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The Montreal model is a comprehensive biopsychosocial framework specifically developed for the clinical administration of ketamine to treat severe treatment-resistant depression {fact:4, fact:10}. This model defines a structured protocol for ketamine treatment, including specific infusion schedules, preparatory psychotherapy, and goal-setting procedures {fact:2, fact:18, fact:40}.
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The Montreal model: an integrative biomedical-psychedelic ... frontiersin.org 56 facts
procedureThe Montreal model clinical team proposes a trial of benzodiazepine and related sedative (BZDR) discontinuation for all patients, which typically entails a slow taper such that final doses occur within several days of the first ketamine treatment, due to evidence that benzodiazepines may dampen or shorten the antidepressant effects of ketamine.
measurementThe Montreal model's six intravenous ketamine treatments provide patients with a similar amount of time in an altered state of consciousness as two doses of psilocybin.
claimThe authors of the Montreal model report that a brief course of ketamine evokes psychological dynamics that resemble an accelerated short-term psychotherapy more closely than a course of electroconvulsive therapy (ECT).
claimThe Montreal model utilizes concomitant psychotherapy, which allows patients to continue conventional psychotherapy sessions semi-independently of the ketamine treatment process at regular or as-needed frequencies.
accountThe Montreal model was developed over 6 years and based on more than 500 ketamine treatments administered to inpatients and outpatients with severe treatment-resistant depression at two McGill University hospitals.
claimThe Montreal model is an approach to integrating ketamine into a broader biopsychosocial intervention for treatment-resistant depression, designed to deliver feasible and robust clinical benefits.
claimThe ketamine treatment situation in the Montreal model is considered an ideal opportunity for behavioral modifications because patients' high expectations and desire to optimize treatment response translate into high levels of engagement in pursuing changes.
procedurePatients in the Montreal model are required to establish at least three mutually acceptable SMART goals to be initiated before beginning ketamine treatments and maintained throughout the process.
procedureThe Montreal model protocol for ketamine treatment involves six relatively brief ketamine infusions over a period of 4 weeks, which differs from the one or two longer psilocybin sessions typically employed in other psychedelic-assisted psychotherapy (PAP) studies.
procedureThe Montreal model requires patients to engage in at least one hour of weekly evidence-based psychotherapy, beginning at least two weeks before the initiation of ketamine treatments.
procedureThe Montreal model clinicians orient all phases of the ketamine treatment process toward cultivating curiosity for current-moment experiences, defusing challenging thoughts, and taking value-driven actions.
perspectiveThe authors of the Montreal model view ketamine experiences as valuable opportunities for experiential learning when paired with appropriate settings and mindsets, rather than viewing them as either essential drivers of psychological benefits or merely inconvenient treatment side-effects.
claimThe authors of the Montreal model suggest that establishing a 'psychotherapy-grade' therapeutic frame is vital for the safety and efficacy of ketamine treatment, especially when treating treatment-resistant depression (TRD) in patients with comorbidities like personality disorders.
procedureKetamine treatment sessions in the Montreal model last approximately 2 hours and require at least one clinician to be present for safety monitoring and accompaniment in a dedicated room.
claimThe Montreal model psychological approach to ketamine treatment is summarized as gentle encouragement to feel emotions, defuse thoughts, and change behaviors.
claimThe Montreal model developers aim to minimize the need for ongoing ketamine treatments because such treatments can be burdensome, costly, and potentially associated with long-term psychological and physiological harms.
claimThe Montreal model clinicians suggest that the psychological processes underlying psychedelic ketamine experiences are not specific to ketamine or Treatment-Resistant Depression, but may arise in any therapeutic situation where a patient receives a powerful psychoactive drug with psychological accompaniment.
claimThe Montreal model recommends screening for obstructive sleep apnea during the medical history assessment for ketamine treatment, as it is a condition commonly associated with depression.
