a useful, multipurpose firewall.

I find it curious that on sufficient doses of MDMA ones eyes can rapidly go back and forth, similar to the EMDR process.

It’s funny that you say that. I’ve taken MDMA once in my life, and I swear it was one of the only times my mind didn’t feel like it was trying to attack me. I felt totally calm and at ease rather than high or euphoric. I haven’t done it again because I’m paranoid about addiction, but I could absolutely see it being effective as a tool for facilitating longer-term treatments. I’d jump at an opportunity to participate in a MAPS study or something similar in a controlled environment.

MDMA is fascinatingly effective. You get some hours of pure bliss, all your fears gone and replaced by compassion.

It should absolutely be treated as something very special - it 'just works'. Using it too often would make it loose it's magic (on a physical level too)

Then again most additions seem to happen with more subtle substances. MDMA is a way too powerful experience to do it casually.

There is very limited evidence that the bilateral stimulation has _any_ impact on treatment outcomes [0].

EMDR is PE with a marketing machine behind it. To quote Robert Ursano, a prominent figure in trauma research and treatment at the VA, “I concur with the view that what's new about EMDR is not helpful and what's helpful is not new,"[1].

There is a disturbing trend of EMDR being billed as a panacea by commercial training institutes without educating clients about equally or more efficacious treatments (PE, CPT) that are studied primarily in academic centres.

0: Chemtob et al., (2000), Davidson and Parker (2001) 1: https://www.washingtonpost.com/archive/lifestyle/wellness/20...

You are correct, but I think you are overlooking a peripheral advantage: (relative) fidelity to the model.

I have sent countless patients to therapists purporting to do DBT, CBT, PE, and others - only to review those sessions with them and hear about poorly delivered supportive therapy with questionable boundaries.

EMDR seems to be delivered with something approximating the actual therapeutic model as studied somewhere around 50% of the time. Which, sadly, is pretty good.

Can you elaborate on what you've seen as far as "questionable boundaries" is concerned?

I went to a licensed therapist who insisted I call my GP to obtain antibiotics for a cold. I explained to her that antibiotics arent effective on viral illnesses, she insisted that yellow phlegm indicates "an infection" this antibiotics would be effective. I am also anaemic due to a genetic condition, and the anemia is mild but basically untreatable. She suggested I look into treating it with "herbs."

That sort of boundary crossing?

I stopped going to her, obviously. Pisses me off i actually paid her.

That's not what I had in mind, but that is also a problem. What I meant by "questionable boundaries" is being more of a hired friend than a therapist, and talking about themselves and their own lives more than they should. Poorly trained therapists tend to take the side of the patient without exception, and rarely challenge the behaviors that can cause them problems. Therapy should feel challenging, and feel like work, at least most of the time. If it's someone telling you that you can do no wrong, that's not useful.

Thanks, you've put into words my somewhat bad experience with therapy.

Do you have any experience with Schema Therapy practitioners?

> EMDR is PE with a marketing machine behind it

What is "PE" in this context?

Googling suggests Prolonged Exposure (PE), and Cognitive Processing Therapy (CPT): https://deploymentpsych.org/blog/staff-voices-pe-or-cpt%E2%8...

I have some experience with Ketamine ... the one I can share is when the hospital administered it via IV to put my dislocated shoulder back in place.

It was wild and would certainly NOT be my choice for a sedative in that situation. It hit fast and at first I felt high, doctors faces started to "melt", then a huge black abyss was in front of me and I felt like I was falling head first into it.

I started yelling "no, no!" because it was a very uncomfortable feeling.

Then as I was coming to the entire room was warped, with echoing voices and laughter.

I'll pass on that, not sure how that would help with depression. It would have to be a VERY small dose.

According to what I can find they were using a dosage of 0.5 mg per kg in this study, but dosages can be as high as 1 to 4.5 mg/kg when used as an anesthetic.

I had the same dose for the same reason, it was very disturbing. Apparently the doctor said it was normal for patients to scream that much.

