more_vert
ONE in five Australians will experience a mental illness in their lifetime, with depression topping the list as the most disabling medical condition worldwide. Ketamine treatment for depression has challenged the dominant monoamine theory of depression – as an N-methyl-D-aspartate (NMDA) receptor antagonist that operates on the brain’s glutamate system, it has a completely different mechanism of action compared with standard antidepressants.
Administered for many decades as a dissociative anaesthetic as well as an analgesic, it is also used recreationally for its mind-altering properties. Disrupting the antidepressant pharmacopeia, ketamine at subanaesthetic doses has recently emerged as a potential effective therapy for treatment-resistant depression, which comprises up to one-third of patients with depression who fail to remit despite multiple trials of antidepressant medications. Placebo- and comparator-controlled trials in treatment-resistant depression have reported high levels of efficacy and rapid onset of action (within hours), which are greater than what is typically found with other antidepressant medications (here and here). It has also been found to be effective in depression that is highly treatment resistant, including failure to respond to electroconvulsive therapy (ECT). However, it remains uncertain as to whether the rapid and robust antidepressant effect often obtained with ketamine translates into longer term benefits.
The most appropriate drug preparation and route of administration remains unclear, with most studies to date using racemic ketamine by intravenous infusion, but also by intranasal, subcutaneous or intramuscular routes (Loo et al, 2016), as well as esketamine given intranasally. The relative benefits of the different preparations have not been systematically compared, and the various routes give rise to differences in peak blood level, total duration, and exposure to ketamine and its metabolites. There is no consensus on the optimum dosages for depression – most randomised controlled trials have used a dose of 0.5 mg/kg, though efficacy has been reported at lower doses. Dose-titration approaches involving an individualised approach – starting at a low dose and increasing the dose until remission occurs – suggest the optimum dose may differ between individuals. There is some suggestion that the optimum frequency of dosing is twice per week and that more frequent dosing may be less effective.
The safety profile of ketamine, especially pertaining to repeated dosing, requires clarification. Serious hepatic and urinary adverse events have been described anecdotally in recreational users of ketamine. Side effects and risks from cumulative exposure are not fully known, with a recent systematic review finding that there is limited or poor quality information on ketamine safety when given in repeated doses, with most studies assessing safety outcomes for only 4 hours after a single dose. Recent research has challenged the existing notion that ketamine’s therapeutic effect is due to blocking NMDA receptors in the brain, with a study finding the antidepressant effect was blocked when ketamine was co-administered with naltrexone (an opioid antagonist), thus implicating the opioid system. Given the “opioid crisis” in the United States, this may be cause for concern about ketamine’s potential widespread use in depression. At present, the onus of responsibility falls on the clinician proposing to give a course of ketamine treatment to monitor for side effects and risk of dependence. This includes the need to formulate and implement an appropriate framework for monitoring safety – we are currently validating a Ketamine Side Effect Tool based on findings of the systematic review.
Despite these unknowns, ketamine is already being administered in clinical practices in Australia and the US. Clinicians considering prescribing ketamine for an individual patient need to have carefully considered a range of questions. What are the regulatory issues? What would be the best route of administration? What is the optimum dose? What is the optimum frequency of administration? For how long? What other psychological or psychosocial treatments should be implemented? What other biological treatments should be co-administered? What diagnoses warrant treatment? Where does ketamine fall within existing treatment pathways? Should standard antidepressant medications and ECT be trialed first? What are the consent issues? A clinical framework answering these questions needs to be thought through if doctors are considering prescribing ketamine.
This was recently highlighted in a Health Care Complaints Commission case that shut down a “ketamine clinic” owing in part to systemic failures in adhering to regulatory issues and safety monitoring. In Australia, there are complex state-based regulations outlining the rules for supply of ketamine, which is classified as a Schedule 8 drug of addiction. For example, in New South Wales, ketamine requires authority from the NSW Health Pharmaceutical Services Unit if prescribed for a period exceeding 2 months. Injectable ketamine is registered by the Therapeutic Goods Administration (TGA) as an anaesthetic agent, but its use in depression is “off label” as it is not TGA-approved or indicated in the product information for the treatment of depression – key points any potential patient would need to be apprised of.
The Royal Australian and New Zealand College of Psychiatrists recommends that psychiatrists considering prescribing ketamine outside of a research setting should ensure the patient is willing and able to consent and they should discuss ketamine therapy with peers (preferably including a second opinion), or seek institutional review by a medicines advisory committee, or seek consideration by an institutional research ethics committee. At a practical level, before being able to administer ketamine, the clinician’s medical practice would need to have the appropriate infrastructure, ensure adequate training of staff administering ketamine, and have a framework for managing acute and potentially serious adverse effects (eg, marked psychotomimetic reactions, abrupt increases in blood pressure). Physical storage of ketamine at a medical practice needs to comply with strict regulations governing Schedule 8 drugs. A comprehensive medical and psychiatric assessment is essential, including the use of structured rating scales. The clinician needs to determine which patients are suitable for ketamine therapy and the nuances of their treatment response. For example, in unipolar versus bipolar depression, the latter tend to respond more rapidly but without data on the incidence of switching. Comorbid personality disorder or substance misuse problems may preclude safe treatment. Referral pathways should consider whether an assessment by a psychiatrist is necessary for treatment to proceed.