measurementIn a cohort study of treatment-resistant depression (TRD) patients receiving ketamine under the Montreal model, all patients were willing to attempt benzodiazepine receptor (BZDR) discontinuation, nearly all achieved total abstinence during treatment, and the majority remained BZDR-free after an average follow-up of one year.
procedureThe Montreal model requires two to three preparatory sessions, ranging from 30 to 60 minutes in length, for patients deemed good candidates for ketamine treatment prior to beginning the treatment process.
claimThe Montreal model of ketamine administration may be valuable for treating patients grappling with depression in the final stages of life.
procedureThe Montreal model incorporates the 'Specific Measurable Achievable Relevant Timely' (SMART) framework for behavioral goal-setting during the evaluation and preparation phases of ketamine treatment.
claimThe Montreal model's flexible approach to psychotherapy integration provides feasibility benefits by removing the requirement for all treating clinicians to be experts in both conventional psychotherapy and ketamine or psychedelic-assisted approaches.
claimThe Montreal model for ketamine treatment seeks to enhance patient engagement in evidence-based psychotherapy by leveraging ketamine's pro-cognitive and anti-suicide effects, as well as the psychological experiences of dosing sessions.
procedureThe Montreal model ketamine treatment process includes the following steps: (1) beginning each treatment with brief exercises like body scans or mindful focusing of attention on the breath, (2) encouraging patients to avoid suppressing emotions or labeling sensations with judgmental terms, (3) encouraging patients to fully experience sensations without becoming entangled in associated cognitions, and (4) maintaining this orientation throughout the ketamine experience and between sessions.
procedureThe Montreal model for ketamine treatment includes four major components: a targeted psychiatric assessment, goal-oriented preparation, weekly concomitant psychotherapy, and a course of intravenous (IV) racemic ketamine infusions consisting of six subanesthetic doses administered over 4 weeks in psychedelic-like treatment contexts.
procedureThe authors of the Montreal model mitigate the risks of patient disappointment and potential suicidality by systematically incorporating explicit discussions about treatment expectations during initial evaluations, emphasizing behavioral changes and establishing backup plans if ketamine treatment is unsuccessful.
claimThe Montreal model of ketamine treatment spreads the total duration of altered states of consciousness over 4 weeks, whereas psilocybin treatment typically occurs over one or two sessions.
claimThe Montreal model uses the Dutch Method to stage treatment resistance in patients undergoing psychiatric assessment for ketamine treatment.
procedureThe Montreal model for ketamine treatment discharges patients once they are psychologically and physiologically ready, with vital signs within normal limits, and provides them with safety reminders and instructions to contact clinicians in case of adverse reactions or distress.
measurementThe Montreal model's six ketamine treatments yield approximately the same amount of time in an altered state of consciousness as 12 psilocybin treatments, but spread out over multiple sessions.
claimThe Montreal model was evaluated in a pragmatic randomized controlled trial (RCT) examining how music influences the physiological and psychological effects of ketamine.
claimThe Montreal model clinicians utilize the concept of a 'window of opportunity' following ketamine treatment, which refers to a period of symptomatic improvement and potentially enhanced neuroplasticity.
procedureThe Montreal model maintenance phase for treatment-resistant depression (TRD) consists of three forms: medication/neurostimulation, concomitant psychotherapy, and maintenance ketamine treatments.
claimThe 'rolling' therapeutic rhythm associated with the Montreal model of ketamine administration is potentially well-suited for managing patient expectations, navigating psychological challenges, and supporting behavioral changes in highly refractory cases.
claimThe Montreal model for ketamine treatment incorporates nonpharmacological psychedelic adjuncts, such as music and psychological support, to ensure treatment experiences serve as opportunities for psychotherapeutic growth.
perspectiveThe Montreal model for ketamine treatment aims to utilize the rapid, transient antidepressant effects of ketamine to facilitate evidence-based psychiatric care, including lifestyle modifications and medication optimization.
