It’s been way too long since there was a new class of drugs to treat depression. Ketamine might be the solution.
The author: Moises Velasquez-Manoff, the author of “An Epidemic of Absence: A New Way of Understanding Allergies and Autoimmune Diseases” and an editor at Bay Nature magazine, is a contributing opinion writer. Dec. 1, 2018
The suicide rate has been rising in the United States since the beginning of the century, and is now the 10th leading cause of death, according to the Centers for Disease Control and Prevention. It’s often called a public health crisis. And yet no new classes of drugs have been developed to treat depression (and by extension suicidality) in about 30 years, since the advent of selective serotonin reuptake inhibitors like Prozac.
The trend most likely has social causes — lack of access to mental health care, economic stress, loneliness and despair, the opioid epidemic, and the unique difficulties facing small-town America. These are serious problems that need long-term solutions. But in the meantime, the field of psychiatry desperately needs new treatment options for patients who show up with a stomach full of pills.
Now, scientists think that they may have found one — an old anesthetic called ketamine that, at low doses, can halt suicidal thoughts almost immediately.
Depression ran in Louise’s family. It had afflicted all her siblings, both of her parents and her grandmother. Prozac had helped Louise for a time, but stopped working for her in the late 2000s, as it sometimes does. No other drug seemed able to lift her dark moods.
After her suicide attempt, Louise’s psychiatrist suggested she try ketamine. She agreed, and received an infusion intravenously. Within hours, her sense of well-being improved. The hospital discharged her. Back home, she discovered that going to the market was no longer a “herculean task.” Getting her car washed wasn’t an insurmountable chore. “Life was better,” she said. “Life was doable.”
Using ketamine to treat depression and suicidality is somewhat controversial. Numerous small studies suggest that it holds great promise, but it’s only now being tested in placebo-controlled trials with hundreds of patients. It is also popular as a club drug in some circles. Like morphine, it may operate on the opioid system, and it can induce feelings of euphoria. Occasionally ketamine abusers develop severe symptoms, including brain damage, persistent hallucinations and a painful inflammation of the bladder called cystitis.
Nonetheless, if proven safe and effective in small doses, ketamine stands to transform how doctors deal with suicidal patients and depression generally.
The drug seems to address a longstanding problem in emergency psychiatry. Sedation and physical restraint aside, doctors have few ways to quickly stop suicidal ideation, or thoughts of killing oneself. The current crop of anti-depressants can take weeks and sometimes months to work, if they work at all. They may also, paradoxically, increase suicidality in some patients. Talk therapy takes time to help as well (assuming it does). Here’s a sobering fact: Some studies indicate that suicide risk peaks soon after patients have been discharged from a medical facility.
Researchers at Yale discovered ketamine’s potential as an antidepressant in the late 1990s and scientists at the National Institute of Mental Health confirmed it the mid 2000s. Numerous studies followed suggesting that the drug helps precisely with that subset of depressive patients — about a third — for whom nothing else works. It doesn’t work for everyone in this group, but when it does, it works within hours, not weeks.
Suicidality doesn’t perfectly overlap with depression. Many people attempt suicide not because they’re clinically depressed, but rather impulsively, because they’ve been fired or they’ve broken up with girl- and boyfriends, or sometimes because they’re just really drunk. I’ve heard people who show up in the hospital in this state — despondent, angry and uninhibited more than depressed — described as “drunkicidal.”
Many are fine once they sober up. For those who aren’t, ketamine may help independent of its effect on depression. And because ketamine is already approved by the Food and Drug Administration, doctors can prescribe it off-label. Meaning that not only does a drug exist right now that could help with depression and suicidality, it’s theoretically available to patients.
I kept thinking about this during the recent spate of high-profile suicides: the chef Anthony Bourdain, the designer Kate Spade, the actress Margot Kidder. Could ketamine have saved any of them? Did they know about it? Did their psychiatrists?
Earlier this year, I wrote about ketamine and depression for Wired, and patients I interviewed told me some version of the same thing — that ketamine changed their lives and, in some cases, saved it.
