Ketamine effectively treats depression. Do the benefits outweigh the risks?

Patient testimonials and hundreds of small studies point to the prescription anesthetic ketamine as a potentially useful treatment for mental health conditions such as major depression and suicidal thoughts. But health experts are alarmed by its growing and widespread use under lax safety conditions.

Last month, the U.S. Food and Drug Administration issued a notice to patients and providers citing the potentially serious physical and psychological dangers of ketamine, which is often administered in clinics or doctors’ offices by intravenous infusion or injection and induces a quasi-psychedelic state filled with fantastical thoughts. . and pictures.

The FDA also argued that because it only approved the drug for use during surgery, it lacked robust clinical trials for the wide range of pain and mental health conditions for which it is used.

The overall benefit-risk profile of ketamine for the treatment of psychiatric disorders is unknown, the agency claims. (The statement does not cover Spravato, a nasal spray that delivers a specific form of ketamine, esketamine, which the FDA approved in 2019 for adults with treatment-resistant depression when taken with antidepressants. But some research shows the spray is not as effective as the intravenous version.)

Not that no one should try the drug. Ketamine works for many people. I’ve seen it change lives, says Sophie Holmes, a psychiatry and neurology researcher at Yale School of Medicine who has documented positive changes in brain imaging while under the influence of the drug. But it’s definitely a case of patient caution, she says.

Ketamine is unique in how quick a response it provides, says Emily Whinkin, a naturopathic physician in Seattle, who recently described significant improvements in anxiety and depression after one to six sessions of ketamine-assisted psychotherapy in 18 patients in her substance use disorder clinic.

Conditions like suicidal depression, anxiety or post-traumatic stress disorder really affect people’s functioning and quality of life and are difficult to treat even with good psychotherapy and expert medication management, says Vhinkin.

Significant side effects

Ketamine should only be administered in settings equipped for emergencies, Holmes says, which is generally not the case for the many wellness clinics and telehealth providers who are adopting the drug for a wide range of mental health applications and fueling a $3 billion industry that is projected to grow 10 percent per year until the end of the decade.

Holmes says more research is needed to better understand who might benefit from ketamine therapy, what the appropriate protocol should be and, most importantly, how it works. The current thinking is that the drug increases the connections between synapses in the brain, allowing new thought pathways to develop.

While some people experience only mild and transient nausea, headache, or an upset stomach while taking the drug, others may experience slowed breathing or increased blood pressure.

If someone already has a heart problem, it could be dangerous, says Holmes, who notes that all potential ketamine patients at Yale undergo an electrocardiogram of the heart beforehand and have their vitals monitored during each session.

Equally important, some clinics also do not provide sufficient psychological support. Patients can be frightened during hallucinations, says Vhinkin. They generally last less than an hour, much shorter than true psychedelics such as psilocybin or lysergic acid diethylamide or LSD. (To capitalize on the growing interest in psychedelic medicine, many clinics advertise ketamine as a psychedelic therapy even though it is not a true psychedelic.)

Post-treatment integration sessions are a vital part of the experience. It’s an opportunity to explore the psychological material that came up during the journey, and if there’s any confusion or confrontation of pre-existing beliefs about the self or the world, it deserves skillful support, says Vhinkin.

As its name suggests, integrative therapy, when properly implemented, also incorporates altered experience into practical action. What is the way forward to use the experience to make a meaningful change in the way you live day to day?, she says.

Perhaps the biggest concern is the increasing use of ketamine in homevia oral capsules or sublingual pills, two poorly understood delivery systems. Thanks to regulations that began in 2020 after the start of the pandemic, only a brief phone screening, rather than an in-person visit, is required before ketamine arrives in a home.

Prescribing for home use is irresponsible, as it should be under the supervision of trained professionals, Holmes insists. Use of these products without concurrent supervision by a healthcare professional may put patients at risk for serious adverse events, the FDA notice said.

Home use also increases the potential for abuse, as ketamine is illegally sold recreationally under the name Special K. This is particularly concerning because some clinics use it to treat substance abuse, says Michael Schatman, an expert in pain medication and medical ethics at New York University School of Medicine, who outlined his concerns in a medical journal this year. “I’ve seen my opioid-addicted pain patients put on nasal ketamine and they go home and abuse it by getting high and then drinking,” he says.

For some, permanent relief

Others worry that the medicine they consider a lifesaver is being misused. Shira Renee Thomas, a 45-year-old artistic director of a performing arts company in Southern California, believes she might not be here if it weren’t for ketamine.

For 25 years, Thomas experienced bouts of depression so extreme that she regularly contemplated suicide. Unable to leave her bed for months, the illness seriously affected her quality of life and disrupted her career as an opera singer.

Over the years, she was hospitalized several times, prescribed about 20 different drugs individually and in combination, and even had electroconvulsive therapy, which she had to stop after she lost so much memory that she couldn’t remember how to drive a car or sign on the check.

Four years ago, Thomas found a clinic that offered ketamine.

My first infusion was like magic, she recalls. While under his spell, she watched the earth goddess effortlessly dismiss the demeaning words she would yell at herself when she was depressed, such as being stupid or useless. That behavior later stopped.

It took several years for the other symptoms to subside, but after close to 100 sessions of ketamine, with ongoing sessions maintained, she has not had a depressive episode for almost a year. (This cost her family about $30,000, because ketamine treatment is often not covered by insurance, although her insurer recently agreed to start paying.)

Given its potential and risks, Schatman wants people to be clearly informed about the pros and cons of ketamine therapy before they receive treatment.

“I have patients who go to infusion clinics and are told it will help them, who don’t even realize they could be hallucinating,” he says. People should also know that there is no scientifically proven protocol, he says, so each provider can make up their own rules about how much and how often to give it.

People need to understand that they are experimenting, Shatman says. Some are in so much pain that they are ready to roll the dice.

If they do, they should increase their chances by seeing a doctor with deep knowledge of the drug who takes safety seriously, he says, as opposed to some local clinic or telehealth provider.