claimThe Montreal model administers ketamine treatments using 'psychedelic paradigm' hallmarks, which include the use of blindfolds, 'rolling' integrative and preparatory psychological support, and music or mindfulness exercises.
measurementThe Montreal model offers one-off ketamine maintenance sessions for responders at a frequency of approximately every 4–6 months.
claimThe Montreal model for ketamine treatment does not mandate a specific type of psychotherapy, but instead requires the use of any evidence-based approach, such as Cognitive Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT), that the patient is willing to pursue.
claimThe Montreal model aims to facilitate experiential learning with ketamine treatments to cultivate engaged, collaborative, and flexible life orientations as a corrective force to the passivity, rigidity, and nihilism commonly found in Treatment-Resistant Depression (TRD).
claimThe Montreal model of ketamine treatment incorporates patient choice regarding music selection, behavioral goals, and the nature of psychological support (such as quiet accompaniment, breathing exercises, or guided body scans) during the six treatment sessions.
accountPatients in the early Montreal model ketamine trials experienced "termination reactions," characterized by reemergent symptoms near the end of the treatment course, because a positive clinical response resulted in fewer treatment sessions and less contact with the clinical team, which patients perceived as beneficial.
procedureThe Montreal model of ketamine treatment for depression is conducted similarly to acute treatments, with an emphasis on revisiting behavioral goals and experiential learning.
referenceThe Montreal model is a comprehensive biopsychosocial approach to using ketamine for severe treatment-resistant depression that was refined over six years in public healthcare settings.
claimPatients referred to the Montreal model service often arrive with unrealistically high expectations for ketamine, anticipating miraculous benefits, a phenomenon the authors describe as paralleling a broader psychedelic 'hype bubble'.
claimIn the Montreal model, the vast majority of patients receive conventional medications, such as antidepressants and mood stabilizers, before, during, and after the ketamine treatment process, and some patients also opt for neurostimulation treatments like transcranial magnetic stimulation.
claimThe Montreal model clinical team observed that ketamine treatment differs from electroconvulsive therapy (ECT) because termination of treatment is a critical consideration in psychotherapy, whereas it is generally only a subject of interest in psychiatry.
procedureThe Montreal model for ketamine treatment preparation involves nine specific goals: (1) establishing a treatment frame, (2) cultivating a therapeutic alliance, (3) psychoeducation and management of expectations, (4) determining behavioral treatment goals, (5) optimizing medications, (6) framing the ketamine experience, (7) trial mindfulness exercise, (8) music discussion, and (9) arranging for concomitant psychotherapy.
claimN,N-Dimethyltryptamine (DMT) and nitrous oxide are short-acting psychedelic-like drugs that may be employed in therapeutic models similar to the Montreal model of ketamine administration.
claimThe Montreal model for ketamine treatment excludes patients with active substance use due to potential iatrogenic harms, but does not exclude patients with personality disorders or acute suicidality, provided safety concerns are managed.
accountAt the outset of the clinic, the Montreal model clinical team proposed a protocol of three ketamine infusions for appropriate patients, with subsequent treatments decided based on clinical response, similar to the protocol used for electroconvulsive therapy (ECT).
measurementThe standard ketamine treatment course in the Montreal model consists of six infusions administered over 4 weeks, with a dosage of 0.5 mg/kg infused over 40 minutes, twice per week for the first 2 weeks and once weekly for the final 2 weeks.
claimThe Montreal model's approach of conducting psychotherapy concomitantly with, but somewhat independently of, ketamine treatments is atypical for psychedelic-assisted therapy but common in standard psychiatric care models.
claimThe Montreal model of ketamine treatment frames the intervention as one that can yield significant benefits, but notes that these benefits are likely to be transient.
referenceThe Montreal model of ketamine for treatment-refractory depression is a biopsychosocial approach developed gradually over years of real-world clinical experiences and research endeavors.