Ketamine for Depression

Chapter One My Journey with Ketamine: I work as a psychiatrist in private practice seeing people who are not quite ill enough to need to be in hospital, but not quite well enough to be managed solely in general practice. Although I am now semi-retired I still see nearly ninety long term patients who have made it quite clear to me that I need to stay around until they are cured. This is proving to be difficult. I had been vaguely aware of Ketamine from sporadic reports of its use over the past fifteen years, but what really attracted my attention was what happened three years ago when one of my patients was given a ten day subcutaneous [under the skin] Ketamine infusion for severe persistent pain. This treatment worked well for her pain, but it also noticeably improved the severe depressive symptoms she was experiencing at that time. A coincidence? Perhaps not having the pain had made the difference? My interest subsided. Then last year I was trying to help a man with chronic, severe Obsessive-Compulsive Disorder [he needed six hours to complete his bathroom rituals] and we were discussing the possibility of brain surgery. One must bear in mind that brain surgery is reserved for the most intractable of cases; all possible treatments have to have been tried, and to have failed, before surgery is contemplated. I then read that intravenous Ketamine had been helpful in reducing OCD symptoms in \a small group of patients treated in America. I discussed this with my patient and, as he was keen to try anything that could help, I sought permission from our local private hospital to test this treatment. The process of obtaining and submitting the required information to be reviewed by the Medical Advisory Council was time-consuming and there was then a period of two months to wait before the next meeting of the Council. During this time I explored all the research I could find on Ketamine downloading over five hundred studies and articles from the fields of Anaesthetics, Pain Medicine and Psychiatry. Deep into this process, and deeper still into Google, I found two articles which led me to change my way of thinking dramatically. The first was by a group of Brazilian psychiatrists, Diogo Lara and colleagues, [1] who reported success in helping people with treatment-resistant mood disorders using very low dose sublingual [under the tongue] Ketamine. This approach was in stark contrast to the vast majority of published trials to date which have used the intravenous route, requiring hospitals, anaesthetists, intensive monitoring and not the least - considerable expense. This led me to consider the next big question – How safe is it to take Ketamine for extended periods? Most of the early trials had involved either the use of single doses or at most, treatment for two weeks. However, the second article I discovered described the quite remarkable work of Varun Jaitly, [2] an anaesthetist and pain medicine specialist working in the United Kingdom. He had been using sublingual Ketamine over the past fifteen years to treat a variety of chronic pain conditions not responding to the usual remedies. He reported that Ketamine was helpful in around 20% of these very tough-to- treat conditions but, more importantly, he had monitored patients over the years and had not observed major problems with long-term use [one patient has been taking it three times a day for 15 years]. In particular there had been no signs of dependence or addiction, nor any indications of the bladder problems that can affect those who abuse Ketamine by taking very high doses regularly for non-medical reasons. Encouraged by these reports and by other small scale studies I found describing the use of oral ketamine I developed a treatment protocol and, after discussions with my peer review group, I began treating some of my most difficult patients with the low dose sublingual method in November 2014 - [see the appendix for the treatment process, consent form, sample scripts, patient information sheets and FAQs.] The most notable features of my treatment are: 1. After a trial dose of Ketamine monitored in my consulting rooms, patients self-administer further doses at home, taking it every second day initially. They continue with their current treatments. 2. If there is no improvement the dose is gradually increased until either clear benefit has been obtained or side effects become troublesome. 3. Those who improve fully then extend the interval between their doses by only taking another when there are signs that their mood is slipping. At this point trials of reducing other medications can begin. 4. For those who partially improve we continue to test combinations of talking therapies, medications, dietary change and exercise along with Ketamine to try and get the best response. Ketamine may be stopped for a trial period to clarify its benefits. 5. For those who do not respond, we continue to search for better treatments. Usually I would expect with any new treatment, be it medication or a different psychological approach, e.g. Mindfulness therapy, that around 10% of the hard-to-treat patients will obtain an appreciable benefit. However, since starting Ketamine about 70% of patients in my trial have clearly improved and 40% have now made full recoveries. Some have not needed to take Ketamine for months. This mirrors the results from trials using the intravenous, intramuscular, subcutaneous, intranasal and oral routes of administration. From my experience there are major advantages to the low dose sublingual method over these other approaches: 1. Patients require less Ketamine over the course of treatment due to the lower doses being administered. 2. Side effects are minimal at these dosage levels. 3. It is very much more affordable for both patients and the government if people can take their Ketamine at home. 4. More people can be seen and treated compared with time-consuming clinic and hospital systems.