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Montreal model
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The Montreal model: an integrative biomedical-psychedelic ... frontiersin.org 83 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 Montreal model of ketamine-assisted therapy frames patient experiences as meaningful in terms of their process and content, with a primary emphasis on experiential learning.
perspectiveThe authors of the Montreal model suggest that incorporating psychological treatment adjuncts into ketamine therapy may feasibly address the major limitations of the biomedical perspective on ketamine.
claimThe Montreal model of ketamine treatment for Treatment-Resistant Depression (TRD) occupies a middle-ground between biomedical and psychedelic approaches to ketamine administration.
measurementIn the Montreal model of ketamine-assisted therapy, blood pressure is measured at 10–15 minute intervals during the ketamine infusion.
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.
perspectiveThe authors of the Montreal model emphasize focusing on the process of how a patient experiences a ketamine treatment rather than the specific content evoked by the treatment, in order to mitigate potential harms like false memories and reduce distress.
claimThe Montreal model was developed to create a structured approach to ketamine treatment that is applicable to complex, real-world Treatment-Resistant Depression (TRD) patients and feasible for implementation in resource-limited public healthcare systems.
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.
procedureThe Montreal model dosing protocol allows for iterative treatment tailoring, such as enabling participants to select music for each treatment session based on their previous experiences and current preferences, rather than using a standard playlist for all patients.
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.
claimThe Montreal model allows for the prioritization of specific therapeutic techniques, such as trauma-focused therapy for patients with comorbid PTSD, when a patient's comorbid conditions suggest a particular approach would be beneficial.
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.
perspectiveThe Montreal model's therapeutic process resembles the gradual exploration and skill-building of conventional psychotherapies like Cognitive Behavioral Therapy (CBT) more than it resembles breakthrough or mystical models of psychedelic-assisted psychotherapy.
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.
referenceThe Montreal model of ketamine treatment integrates neurobiological and psychological benefits, frames psychoactive effects as opportunities for experiential learning, emphasizes the importance of "set and setting," and utilizes subanesthetic dosages of 0.5–1.0 mg/kg with clinicians present and concomitant psychotherapy.
claimThe Montreal model psychological approach to ketamine treatment is summarized as gentle encouragement to feel emotions, defuse thoughts, and change behaviors.
procedureThe Montreal model combines structured psychiatric care and concomitant psychotherapy with six ketamine infusions, which are administered with psychedelic-inspired nonpharmacological adjuncts such as rolling preparative and integrative psychological support.
claimIn the Montreal model, as patients with treatment-resistant depression improve, treatment goals evolve from evidence-based lifestyle changes to 'committed action' goals that align with an individual's unique values, consistent with Acceptance and Commitment Therapy (ACT).
claimClinicians utilizing the Montreal model of ketamine-assisted therapy consider emotional release as a hypothesized psychotherapeutic mechanism alongside experiential learning.
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.
claimThe Montreal model for treating patients with treatment-resistant depression (TRD) often involves setting goals such as 20 minutes of daily walking and establishing fixed sleeping hours to address irregular routines and behavioral deactivation.
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 a 90-minute psychiatric assessment as the first step of treatment, which includes confirming psychiatric diagnoses, reviewing current and past treatments, and eliciting current-moment lifestyle factors, in addition to standard medical investigations.
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.
perspectiveThe Montreal model clinical team recommends reducing the use of benzodiazepines and related sedatives (BZDRs) for patients with treatment-resistant depression, citing evidence of tolerance, potential harms, and questionable long-term efficacy.
claimPatients in the Montreal model report that collaborative selection of treatment elements provides direct benefits, such as music suited to the treatment, and indirect benefits, such as increased feelings of engagement and autonomy.
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.
measurementApproximately half of the patients referred to the Montreal model service actively receive long-term benzodiazepines and related sedatives (BZDRs), often at high doses.
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.
claimThe Montreal model describes its treatment phases as 'rolling' rather than the three distinct phases of preparation, treatment, and integration found in other psychedelic-assisted psychotherapy (PAP) models, because each treatment serves as preparation for the subsequent treatment and integration of the previous one.
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.
procedureThe Montreal model of ketamine-assisted therapy follows a structured session course consisting of seven steps: (1) Check-in: Review recent life events, medical/psychiatric risk, symptomatic changes, treatment changes, and progress on goals. (2) Rolling integration: Discuss the previous ketamine treatment experience and its relevance to day-to-day life. (3) Establish intentions and activities: Mutually agree on goals, music, and the degree of clinician guidance. (4) Ketamine initiation: Verify baseline hemodynamic parameters, psychological readiness, and consent, then install an intravenous line and start the infusion. (5) Ketamine infusion: Conduct a brief mindfulness exercise; if using music, play a 50–60 minute playlist; if not using music, encourage openness and acceptance while monitoring blood pressure (every 10–15 min), heart rate, and oxygen saturation. (6) Debrief: Engage in a 20–30 minute discussion following the 40-minute infusion or music playlist, prioritizing validation of emotions and revisiting intentions. (7) Rolling preparation: Review and discuss plans for the subsequent days and the next treatment, including behavioral goals.
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.
claimThe Montreal model focuses behavioral goals on evidence-based lifestyle changes, including improving sleep hygiene, improving diet, establishing consistent routines, engaging in meaningful social activities, and increasing levels of physical activity.
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.
measurementIn the Montreal model of ketamine-assisted therapy, the ketamine infusion lasts for 40 minutes.
claimThe Montreal model of psychedelic-assisted therapy aligns with Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) models by viewing psychedelic experiences as opportunities for experiential learning, such as learning to let go.
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.
measurementIn the Montreal model of ketamine-assisted therapy, the debriefing session following the ketamine infusion lasts for 20–30 minutes.
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.
claimThe Montreal model allows flexibility in therapist selection for concomitant psychotherapy, permitting the use of external therapists from hospitals, referring psychiatric services, the community, or learners rotating in the service.
perspectiveThe Montreal model researchers hypothesize that their 'slower-but-steadier' endeavor is better suited to complex patients suffering from severe and chronic treatment-resistant depression (TRD) because the six treatment visits provide multiple opportunities to engage in the treatment process, revisit behavioral goals, and consolidate insights.
claimThe challenges and potential solutions described in the Montreal model for ketamine therapy may hold relevance for the upcoming transition of drugs like psilocybin from clinical trials to clinical care.