Does Ketamine Live Up To The Hype In Depression
Stephen M. Strakowski, MD Gerard Sanacora, MD, PhD Charles B. Nemeroff, MD, PhD
This transcript has been edited for clarity.
Stephen M. Strakowski, MD: Hello. Thank you so much for joining us today. I’m very excited to have two very illustrious and intelligent guests talk us through an interesting topic, the use of ketamine for depression.
I’m Dr Stephen Strakowski, a professor of psychiatry at both Indiana University and the Dell Medical School at the University of Texas at Austin. With me, I have Dr Gerard Sanacora, professor of psychiatry and director of the Yale Depression Research Program at Yale School of Medicine, and Dr Charles Nemeroff, professor and chair at the Dell Medical School at the University of Texas at Austin. Welcome, gentlemen.
To me, at least, ketamine seems to have hit the scene and been adopted pretty quickly for the treatment of depression, after years of watching things slowly develop. Gerry, where are we with ketamine in the treatment of depression? What do we know about it at this point?
Nasal Mist Depression Treatment
In recent years, there have also been studies that have looked at a more controlled long-term use to treat depression. A nasal mist containing ketamine was developed by John Krystal, chief of psychiatry at the Yale-New Haven Hospital.
This nasal mist is administered about once a week, and in some people has been shown to ease symptoms of depression in just a few hours. This is still in its trial stage and has yet to be approved by the FDA for clinical use. However, it shows enormous promise for helping people with depression who dont respond to other forms of treatment.
What Does A Ketamine Treatment Consist Of
Rather than being a first-line treatment, Dr. Levine says, ketamine is given when other antidepressants dont work. Its administered by an IV infusion in the arm, and typically the effects last for anywhere from days to weeks. Generally, its administered in a tapering sequence in which patients receive three infusions the first week, two in the second week, once weekly for the next three weeks, and then moving to maintenance of, on average, once per month, Dr. Levine says.
Ketamine has also been used in cases of bipolar disorder, but it is not indicated for patients with active psychosis, mania, or unstable cardiovascular disease, Dr. Levine says. Nor is it indicated in children, he adds.
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How Is Ketamine Abused
Most of the ketamine sold illicitly is stolen from veterinary clinics or trafficked from Mexico.12 Rather than being sold on the streets, ketamine is usually distributed through friends and acquaintances. The liquid form is injected or reduced to crystals, which are ground into a powder and snorted, smoked, or added to drinks.13 Powdered ketamine is often added to tobacco or marijuana cigarettes or mixed with MDMA , cocaine, and meth. Alarmingly, ketamines odorless and tasteless properties have made it a notorious choice for date rapists.13
Potential For Abuse And Addiction
These are just some examples of the medicines available. Other types of medicines work on other areas of the brain and body to prevent or minimize depression based on the persons individual symptoms and needs.
According to an article from the National Institute of Mental Health, recent studies have been performed on a medicine with a makeup that is similar to ketamine. This medicine, called GLYX-13, has shown promise in having a similar action as ketamine without the side effects and addictive potential. More research is being performed.
Non-medicine treatments for depression are also available and can provide long-term benefits. Various types of therapy from an experienced professional can provide positive outcomes. A recent study in the Journal of Affective Disorders demonstrates that Cognitive Behavioral Therapy has shown positive outcomes in treating depression. In fact, the study shows that outcomes from actual clinical treatment are even more positive than clinical trial studies showed them to be, with significantly longer-lasting results.
Therapy, in combination with some medications if needed, is considered to be the first line of depression treatment.
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Ketamine As An Antidepressant
Over the years, research has been carried out to determine whether ketamine can alleviate depression. Though results look promising for people who have treatment-resistant depression, ketamine is an addictive drug. As a result, it should not be used as a medication among those with a substance use disorder.
However, due to these findings, many people with depression and substance abuse problems believe that ketamine is suitable. Unfortunately, though, this is not true.
