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. 2023 Sep 19:14:1268832.
doi: 10.3389/fpsyt.2023.1268832. eCollection 2023.

The Montreal model: an integrative biomedical-psychedelic approach to ketamine for severe treatment-resistant depression

Nicolas Garel  1 , Jessica Drury  1 , Julien Thibault Lévesque  2 , Nathalie Goyette  3 , Alexandre Lehmann  4   5 , Karl Looper  1   2 , David Erritzoe  6 , Shannon Dames  7 , Gustavo Turecki  1   3 , Soham Rej  1   2   8 , Stephane Richard-Devantoy  1   3 , Kyle T Greenway  1   2   6
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The Montreal model: an integrative biomedical-psychedelic approach to ketamine for severe treatment-resistant depression

Nicolas Garel et al. Front Psychiatry. .

Abstract

Background: Subanesthetic ketamine has accumulated meta-analytic evidence for rapid antidepressant effects in treatment-resistant depression (TRD), resulting in both excitement and debate. Many unanswered questions surround ketamine's mechanisms of action and its integration into real-world psychiatric care, resulting in diverse utilizations that variously resemble electroconvulsive therapy, conventional antidepressants, or serotonergic psychedelics. There is thus an unmet need for clinical approaches to ketamine that are tailored to its unique therapeutic properties.

Methods: This article presents the Montreal model, a comprehensive biopsychosocial approach to ketamine for severe TRD refined over 6 years in public healthcare settings. To contextualize its development, we review the evidence for ketamine as a biomedical and as a psychedelic treatment of depression, emphasizing each perspectives' strengths, weaknesses, and distinct methods of utilization. We then describe the key clinical experiences and research findings that shaped the model's various components, which are presented in detail.

Results: The Montreal model, as implemented in a recent randomized clinical trial, aims to synergistically pair ketamine infusions with conventional and psychedelic biopsychosocial care. Ketamine is broadly conceptualized as a brief intervention that can produce windows of opportunity for enhanced psychiatric care, as well as powerful occasions for psychological growth. The model combines structured psychiatric care and concomitant psychotherapy with six ketamine infusions, administered with psychedelic-inspired nonpharmacological adjuncts including rolling preparative and integrative psychological support.

Discussion: Our integrative model aims to bridge the biomedical-psychedelic divide to offer a feasible, flexible, and standardized approach to ketamine for TRD. Our learnings from developing and implementing this psychedelic-inspired model for severe, real-world patients in two academic hospitals may offer valuable insights for the ongoing roll-out of a range of psychedelic therapies. Further research is needed to assess the Montreal model's effectiveness and hypothesized psychological mechanisms.

Keywords: depression; implementation science; ketamine; pharmacology; psychedelics; psychotherapy.

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Conflict of interest statement

AL has received grant support from MED-EL and Oticon Medical. DE has received funding from NIHR and was scientific advisor for Mydecine, Entheon Biomedical, Clerkenwell Health, Smallpharma Ltd. and Field Trip Health Ltd. SR received a salary award from the Fonds de recherche du Québec - Santé, receives grant funding from Mitacs, is on a steering committee for AbbVie, and owns shares of Aifred Health. The remaining 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.

Figures

Figure 1
Figure 1
Overview of the treatment components and session activities of the Montreal model of ketamine for treatment-resistant depression.
See this image and copyright information in PMC

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