In a clinic environment they wouldnt be putting ur arm back :) . U would be in a calm environment with nice music and blind folds

Some follow a low dose of around 30-35mg and some go up to 150mg which I found to be life changing

In a situation like that where you're in pain and anxious to start with, and are not prepared for what's going to happen, I can imagine it would be pretty horrible. I was in a comfortable situation and well-prepared when I got my first IV, and there were still a couple of brief, scary moments in the experience. And as someone else said, you probably got a much bigger dose, putting you deep into k-hole territory, if not actually knocking you out. When used for therapy, that kind of dose is usually reserved for those with chronic pain or other conditions, not depression or suicidal ideation.

I don't think they would have given you the same dose if it was to treat depression. By the sounds of your trip, you had way more than the standard dose (even by recreational standards).

Also transcranial magnetic stimulation which is FDA approved for treatment of depression. No drugs involved.

A treatment is either changing brain chemistry with the risk of side effects of some kind or it isn't and there is no potential benefit.

There are side effects with rTMI and they can be very serious, however, they are not typical. Side effects include: Headache, Scalp discomfort at the site of stimulation, Tingling, spasms or twitching of facial muscles, and Lightheadedness [0]. Serious side effects can include: Seizures, Mania, particularly in people with bipolar disorder, and Hearing loss if there is inadequate ear protection during treatment [1].

Particularly in the issues around PTSD that was induced alongside cranial trauma, rTMI is an unlikely treatment, though still viable. The issue is that PTSD and concussions share strong co-morbidities. If you have a concussion, your physician is more likely to suggest other treatments, as rTMI may cause other issues. In reading through the literature, I cannot find a case where an issue was seen, but I can understand the caution with such a new technology. That said, there may have been cases that I am unaware of. I'll be very clear here, I am not a medical doctor. If you are considering rTMI treatment, please see a physician.

[0] https://www.mayoclinic.org/tests-procedures/transcranial-mag...

[1] https://en.wikipedia.org/wiki/Transcranial_magnetic_stimulat...

My doctor prescribes ketamine for take home use. Unfortunately infusion clinics are taking advantages of patients by administering the most expensive ROA. Keep in mind that the IV ROA has not been proven more effective or safe than cheaper ROAs.

Ketamine's antidepressive effects are by far the most potent when ketamine is administered as an IV drip over a long period of time, like 40ish minutes. If you simply inject it all at once, you will definitely go to la la land, but the duration will be too short.

And if you're talking about starting an IV on yourself... without training, the risks of really bad health issues, including death, are pretty high. Almost no one outside of professional health care has that training. Even if they did, you still need to be monitored by someone else via pulse ox and sometimes blood pressure for safety reasons, and said person monitoring you needs to have the training to know how to help you if something goes wrong. Keep in mind that if ketamine is effective for you, you will end up needing to keep taking it for a long time, typically every 3-6 weeks, or the effects wear off. That frequency multiplies the risks.

In short, I see the ratio of risk to effectiveness for home use ketamine to be emphatically not worth it. Unless you have a partner / friend who has the necessary training.

I know from talking to my doctor that of the $375 I pay, his cost for the ketamine he uses for that one treatment is under 10 bucks. If you've got a medical license, you get access to buy legit pharma drugs very easily. I believe he told me that one vial of Ketamine is something like $20 and there's multiple doses in there.

> Ketamine's antidepressive effects are by far the most potent when ketamine is administered as an IV drip over a long period of time, like 40ish minutes. If you simply inject it all at once, you will definitely go to la la land, but the duration will be too short.

No one understands the exact mechanism of ketamine for depression even though there has been a lot of research and speculation on this topic. Therefore, you can't say which ROA is best for patients or if one works better than another.

Furthermore, all studies have been small and short in duration so there's no statistical significance to the fact that the IV ROA is used more in studies. If IV was the only route that worked it would be the first anti-depressant with that designation. Because of the cost of infusions patients are right to be skeptical about doctors that are running clinics.

> In short, I see the ratio of risk to effectiveness for home use ketamine to be emphatically not worth it. Unless you have a partner / friend who has the necessary training.

My doctor has clinical experience with ketamine and about 2+ years of prescribing patients with TRD with sublingual ketamine that is taken at home. Ketamine is an incredibly safe drug and nothing about his practice has changed. His insurance has even stayed the same. I know that’s a common justification for high prices from docs that run IV clinics.