While people who have not previously had substance abuse problems might be able to use ketamine to treat depression without the risk of addiction, this is not a realistic option for people with an addiction.
Instead, many different treatments are available for depression, many of which can be found in rehab centers, like our own.
Intervention And Next Steps
Family and friends of a person who is abusing Ketamine may have tried to reason with their loved one, only to be met with anger and denial. An individual who is in his or her addiction is rarely open to reasonable discussions about their problem because they do not believe they have one.
A skilled interventionist can help by guiding an effective intervention.
During the intervention, the family and friends not only confront their loved one, stating they will no enable the addiction, but offer their love and support for the addicts treatment and recovery.
An intervention is a highly charged, emotional, and unpredictable event which should be managed by a professional interventionist. The interventionist will do pre-intervention research and interviews with the family to determine any deeply entrenched enabling behaviors and other specifics related to the person suffering from addiction.
A successful intervention culminates with the interventionist motivating the user to agree to seek treatment. Admission to a drug treatment facility typically follows immediately after the intervention ends.
Common Questions About Rehab
- Loss of coordination
- Rapid breathing
Reviewed by Certified Addiction Professional: October 29, 2019
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Is Ketamine Addictive When Used For Therapy
Medical Editor: Dr. David Cox, PhD, ABPP
Ketamine is a landmark drug that gained fame on the battlefield, in dance clubs as a party drug, and more recently, as a novel treatment for depression. Like many psychedelics, its reputation as a medicine has been out-shadowed by propaganda from the War on Drugs. Focusing on misconceptions from anti-drug lobbying can prevent the real dangers of the substances potential for harm and addiction from being discussed. If one is considering ketamine for therapeutic purposes, there may be questions regarding its potential for abuse. Keep reading to learn what ketamine is, how people can abuse it, and if addiction is a risk in medical settings.
What This Means For You
Like any kind of depression treatment, the use of ketamine needs to be discussed with your healthcare professional, particularly since it’s a controlled substance with an addiction risk. If you’re experiencing depression, talk with your doctor about treatment options that could be a fit for you. If you are having any thoughts of suicide, help is available 24/7 at the National Suicide Prevention Hotline: 1-800-273-8255.
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When Other Antidepressants Dont Work
Ketamine is typically an option for treatment-resistant depression and when other antidepressants dont work. For example, some of the most common drugs for depression are selective serotonin reuptake inhibitors . But, only 37 percent of people who use SSRIs experience full remission. Meanwhile, roughly 70 percent of people who receive ketamine as a treatment achieve remission after just a single series of infusions.
All of this information probably sounds appealing, but lets slow down and understand what ketamine is and how it works before we dive into a revolutionary treatment path.
Physical Symptoms Of Ketamine Addiction:
- Finding that you have built a tolerance to ketamine, meaning that you need to take higher doses on a more frequent basis, in order to experience the desired effects
- Experiencing a range of unpleasant withdrawal symptoms if you stop taking ketamine
- Lack of coordination and motor skills
- Intense cravings for ketamine
Contact Priory today
For further information on how you can take steps to overcome your ketamine addiction at Priory, call us today on , and our dedicated experts will be able to advise on the next steps to receiving ketamine addiction treatment.
This page was clinically reviewed in July 2021 by Sam Hickey.
Ketamine withdrawal can result in a wide range of severe and sometimes distressing withdrawal symptoms. Withdrawal symptoms appear when your body is no longer receiving a substance that it is used to having, causing severe psychological and physical effects.
Psychological symptoms of ketamine withdrawal may include:
- Severe depression
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Extended Data Fig 5 In Vitro Nmdar Inhibition In Acute Brain Slices Of The Nac
a, Example traces of NMDAR EPSCs induced by electrical stimulation in the NAc, recorded in Mg2+-free aCSF. Top: before bath-application of ketamine bottom: with 50µM ketamine. Stimulation artefact was removed. Scale bar is 50ms, 50 pA. b, NMDAR EPSCs before and with ketamine. n=5 cells. Data are presented as mean ± SEM. **P< 0.01.
