[Interview] Dr. Eshkevari on Avesta’s Approach to Personalizing Ketamine Therapy

Dr. Ladan Eshkevari leads Avesta’s ketamine clinics with a unique blend of expertise, empathy, and personal insight. In this interview, Dr. E shares her journey from nurse anesthetist to Georgetown University professor to ketamine therapy pioneer. She highlights how personal experiences with mental health have influenced Avesta’s compassionate treatment philosophy. She discusses the team’s training, credentials, and heart-centered approach. And she offers honest advice to patients who seek ketamine therapy when all else has failed. 

Interview Questions:

• Why do you do what you do in the ketamine therapy space?
• Tell us the story about how and when you started Avesta.
• What makes someone qualified to be a ketamine provider?
• What are Avesta’s core values?
• Do you follow a standardized ketamine protocol, or is each patient’s treatment plan tailored?
• Do certain types of patients see higher success rates from ketamine therapy than others?
• What is your advice for people who don’t respond well to ketamine?
• How did you choose the Avesta team, and what training did they undergo?

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Full Video Interview

**Disclaimer – This interview transcript has been edited for brevity, clarity, and grammar.

I’ll be honest with you: I’ve had personal experience with mental health. Someone very close to me, a family member, struggled her whole adult life with depression, anxiety, and chronic pain due to Lyme disease. 

So having a family member…  dealing with these issues that compound one another, where there were no good medications or therapeutics, led me to take this [ketamine practice] on as much more of a personal journey than the average healthcare provider. 

As I was adding new studies to my lectures, I became more familiar with the [ketamine therapy] protocols and what was really being done in this space. It was interesting. But it was also a good way of teaching students about the off-label use of yet another medication that was found to be useful and [in this case, an] anesthetic that was found to be useful in mental health.

So, that colleague and I ended up opening a ketamine clinic in the [Washington D.C.] area. It was actually the first ketamine clinic in the DMV area. 

And then, my partners wanted to take that clinic in a very different direction, more on the wellness side than the medical pain management side of ketamine. So we parted ways amicably, and then I opened Avesta to really take care of mood disorder and chronic pain patients. So that’s how the whole idea came about.

First of all, it has to be someone who has prescriptive authority. So someone who can prescribe the medication. But there are many different models and ideas [within that space]. 

Should it be a psychiatrist? Psychiatrists are physicians. They can prescribe ketamine. They also know the mental health side. So maybe that’s a good provider. 

Or is it better if [providers] are anesthesiologists or nurse anesthesiologists who have prescriptive authority while also understanding the side effects and the dangers of using a drug like ketamine? [Anesthesiologists] can then collaborate with a mental healthcare provider. 

Or is it better if that psychiatrist or mental health nurse practitioner is taught how to manage some of [ketamine’s] dangerous side effects…

Safety and accessibility are paramount.

My idea is that ketamine is a useful drug. It’s useful for so many patients. We have found an 80% efficacy rate with our [Avesta] patients, ranging from 18 to 65. 

So why would anyone want to pigeonhole this drug and say it belongs only to anesthesia providers or it only belongs to mental healthcare providers? I think the more people that can access this type of care as carefully and safely as possible, [the better].

So, in my opinion, [qualified ketamine providers] should be [practitioners] who understand how the drug works. [This includes understanding the] pharmacokinetics and dynamics of the drug, what happens to the drug in someone’s body, and the worst things that can happen.

This [questioning] is an anesthesia mentality. ‘What is the worst thing that can happen with this drug? And whatever the worst thing is, am I qualified and able to handle it?’ If the answer is yes, then [the practitioner] can safely [provide] ketamine for patients. 

If the answer is no, then I think [the practitioner] needs additional training to get to that point. 

Then, the anesthesia providers, for whom the answer will always be ‘yes,’ should have collaborative relationships with mental healthcare providers in their community. Because [ketamine] isn’t a drug that works in isolation. It works best with therapy, integration therapy, or ketamine-assisted therapy. And those [modalities] require a different skill set than what anesthesia providers can support.

Some people come in after years and years of therapy, and they start out saying, 

‘I’ve tried therapy. I’ve tried medications. None of it works. I have a prescriber. But I don’t wanna deal with therapy…’ They want come in and do the ketamine [sessions]. And they think that’s what is going to really help them. We don’t judge. We cater to that person. 

We also have other patients who come in and need more support. They might need initial coaching to get into the right mindset, especially patients who are very anxious. They might benefit from a couple of sessions of [learning how] to manage anxiety, how to get in the right head space, and then how to integrate [the therapy into daily life]… 

[The first approach that] makes the most sense with any patient is, what does the research show works best? So, we put every patient through our initial induction phase. That’s pretty standard. 

We now have a really strong body of evidence [supporting] ketamine [therapy] twice or three times a week for two to three weeks for a total of six treatments. Some people might need a seventh or eighth [infusion], but that initial protocol is generally standard.

The dosing might vary, though. That’s very individual. [Ketamine doses] range from 0.34 milligrams per kilo, depending on the patient’s age, to 0.5 milligrams per kilo to maybe 1.5 or 2 milligrams per kilo. 