Ketamine works differently from other antidepressants. The prevailing theory is that it affects the brain’s glutamate system, which scientists now realize may be involved in depression, rather than the better-known serotonin pathway used by drugs like Prozac. Animal research suggests that partly blocking certain glutamate receptors increases brain plasticity — the ability of the brain to make new neuronal connections — and corrects some of the abnormalities that result from chronic stress. These salutary effects on the brain, coupled with how quickly ketamine works, have inspired a flurry of research. A number of drugs either derived from ketamine, or based on how scientists think it works, are in development. The pharmaceutical companyJanssen is working on a nasal spray.
But ketamine has what many view as a major flaw. It can produce dissociative and hallucinatory side effects while it is being administered. Patients can feel as if they’ve left their bodies or that they’re dying. Louise described her first ketamine experience as being like Picasso’s painting “Guernica” — disjointed and unpleasant. But subsequent treatments, she said, were “wonderful” — full of images of birds, fish and whales.
Questions also remain about the safety of long-term use. Depressed patients often have to return for “booster” treatments (Louise finds that she needs an infusion once a month). The drug is considered safe when given once, but no one is sure how repeated doses may affect the brain. And ketamine can be addictive, too.
Nonetheless, dozens of clinics have opened around the country offering ketamine infusions as an off-label treatment for depression. Views on these clinics run the gamut from concerns about profiteering (Louise’s treatments cost $500 out-of-pocket; most insurance companies don’t cover ketamine when it is prescribed off-label) to acknowledgment that they may be helping desperately ill patients.
Dr. Jeffrey Lieberman, the psychiatrist in chief of Columbia University Medical Center, told the health care news site STAT that some patients may be “getting fleeced.”
Dr. Samuel Wilkinson, a Yale psychiatrist who studies ketamine, worries that some of these clinic operators forgo more established treatments to try ketamine. Case in point: Louise refused electroconvulsive therapy, because she remembers it making her mother and grandmother into “living zombies.” In Dr. Wilkinson’s view, patients should strongly consider all other reasonable possibilities before moving to ketamine. (And electroconvulsive therapy, which retains a gruesome reputation, has in fact improved greatly, he said.) He also worries that patients’ suicidal impulses could seem to disappear after ketamine treatment, leading to discharge from the hospital, but then rebound after the ketamine is stopped or tapered — something he’s seen happen in a research setting.
The deeper issue here is one of weighing the risks of new treatment that hasn’t been fully vetted and has unclear long-term side effects against a condition whose primary symptom is the urge to kill oneself.
Dr. Michael Grunebaum, a Columbia psychiatrist who studies ketamine, thinks the drug should no longer be relegated to a last-line treatment. “It makes sense that it move up in the treatment algorithm in E.R.s and inpatient units,” he told me. (Although if emergency rooms everywhere began offering ketamine, it could create new problems, he adds. As has occurred with opioids, people might claim to be suicidal when, in reality, they’re trying to get high.)
The most ringing endorsement of ketamine may come from those on the front lines of medicine: E.R. doctors. I met Louise through a doctor friend, Lowan Stewart, who works at the emergency room in Santa Fe, N.M., where she was first admitted after overdosing. He also treats patients at the ketamine clinic where Louise ended up going. Generally speaking, the protocol in emergency rooms doesn’t include giving suicidal patients ketamine, and he argues that this should change.
His view, informed by the extreme backdrop of the E.R., is worth considering. He regularly sees patients with gunshot and knife wounds, people experiencing psychotic episodes, car accident and drug overdose victims — and of course suicidal patients. Sometimes these patients beg him to kill them. Other times they threaten or attack police officers — an attempt at “suicide by cop.” Once he stabilizes them, he often has to lock them in a padded room for up to 24 hours dressed only in tearable paper pajamas, perhaps sedated, until a psychiatrist arrives. “It’s horrible,” he told me. The reality of a busy E.R. is that these patients often end up crying alone, he said.
E.R. doctors are often quite familiar with ketamine; Dr. Stewart uses it as an anesthetic regularly on children precisely because it’s considered so safe. Now that research has revealed its potential to treat depression and stop suicidal impulses, he thinks that doctors should offer it to suicidal patients in the E.R. “We could help so many people,” he said.