Who Is A Good Candidate For Ketamine Treatment
Dr. Yermus says that anyone dealing with depression or anxiety who is in good physical health and has an open mind is a candidate for treatment.
However, the government is a bit more exacting when it comes to prescribing the esketamine nasal spray. The FDA has only provided approval for the treatment of treatment-resistant major depression and major depressive episodes associated with serious suicidal ideation and/or behavior, says Dr. Sanacora.
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What Happens During A Ketamine Overdose
A ketamine overdose can occur when the substances is taken in large amounts or when combined with other substances.
Because ketamine is consumed in liquid and powder form, or mixed in these forms with other stimulantsthere is a high chance that a person using this drug has little to no idea of how much is being consumed.
This leaves plenty of room for excessive amounts of ketamine to be taken, amounts which can lead to an overdose. Likewise, snorting and injecting ketamine are common ways to consume ketamine, so this permits quick entry into the bloodstream.
The World Health Organization estimates that, when injected, lethal doses of ketamine begin around 11 mg/kg of body weight. This could be a dosage of about 680 mg for a person around 60 kg.
When a person is experiencing a ketamine overdose, the following can be observed:
- Chest pain
While ketamine addiction is serious, treatments can help. Treatment for ketamine addiction often involves some type of psychotherapy, such as cognitive-behavioral therapy , motivational enhancement therapy, family therapy, or group therapy.
Cognitive behavioral therapy can assist with changing the thought patterns that play a role in supporting drug use and addiction. It can also help develop new coping skills and ways of thinking.
Rehabilitation centers can help with different treatment options, detox programs, and other necessary assistance for overcoming dependency.
Misconception #: Its Okay To Mix Ketamine With Alcohol
Because ketamine is known as a club drug, many people think that it is okay to mix alcohol with ketamine. In reality, mixing the two substances together can lead to worse side effects, more extreme memory loss, sedation, and potentially overdose. In 2011, there were 1,550 recreational ketamine use-related emergency department visits, of which 71.5% also involved alcohol.
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Urinary And Liver Toxicity
Urinary toxicity occurs primarily in people who use large amounts of ketamine routinely, with 2030% of frequent users having bladder complaints. It includes a range of disorders from cystitis to hydronephrosis to kidney failure. The typical symptoms of ketamine-induced cystitis are frequent urination, dysuria, and urinary urgency sometimes accompanied by pain during urination and blood in urine. The damage to the bladder wall has similarities to both interstitial and eosinophilic cystitis. The wall is thickened and the functional bladder capacity is as low as 10150 mL.
Management of ketamine-induced cystitis involves ketamine cessation as the first step. This is followed by NSAIDs and anticholinergics and, if the response is insufficient, by tramadol. The second line treatments are epithelium-protective agents such as oral pentosan polysulfate or intravesical instillation of hyaluronic acid. Intravesical botulinum toxin is also useful.
Liver toxicity of ketamine involves higher doses and repeated administration. In a group of chronic high dose ketamine users, the frequency of liver injury was reported to be about 10%. There are case reports of increased liver enzymes involving ketamine treatment of chronic pain.
Are There Risks Of Long
Ketamine is a potent sedative and hallucinogen, so long-term abuse of this substance can cause serious physical and mental health effects, such as:
- Memory problems.
- Ulcers or pain in the bladder.
- Kidney problems.
- Contracting infectious diseases, such as HIV and hepatitis, from shared needles.
The drug has also been used as a date rape drug, so a person who accidentally ingests ketamine is at a higher risk of contracting STDs.
What Is Ketamine Exactly
Although it was first discovered in 1956 and used as an anesthetic for animals, ketamine was cleared by the FDA in the 1970s as a human anesthetic. Since then, it’s been used extensively to sedate patients for surgery, including soldiers injured in the line of duty during the Vietnam War.
