Author: Lori Calabrese, M.D.

By Moises Velasquez-Manoff –
Contributing Opinion Writer

It’s been way too long since there was a new class of drugs to treat depression. Ketamine might be the solution.

In May of 2017, Louise decided that her life was just too difficult, so she’d end it. In the previous four years, three siblings and a half-sibling had died, two from disease, one from fire and one from choking. Close friends had moved away. She felt painfully, unbearably alone. It would be the fourth time Louise (I’m using her middle name to protect her privacy), then 68, would attempt suicide, and she was determined to get it right.

She wrote a letter with instructions on where to find important documents and who should inherit what. She packed up her jewelry and artwork, addressing each box to particular friends and family members. Then she checked into a motel — homes where people have committed suicide lose value and she didn’t want hers to sell below market — put a plastic sheet on the bed, lay down and swallowed what she figured was an overdose of prescription pills with champagne.

A few days later, she woke up in a psychiatric ward in Albuquerque. The motel maid had found her. “I was very upset I had failed,” she told me recently. So she tried to cut her wrists with a bracelet she was wearing — unsuccessfully.

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.Please disable your ad blockerAdvertising helps fund Times journalism.How to whitelist

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.

Informed opinions on today’s vital issues.Subscribe to The New York Times

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.

[Discover the most compelling features and reporting from The New York Times Opinion section, selected by our editors. Sign up for the Sunday Best newsletter.]

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 antidepressantin the late 1990s and scientists at the National Institute of Mental Healthconfirmed 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?

Get our weekly newsletter and never miss an Op-Doc

Watch Oscar-nominated short documentaries from around the world made for you.SIGN UP

“More patients should be aware of this,” Louise told me. “It really is a godsend.”

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 company Janssen 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.

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.

[Read the Original Post Here]

Ketamine is showing promise in alleviating suicidal thoughts.

DEREK BERES 03 December, 2018

• The popular party drug has shown promise in stopping suicidal thoughts in a number of small clinical studies.
• First synthesized in 1962, the anesthetic was used to treat Vietnam War soldiers in the early seventies.
• Though the accompanying hallucinations are a roadblock to widespread therapy, innovations in psychiatry are necessary.

The dirtiest drug I ever tried was ketamine. Besides having a general aversion to snorting powder, I vividly recall one evening in 1995 when, after ingesting a hearty dose of the anesthetic, I could no longer tell the difference between standing, sitting, and lying down. Fortunately I was in a safe environment; the effects eventually wore off, my relationship to gravity restored. The following morning was rough, causing me to swear off the drug forever.

Bad experiences create aversions. There are too many horror stories to count about the curious traveler landing in Los Angeles to partake in recreational marijuana who ends up eating fifty milligrams when five would have sufficed. Once that experience is locked into memory it’s doubtful you’ll ever enjoy an edible again. Dosage matters. If you’re not careful, you’re writing off a potential beneficial therapy due to ignorance and over-enthusiasm. Getting back on the horse, as it goes, takes a certain determination.

Ketamine isn’t actually dirty, I just took too much. Others are finding a lot of benefit to the chemical. The recent uptick in clinical cases promoting ketamine as an antidote to suicidal thinking is one such victory.

This isn’t exactly new. In June, 2017 I covered this study, discussing the means by which ketamine works:

Ketamine is responsible for blocking the N-methyl-D-aspartate (NMDA) receptor, which causes an immediate alleviation of depressive effects, while another metabolite in the drug helps the effects last for hours. This blockage is also what causes the hallucinogenic effects.

First synthesized in 1962 by Wayne State University chemistry professor, Calvin Stevens, it was first tested on human prisoners (following animal trials). Regardless of the ethics of testing on the prison population, it was approved for clinical use by the FDA in 1970. Shortly thereafter it was used an anesthesia in the Vietnam War.

Ketamine was also immediately used outside of clinics and hospitals, quickly “discovered” by the psychedelic community. By the time I stumbled into it in the nineties, it was synonymous with ecstasy on the rave scene. It wasn’t until 1999 that the US government labelled it as a federally controlled substance. It has never been an especially blacklisted drug, not to the level of other clubbing substances.

Now, with life expectancy dropping in America for the second straight year due to the opioid crisis and increased rates of suicide, ketamine is being looked at more closely. There is no single reason for these data about declining life spans, Moises Velasquez-Manoff writes in the NY Times,

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.

Ketamine might be that treatment, he continues, noting that it has been shown to “halt suicidal thoughts almost immediately.” Not that there aren’t hurdles to overcome. Cultural associations are one, but there is evidence that ketamine causes brain damage, cystitis, and persistent hallucinations in abusers. Abuse is key here. Like my dreadful evening, too much is too much.

Current treatments for depressive and suicidal disorders can take weeks to months to kick in, however, some of which actually increase the likelihood of suicide. Velasquez-Manoff writes that ketamine operates differently from antidepressants by working on the brain’s glutamate system rather than the serotonin system—most of the body’s serotonin is produced in the gut, anyway.

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.

The hallucinations present another hurdle for clinical usage. If you’re not accustomed to such mind states, doing so while lying back in a doctor’s chair might not be the place to start. Or…it might be. “Setting” has long been an integral part of the psychedelic experience, as important to the outcome as strength and dose of the substance. Feeling safe under the guidance of an experienced professional might allow for mind wandering without the accompanying fear.

Which has, in fact, always been a part of the psychedelic experience. Ayahuasca should not be consumed alone or out on the scene; the shamanic ritual is a necessary component. Separating substance from context is certain to result in a terrifying experience, which is a shame given the potential therapeutic applications of these substances.

Ketamine might not have the stamp of approval yet, but the fact that it’s being treated seriously is a good start. We know our current drug program is not working. All options should be on the table. That we live in one of the most advanced civilizations ever, with a wealth of resources and information, yet cannot take care of an increasing number of citizens is problematic. There is no singular solution, so we have to exhaust all possibilities.

[Read the Original Post Here]