Ketamine for treatment-resistant depression: when and where is it safe?

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Ketamine is approved for hard-to-treat depression, but how safe are ketamine outpatient clinics?

Ketamine is an unusual type of psychedelic drug – called a dissociative – that is experiencing a resurgence in popularity. Originally derived from PCP, or “angel dust”, ketamine has been used in hospitals and veterinary clinics as an anesthetic for decades, and has been cited as a drug of abuse under the nickname “Special K “.

It is the effects that ketamine reliably produces that underpin its medical and recreational uses: pain control, forgetfulness, intoxication, dissociation, and euphoria. Recently, it has been used more widely due to its approval for treatment-resistant depression (TRD) – that is, severe depression that has not improved with other therapies, including people who have suicidal thoughts.

Evidence of the benefits of ketamine

A prescription version of ketamine called esketamine (Spravato), administered by nasal spray, was approved in 2019 by the FDA for TRD; however, according to the guidelines, it should only be used “under the supervision of a health care provider in a licensed physician’s office or clinic.” This means healthcare professionals have to watch you use it and then follow you after you’ve taken your dose, checking your vital signs and clinical status.

The effectiveness of ketamine for TRD was first demonstrated for short-term treatment in research that resulted in clinically and statistically significant decreases in depression scores for ketamine compared to placebo ( in both groups of this study, patients continued to take their usual antidepressants due to not treating TRD in the placebo arm.) Nasal ketamine was found to have longer-term efficacy, in a study where ketamine (plus the regular antidepressant) helped people stay in stable remission 16 weeks after starting treatment.

Relief from TRD with ketamine occurs quickly. Instead of waiting for an SSRI to hopefully bring some relief over the course of weeks, people suffering from the crushing weight of depression can start feeling the benefits of ketamine in about 40 minutes.

Is ketamine the right treatment for you?

This is a discussion that should include your primary care physician, your mental health care provider, and any other healthcare professionals who care for you. It is important to remember that ketamine is not a first option treatment for depression, and it is usually only used when other, older treatments have not worked. It is not believed to be curative; on the contrary, it improves the symptoms for a while. It’s easier to say who is not suitable for ketamine treatment, depending on side effects.

Should you go to a ketamine clinic for treatment?

Independent, outpatient ketamine clinics are popping up everywhere. It is estimated that there are currently hundreds if not thousands of such clinics – almost all of which were established in 2019 when ketamine was approved for TRD. Typically, these clinics are for-profit businesses made up of a psychiatrist or anesthetist (who can administer the infusion), a nurse, a social worker, and (of course) business people. who make everything work.

While writing this article, I called several ketamine clinics, posing as a patient, to investigate what would be involved in receiving ketamine therapy. Most of them seemed willing to provide me with ketamine without any major hurdles, after an introductory medical interview by a nurse or social worker. A few clinics demanded a communication or diagnosis from my psychiatrist – and that seemed quite reasonable.

The clinics operate on a fee-for-service arrangement, so you would be paying out of pocket, as insurance rarely covers this treatment. In the Boston area where I live, ketamine infusions cost about $600 each, and a course of six infusions and clinical reassessment are generally recommended. (I should note that ketamine clinics affiliated with medical academic institutions seem to have more safeguards in place, and they can also enroll people in clinical trials.)

Are Ketamine Clinics Safe?

These ketamine clinics raise many questions – namely, what do you look for in a reputable and safe ketamine clinic? Currently, we do not yet have definitive answers to this question. One wonders if a ketamine infusion, which can cause a profound dissociation from reality, would be better controlled in a hospital setting, where there are safety protocols in case something goes wrong. It was unclear (in part because I did not go through the therapy) the degree of communication, if any, between the staff at the ketamine clinic and your health care providers, and generally the treatments that you receive would not be included in your main electronic medical record.

What are the side effects?

Ketamine is generally considered safe, including for those with suicidal thoughts (thoughts or plans of suicide). The main side effects are dissociation, intoxication, sedation, high blood pressure, dizziness, headache, blurred vision, anxiety, nausea and vomiting. Ketamine is avoided or used with extreme caution in the following groups:

  • people with a history of psychosis or schizophrenia, as there is concern that the dissociation produced by ketamine may worsen psychotic disorders
  • people with a history of substance use disorder, as ketamine can cause euphoria (likely by triggering opioid receptors) and some people can become addicted to it (so called substance use disorder use of ketamine)
  • adolescents, as there are concerns about the long-term effects of ketamine on the still-developing adolescent brain
  • pregnant or breastfeeding people
  • older people with symptoms of dementia.

More detailed research needs to be conducted on the long-term benefits and side effects of ketamine treatment, as well as its safety and effectiveness for adolescents and the elderly, as well as emerging indications for ketamine therapy. ketamine for PTSD, OCD and alcohol use disorders. , and other mental health issues.

Finally, there is concern that with repeated doses, ketamine may begin to lose its effectiveness and require larger doses to produce the same effect, which is not long lasting.

Ketamine could give hope to people with severe depression

Severe, treatment-resistant depression can rob people of hope for the future and hope that they will ever feel better. Ketamine can bring help and hope to patients who have found no relief with other treatments. Given its effectiveness in people contemplating suicide, it is plausible that ketamine could save lives.

As we learn more about ketamine research and people’s experiences in new clinics, we will be better able to answer questions about ketamine’s long-term effectiveness and guarantees. necessary for treatment. We can also find out who is most likely to benefit safely from ketamine therapies and the best method of delivery: intravenous infusion, nasal spray, or pill.

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