Before commencing treatment, a detailed consenting process would be required, involving discussion of the evidence base, that it is an off-label therapy, and what alternative evidence-based treatments are available to the patient. Dosing guidelines and a treatment protocol should be devised including consideration of the route, dose and frequency of administration. These treatment parameters all warrant careful consideration when embarking on ketamine treatment – and with limited evidence at present to guide these choices.
Ketamine has been compared with ECT in terms of its efficacy, rapidity of onset and frequency of administration. However, as for ECT, there is a substantial risk of relapse after acute treatment and strategies to prevent relapse should be part of pre-treatment planning. A framework for determining the duration of treatment should be devised and discussed with the patient, especially given the regulatory restrictions. As the effects of ketamine administration tend to be short-lived, consideration of concurrent antidepressant medication is essential to prevent relapse.
The promising results of ketamine for depression in clinical trials mean that both patients and clinicians are eager to access treatment. However, key questions remain to be answered regarding the safety of repeated dosing, quantifying the potential for misuse and determining where ketamine fits in relation to existing treatment pathways. In addition, the clinician should be mindful of strict regulatory controls, a need for a detailed consenting process, and formulation of treatment protocols with an appropriate safety monitoring framework. Ketamine offers the hope of a new treatment for depression, with potential advantages over existing antidepressant medications and ECT. However, there remain important unknowns that require clarification before it becomes a more mainstream treatment for depression.
Dr Adam Bayes is a psychiatrist and Senior Research Fellow at the Black Dog Institute and Clinical Senior Lecturer at UNSW Sydney. His research focus is mood disorders and novel treatments for depression, including ketamine.
Professor Colleen Loo, psychiatrist, is a researcher and clinical expert on ECT and novel treatments: transcranial magnetic stimulation (TMS), transcranial direct current stimulation, and ketamine. She is at UNSW Sydney, St George Hospital and heads the TMS Clinic at the Black Dog Institute.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.
Loading ...
Update: After 10 years of research in this field, I have now established a ketamine treatment clinic at the Black Dog Institute and one at the Ramsay Northside Clinic at St Leonards, both in Sydney. Both clinics require referrals from the person’s own treating psychiatrist. We aim to treat those with treatment resistant depression, for whom ketamine is a reasonable treatment, after careful evaluation and with careful monitoring.
hi I am a next of kin of a BiPolar Type 1 and have watched its rapid cycles on Olanzapine and Lithium which is unfortunately counteracted by his persistent heavy smoking and now drinking Red Bull which is a strong stimulant drink having Caffeine as ingredients. I know someone who has responded well to Ketamine infusion and wonder if it will help this BP Type one to rewire his brain and increases his BDNF level to try recover or at least delay the einevitable Raoid Cycles returning at only 6 months intervals Thank you
Ketamine infusions saved my life.
I have been suffering major depression since the age of 13, I am now 41 and have been through almost the entire spectrum of conventional AD including the very first of their kind the tricyclics, neuropathic pain medication such as ended treat your depression by sedating you to the point where you get relief from the depression because you are sound asleep, a life of sedation is no way to live. The mono amine oxidiser inhibitors are to dictatorial in the approach that must be taken the close monitoring of your diet and what ever other negative contradictions may occur with the interactions with the MOA meds.