In addition to sedation, the trance-like state ketamine produces comprises pain relief amnesia and a sense of dissociation, like you’re outside of your body. Taking a high dose of ketamine may lead to a psychedelic experience known as a k-hole, involving severe dissociation, intense visual hallucinations, and feelings of unreality.
Where Ketamine Fits In The Treatment Algorithm
Strakowski: Where would each of you put it in your algorithm, in terms of who gets it, when, and where it fits in.
Sanacora: Charlie, I agree with you that there is a real concern of leapfrogging other treatments without good cause. In our interventional psychiatry service, the large majority of people we see have failed at least four treatments. Probably about half have tried electroconvulsive therapy and either find it intolerable or are not able to use it. This is a group I think you can clearly argue for using ketamine.
As you scale back from that, there are two large studies underway. One is the study sponsored by the Patient-Centered Outcomes Research Institute that we’re part of, which is a direct head-to-head comparison between ECT and ketamine. There’s also the Canadian group looking at a very similar study. We’ll get an answer to that soon.
But the FDA approval at least is for treatment-resistant depression, which is having failed two treatments. That really should be a minimum. Those data really suggest that the people that had failed more treatments actually separated better and did better. So it really is for more severely treatment-resistant patients. Where exactly we put it in the algorithm is an individual decision based on the patient.
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Providing Help For Veterans
In addition to depression, ketamine may ease the post-traumatic stress disorder that many veterans experience. PTSD, a mental health problem that people can develop after experiencing some type of trauma, such as combat, can be treated effectively with ketamine, says Aimee Cabo Nikolov, BSN, who with her husband, Boris, runs the Ketamine Medical Clinic, a division of the Neurosciences Medical Clinic, in Miami. Some researchers have called ketamine the most important discovery in half a century, Nikolov says, adding that about 35% of the patients in their clinic are military veterans seeking treatment for PTSD. For many veterans suffering from PTSD, ketamine is providing hope after other kinds of treatment didnt give them the results they needed, Nikolov says.
At the Ketamine Medical Clinic, where around 105 patients have been treated with ketamine, between 75 and 80% felt better on the treatment as compared to more traditional medications for depression. That rate is around 35 to 40%, Nikolov says.
Is Ketamine The Right Treatment For You
This is a discussion that should include your primary care doctor, your mental health provider, and any other health care professionals who care for you. Its important to remember that ketamine isnt a first-option treatment for depression, and it is generally used only when other, more longstanding treatments havent been effective. It is not thought to be curative rather, it improves symptoms for a certain amount of time. It is easier to say who isnt appropriate for ketamine treatment, based on the side effects.
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Here’s What My First Ketamine Trip Looked Like:
Per the instructions, I didn’t eat for four hours before my treatment. There’s potential for nausea when taking ketamine, so Mindbloom provided me with anti-nausea medication, which I took one hour before I began my treatment.
When it was time to begin, I tucked the ketamine tablet inside my lip to let it dissolve. I swished it around with my saliva to help it absorb into my bloodstream, and then I spit the rest out. I turned on a zen Mindbloom playlist, put on an eye mask, and laid down in bed to let the trip begin.
Mindbloom encourages you to set an intention before each treatment something that’s not quite a goal but perhaps a question you want answered or a topic you want to explore. Mine was finding joy. As the session began, I felt a strong need to connect to something deeper and more powerful than myself, something spiritual . Then I saw an image of myself as a child. My first instinct was to fold her in my arms and protect her from everything to come in life. It made me weep.
Behind my closed eyes, I saw some mild visuals of swirling shapes and colors. I never felt scared or overwhelmed at any point simply like I was floating down a river and observing thoughts, feelings, and memories as they passed by. I felt euphoric and slightly detached from my body, which felt somewhat tingly and numb, but I was still aware of the room around me.