The reason I’m not going anonymous on this is because I feel passionately that we need to stem the tide of shady ketamine doctors that don’t give a shit about patients. When I asked my doctor why he wouldn’t charge me a lot of money (he could!) for the treatment he asked me, “Would I charge you a lot for Lexapro because it works?” Good point.

See this book for background on Ketamine and the studies completed: Ketamine for Treatment-Resistant Depression: The First Decade of Progress (2016)

https://books.google.com/books/about/Ketamine_for_Treatment_...

I agree with you that what works best for some may not work the best for others. I disagree that doctors who charge a few hundred bucks for this "don't give a shit" about their patients. I also know that, from personal experience, sublingual ketamine did very little for me (tried that before IV). Doc then suggested IV use, and said most patients end up needing the IV route.

You don't need to start your own IV to do it at home. I've been getting IV ketamine occasionally for around 8 years. I've also been using a prescription ketamine nasal spray for most of that time. For me, the effects of the two are nearly the same. Intranasal only has about 20% of the bioavailability of IV, supposedly, although in my experience it's closer to 10%. It takes quite a few sprays to achieve the same level of the drug as the IV treatment provides, but it works.

$130 gets me 3000mg in a spray every month. That's enough for about 4 IV-equivalent treatments even with the low bioavailability. The biggest difference is that the intranasal (of course) absorbs more slowly than an IV, so some of the effects last for 2-3 hours after I stop administering the spray, whereas once the IV runs out, I'm ready to leave the clinic in about 15 minutes. (Taking an uber or the subway rather than driving, obviously.)

The therapeutic index for ketamine is ridiculous and I know I don't have adverse reactions to it, so I'm not at all concerned about harming myself with it accidentally. I wouldn't recommend it for anyone who hasn't had some IV treatments, partly because a small number of people do have strong negative reactions to it, and partly because it would be really difficult to know what kind of effect you need to achieve. It's pretty easy for me to tell how high the levels in my blood are because I'm so familiar with how it feels as the IV dose escalates.

While I wouldn't recommend it for an initial treatment, I would recommend it to anyone who has been successfully treated with ketamine. Unfortunately, I think that it's harder to get now. I know my doctor has stopped prescribing it to patients because too many people were selling or abusing it.

Is this in the US?

Yes it is.

Anecdata is also all that supports TMS and Ketamine. There's not been sufficient time for longitudinal studies to be conducted or more efficacious protocols to be developed.

Had your loved one tried ECT prior to ketamine infusion? Though its reputation has been sullied by popular culture, it is bar none the most efficacious treatment we have for treating severe and persistent depression, and its efficacy is well supported by decades of research and outcome tracking.

The enthusiasm for ketamine and TMS undoubtedly outstrips the evidence and is driven by financial motivations. But to call it "anecdata" is a bit harsh. The available evidence certainly eclipses some of the other recommendations in the comments (CBD, lsd/psilocybin - before I get angry responses, these look promising but the data just aren't there yet).

Where I totally agree with you is ECT. It is, with a bullet, the best-supported intervention for treatment-resistant depression, and it's not even close. It is an absolute tragedy that it has such an unfairly terrible reputation. Even before anesthesia was a universal element of ECT, it was never as bad as usually portrayed in popular culture.

It is harsh, but where's the fun in the comment section of an HN post on psychology without a little hyperbole?

My disdain comes from seeing people I'm close to repeatedly pushed towards those treatments by practitioners who, when asked to provide references supporting their endorsement supply anecdotes about past or current patients rather than DOIs. There are specific TMS protocols that appear to have some growing amount of evidence behind them, but ketamine still seems to be a wildly variable cash grab that requires further data before anything can be said about its efficacy.

The negative side effects of ECT can be dramatic and life-changing. I've known people who lost significant chunks of their memory (and that's with modern ECT), and they said it was worth it for them... but I have zero interest in risking that. If the alternative is killing yourself, it might be worth it, but for TRD without attempted or planned suicide, I have never even considered ECT seriously.

That can be a side-effect, especially with bilateral lead placement. With unilateral placement, it's pretty occasional. I wonder if knowing two people with the same problem indicates a local psychiatrist using bilateral approaches more than usual?

I would like to add MDMA too to that list