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 ideation. But health experts are concerned about its growing and widespread use amid lax security.

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 used in clinics or doctors’ offices by injection or injection and produces a quasi-psychotic state filled with fantasy. thoughts and ideas.

The FDA also claims that because it has only approved this drug for use in surgery, there are no strong 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 asserted. (The statement does not include Spravato, the delivery of a special 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 as effective as intravenous version.)

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

“Ketamine is unique in how quickly it works,” says Emily Winkin, a naturopathic doctor in Seattle who recently described significant improvements in anxiety and depression in 18 drug abuse patients in her clinic after one to six sessions of ketamine-assisted psychotherapy. disturbance.

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,” Winkin says.

Significant side effects

Ketamine should only be used in settings equipped to handle medical emergencies, Holmes said, which is generally not the case with the many health clinics and telehealth providers that take the drug for widespread mental health use and fuel the $3 billion industry. which is predicted. with 10 percent annual growth by the end of the decade.

Holmes says more research is needed to better understand who can benefit from ketamine therapy, what the appropriate protocol should look like and, importantly, how it works. 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 upset stomach while using the drug, others may experience slowed breathing or increased blood pressure.

“If someone has a heart problem, it can be dangerous,” says Holmes, who notes that all prospective ketamine patients at Yale undergo an electrocardiogram beforehand, and their vitals are monitored each time. during the session.

Equally important, some clinics also do not provide sufficient psychological support. During hallucinations, patients can become fearful, Winkin says. They usually last less than an hour, which is much shorter than for true psychoactive drugs 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 an actual psychedelic drug.)

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 with pre-existing beliefs about the self or the world, that deserves skillful support,” says Winkin.

As its name implies, integrative therapy, when done properly, also incorporates altered experience into practical action. “What is the way to use the experience to make a significant difference in your daily life?” he says.

Perhaps the biggest concern is the growing use of ketamine in the home, via oral capsules or sublingual tablets, two delivery systems that are poorly understood. Thanks to the regulations, which began in 2020 after the epidemic began, only a short-term telehealth appointment, rather than an in-person visit, is needed before ketamine can be delivered to the home.

“It is irresponsible to prescribe it for home use because it should be supervised by trained professionals,” Holmes argued. Use of these products without a healthcare provider “may put patients at risk for serious adverse events,” the FDA said in the notice.

Home use also increases the potential for abuse, as ketamine is sold illegally under the special K name. That’s especially concerning because some clinics use it to treat substance abuse, said Michael Shatman, a pain management and medical ethics expert at NYU. York University School of Medicine, who outlined his concerns in a medical journal earlier this year. “I’ve seen my pain patients who are opioid addicts have been given nasal ketamine and they’ve gone home and abused it” by topping up and then eating, he says.

For some, lasting relief

Others worry that the drug they see as a lifeline is being abused. Shira Renee Thomas, 45, artistic director of the 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 severe that he regularly contemplated suicide. Unable to leave her bed for months, the illness seriously affected her quality of life and derailed her career as an opera singer.

Over the years, he has been hospitalized several times, prescribed about 20 different medications, individually and in combination, and even underwent electroconvulsive therapy, which he had to stop after losing so much memory that he couldn’t remember how to drive a car or sign his papers. name: on the check.

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

“My first infusion was like magic,” she recalls. Under her spell, she watched as the earth goddess effortlessly brushed away the derogatory words she shouted at herself when she was depressed, such as that she was stupid or useless. That behavior later stopped.

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

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

“I have patients who go to infusion clinics who are told it will help them who don’t even know they may 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’re experimenting,” Shatman says. Some are in so much pain that they are willing to roll the dice.

If they do, they should increase their odds of seeing a specialist with in-depth knowledge of the drug who takes safety seriously, he says, “as opposed to a local clinic or telehealth provider.”