[Dosing is the] second part of the treatment where we really individualize [the amounts] and taper patients off slowly. 

We may [also] start to talk to the patient about adding exercise [and nutritional habits]. [Nutrition is about simplifying and adding more foods to their diet. I always tell patients to eat foods of every color. If radishes are in season, incorporate red radish. Incorporate yellow bananas, orange pumpkins, and leafy green vegetables.

Post-treatment protocols

We also talk to patients about a cadence of how and when they should come back for their ketamine treatment. But even more importantly, [we discuss] how to sustain the new neurons they’ve grown. 

We discuss how they maintain [the ketamine benefits] on their own, so they’re not relying on Avesta [long-term]. 

We don’t want patients to be on lifetime ketamine therapy. In fact, in our clinic, we’re very adept at getting people to the point where they only come back for boosters or not at all. Patients are doing so well with their own therapy and regimen that they don’t need to come back. 

So, are there standard [ketamine therapy] protocols? Yes. But are there [also] opportunities to individualize the plan? Absolutely, 100%.

I think sometimes, unfortunately, when people are a little older, their brain is not neuroplastic enough [for ketamine therapy]. 

I would say the ideal patient–although our youngest is 15, I think–is somewhere in that late teen, early 20s [range] all the way to around 65, maybe 70-year-olds. But after that, I think the brain is less neuroplastic. 

And then I think the people who get the most out of [ketamine] treatments are people who really dedicate [themselves to the protocol.

They come in determined to dedicate the next month to ketamine-assisted therapy, coming in twice a week for three weeks. In between, they focus on integration therapy, changing their diet, eating healthier, and exercising to take better care of themselves.

And exercising means that once people are more functional, they start going for a walk, even if it’s a block one day, three blocks a month later, or five blocks the following month. 

So I think it’s people who really take it seriously and start to build their life around their own selves. That self-care is becoming at the core of everything and really beating down the negative talk, the negative internal talk, the ruminations, and some of the ideations that people with depression and anxiety tend to have. 

[So patients who receive ketamine] and are truly dedicated to a wellness regimen of taking care of themselves, I think they’re the ones that benefit the most.

By the time people come to ketamine, they’ve tried all the medication regimens and all the different types of classes of drugs. But maybe that patient could benefit from some intensive outpatient program or even an intensive inpatient program where they can really start to refocus on their own care. 

Other ketamine alternatives

Not giving into the ruminations or the negative thinking [is essential]. Maybe even trying a different modality [could help]. Maybe TMS (transcranial magnetic stimulation). Maybe even psilocybin. 

There are some studies currently ongoing. If patients go to clinicaltrials.gov, they can find clinical trials that now accept patients for psilocybin therapy. 

There are other [modalities] coming [too], like MDMA therapy, 

There are [also] other newer drugs that are coming along that I think patients could try if something like ketamine doesn’t work. 

So, there are lots of options out there. I always advise patients that if the ketamine doesn’t work, they should confer with their psychiatrist or mental health nurse practitioner to figure out what else they could try. 

Many providers are very adept at signing their patients up for research studies. Those are some of the things that can be done.

So, all of our medical assistants hold four-year degree college degrees, mostly in the psychology and sociology fields.

And then, as far as our hands-on licensed healthcare providers, again, we really admire nurses with undergraduate degrees or RNs. They provide a lot of very valuable healthcare to the population at large. But in our clinic, we really want advanced practice nurses. 

We like the [advanced practice] nursing model. We do not use physicians very much. Our main collaborator is a physician, Dr. Delamo, who is phenomenal and amazing and has over 30 years of anesthesia practice. We work very well with [Dr. Delamo]. 

But generally speaking, our healthcare providers come from the nursing model because that model really isn’t about the disease. It’s much more about wellness and the health of the patient. All of our nurses have a background as emergency room nurses or intensive care unit nursing, or infusion nursing.

Why Avesta only hires advanced nurses

The reason is that these nurse practitioners with advanced practice training come to us with the basics of monitoring a patient. 

They know how to monitor heart rate and blood pressure–some of the things that can go wrong when doing ketamine, even though it’s a very safe drug. 

Our nurse practitioners are really adept at handling those situations. And then on top of that, they have advanced practice degrees where they come at the patient holistically. 

And what we do is we train them on the pharmacokinetics and dynamics of ketamine. We talk about ketamine infusions and dosing. We also talk about getting patients in the right headspace for going into the journey. 

We’re also working towards utilizing mental health colleagues to help our nurse practitioners understand how to bring people out of the journey during that acute phase between ketamine [dissociation] and reality, if you will.

[This training will help patients] anchor some of the things that came up during that ketamine session into their integration therapy session with a mental healthcare provider–whether it’s their therapist or one of our integration therapists. 

So we really [take our care team credentials] very seriously. They have to be people for whom mental health is a true interest. And the additional training that we provide [is also essential].

Do you have more questions for Dr. Eshkevari and the Avesta ketamine team? Contact us today, and we’ll gladly tell you more about our ethos, experience, and infusion clinics in Washington, D.C., and Virginia.