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 severe depression and suicidal thoughts. But health experts are alarmed by its growing and widespread use under lax safety conditions.

Last month, the US Food and Drug Administration issued a warning to patients and providers outlining the potentially serious physical and psychological dangers of ketamine, which is often administered in clinics or offices. of the practitioners by infusion or intravenous injection and induces a quasi-psychedelic state full of fantastic. thoughts and images.

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

“The overall benefit-risk profile of ketamine for the treatment of psychiatric disorders is unknown,” the agency said. (The statement does not cover Spravato, a nasal spray delivery of 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 that the spray is not not as effective as the intravenous version).

It’s not that no one should try the drug. “Ketamine works in a lot of people. I’ve seen it change lives,” says Sophie Holmes, a psychiatry and neurology researcher at the Yale School of Medicine who has documented positive changes in brain imaging while under the drug influence. But it is definitely a case of patient attention, he says.

“Ketamine is unique in terms of the rapid 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 his clinic with the use of substances. disorder

Conditions such as suicidal depression, anxiety or post-traumatic stress disorder “have a real impact on people’s functioning and quality of life and are difficult to treat even with good psychotherapy and expert medication management” , says Whinkin.

Significant side effects

Ketamine should only be administered in settings equipped to treat medical emergencies, Holmes says, which is not generally the case for the many wellness clinics and telehealth providers that adopt the drug for a wide range of mental health applications and feed a $3 billion industry that is expected. growing 10 percent annually by the end of the decade.

Holmes says more research is needed to better understand who could benefit from ketamine therapy, what the proper protocol should be, and, most importantly, how it works. The current thinking is that the drug increases the connections between synapses in the brain, which allows new ways of thinking to develop.

While some people only have mild and fleeting nausea, headache, or stomach ache while on the drug, others may have slowed breathing or increased blood pressure.

“If someone has a pre-existing heart problem, this could be dangerous,” says Holmes, who notes that all prospective ketamine patients at Yale first undergo an electrocardiogram heart test and their vitals are monitored during each session.

Equally crucial, some clinics do not provide sufficient psychological support. Patients can be frightened during hallucinations, says Whinkin. These usually last less than an hour, much shorter than for real psychedelics like psilocybin or lysergic acid diethylamide, or LSD. (To capitalize on the growing interest in psychedelic medicine, many clinics advertise ketamine as psychedelic-assisted therapy even though it is not a true psychedelic).

Post-treatment “integration” sessions are a vital part of the experience. “It is an opportunity to explore the psychological material that has appeared during the journey, and if there is a confusion or confrontation of pre-existing beliefs about oneself or the world, which deserves qualified support,” says Whinkin.

As its name implies, integration therapy, when done well, also incorporates altered experience into practical actions. “What is the way forward to leverage the experience to make a remarkable change to the way we live on a daily basis?” he says.

Perhaps the biggest concern is the growing use of ketamine at home, via oral capsules or pills held under the tongue, which are two delivery systems that are poorly understood. Thanks to regulation that began in 2020 after the start of the pandemic, only a short telehealth appointment is needed rather than an in-person visit before ketamine arrives at home.

“The prescription for home use is irresponsible, because it must be taken under the supervision of trained professionals,” insists Holmes. Use of these products without simultaneous monitoring by a healthcare provider “may place patients at risk for serious adverse events,” the FDA warning says.

Home use also increases the potential for abuse, as ketamine is sold illegally recreationally under the name Special K. This is particularly concerning as some clinics use it to treat substance abuse, says Michael Schatman, an expert in pain medicine and medical ethics in New. York University School of Medicine, which outlined its concerns in a medical journal this year. “I’ve seen my pain patients, addicted to opioids, given nasal ketamine and they went home and abused it” by smoking and then bingeing, he says.

For some, lasting relief

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

For 25 years, Thomas experienced bouts of depression so extreme that he regularly thought about suicide. Unable to leave her bed for months at a time, the disease severely impacted her quality of life and derailed an opera singing career.

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

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

“My first infusion was like magic,” he recalls. While under her spell, she saw an earth goddess effortlessly throw away the demeaning words she yelled at herself while depressed, like she was stupid or useless. This behavior stopped later.

It took several years for the other symptoms to subside, but after nearly 100 ketamine sessions, with ongoing maintenance sessions, he hasn’t had a depressive episode in nearly a year. (This cost his family about $30,000, because ketamine treatment is often not covered by insurance, although his insurer recently agreed to start paying).

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

“I have patients who come into infusion clinics who are told that this will help them, who are not even aware that they may be hallucinating,” he says. People should 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.

“People need to understand what they’re experiencing,” Schatman says. Some are in so much pain that they are willing to roll the dice.

If they do, they’ll increase their chances by seeing a practitioner with a deep understanding of the drug who takes safety seriously, he says, “as opposed to a local clinic or telehealth provider.”