I have tried a couple of session of TMS and it felt like my face was experiencing a stroke ECT therapy scares the shit out of me and doesn’t have a success rate of more than 25% and of that 25% it is statistically likely there is a further 25% of relapse after 4 months. Not a very effective treatment one would say. Does anyone know of a clinic in Australia administering ketamine for treatment resistant depression.?If no can anyone recommend a physician in the states that will treat this mentally debilitating illness? I would be on the next plane there if someone can point me in the right direction? Thank you
I agree with the sufferers above. I too suffered major depressive bouts with NO relief from standard antidepressants- just a whole lot of horrible side effects. I was told to try ECT. I went to the hospital to discuss this and was told it doesn’t work for 50% of people and 25% of those who it does work for relapse within four months. Can also cause cognitive damage. At my wits end, I went to the USA at great personal expense and feeling like shit on the long flight with psychosomatic head pain, suicidal thoughts and the rest. I was lucky as I am one of the 60-70 percent of people who haven’t responded to standard ADs who responded well to ketamine IV. After the first one, I felt l MUCH better. On my return to this part of the world, the trouble started. Finding a doctor who is willing to prescribe it is very difficult. I am doing my best to lobby the public health service to prescribe it as it is an effective treatment that is at least worth a go for those suffering. I am sick and tired, like the people above, of being told what I can put in my own body. People can sign waivers! Cancer sufferers take all sorts of nasty drugs and don’t get all this opposition! I think it is because the bloody pharmaceutical companies are against it. The shit they make costs a fortune. Johnson and Johnson’s nasal spray is not available in this part of the world yet, but it is NOT as effective as it is made from Esketamine, not Ketamine and is difficult to know what dose you are getting. You also have to pay about $900 a dose, need it twice a week and need to stay in the GP’S office for two hours. NOT FLAMING PRACTICAL! I am lucky but I don’t want to go into detail here because of all the bastards who don’t want people to have access to it. They are not suffering. As for dependence issues. Duh! Of course you need to carry on taking it – just like diabetics take insulin. People who are lucky enough to get relief from standard antidepressants have to take them for life if they have more than a couple of bouts. I don’t take any recreational drugs, smoke, or drink. I take Ketamine because it helps me, not because I want to get ‘high’ – which is a lot of shite anyway, I haven’t had any terrible treatments because I went to people who know what they are doing. I tried many other things. I’d live in the USA if I could because at least it is available freely there. It is expensive because there they use IV and need anaesthetists and premises etc. However, competition keeps prices reasonable. IM is another option and it is cheaper, but not as effective. Oral is not as good but okay as extenders. It is not as good because a lot of it doesn’t make it to your brain. It should be available at mental health clinics, GP’s or hospitals with a referral because most of us who suffer from severe depression can’t work or only work part time. Also, the premises are already there and nurses can give IM shots so it is cost effective. I went from being a suicidal, desperate, extremely ill person to going back to work within one week of my first treatment.
I have suffered treatment resistant depression for about 23 years and think about death as an option almost every day. I need help from my aging mother to get by emotionally and physically.
People like me need help NOW, The drugs available now are not safe anyway so why pretend they are.Iv’e tried countless SSRI and SNRI with no positive result and often negative ones and currently take Dex-amphetamine daily that helps alot but the roller coaster effect is very hard to live with leaving me depressed in the morning and evening as the drug wears off.
It’s time to let us decide what we want to try with our bodies. who’s kidding who. I was recently prescribed 30 mg APO-MIRTAZAPINE that put me into a extremely sedated state for 3 days, I couldn’t stay awake or function at all. If these types of drugs can already be prescribed why not let patients decide if it’s worth trying or not before they end up giving in to there suicidal thoughts.
Hi
as a carer i have been on a long unending journey
over several years with my mother who has depression
and has been in & out of mental institutions and tried many medications.
we are hoping to get some relief for her depression
by trialling Ketamine at a trial center if it is still recruiting
we are always hopeful this may help.
Hi im jason been suffering major depression for 25yrs in and out of hospital s ..i ve tried all the medications ..contentplate suicide alot …the way i feel daily i cannot put into words yet we have ketamine a known medication that had been studied for nearly 20yrs for depression yet we still rather stuff around and not use why many of us suffer greatly everyday for days months and years .who in the government is willing to step us and fight for this because at the monment i see no one doing anything .living like this is murder .thoughts of suicide .i ll say this with confidence the government doesn t care …we don t want want statistics on mental ilnes we want action ..enough is enough something needs to be done a hell of alot faster .i see the australian government lazy and want other governmwnts to do the work for them
Very pleased that this work is continuing ref Pain Medicine vol 7 n 1 2006
I believe the dose of 0.5 mg causes too many side effects and the titration method allows adequate dose and duration of treatment
I had hoped to develop a chemical marker to measure the effects of ketamine, rather than rely on clinical measures of pain, depression etc which are too vague.
I was hoping that the radiologists could measure a transmitter such as glutamate
There is also evidence that ketamine could be useful in other diseases in which the nmda receptor is overactive eg parkinsons and tinitis
I would be very interested in receiving more information from you
Graeme Correll
Retired anaesthetist
This article fails to mention the oral and sublingual routes of administration which have also been shown to be effective in helping people with TRD. There has been published work by Lara et al in Brazil, Domani et al in Israel and in Australia, DeGioannis et al from Brisbane, who have safely treated over 800 patients over the past 6 years with results comparable with other routes of administration.
Additionally work by pain physicians e.g Varun Jaitly in the UK who has been using daily home-based sublingual ketamine for his patients for over 18 years now and Lucinda Grande in the USA who has treated over 400 patients over the past 5 years with low levels of side effects, illustrate the practicality and safety of this approach.
By focussing exclusively on Clinical trial data, which has been limited severely by the fact that ketamine is off-patent thereby not worth pharmaceutical company investment, the article is missing rapidly increasing evidence as to efficacy and safety of ketamine therapy. One company however, Johnson and Johnson, who have developed “Esketamine” have now shown both efficacy and safety data for over 800 patients treated for up to 12 months and have recently applied for FDA approval for their intranasal preparation.