Special K and Depression

White Coat Black Art11:16Special K (Mini-podcast)

Can a drug best known as a "party drug" become a mainstream treatment for depression?

Some psychiatrists say ketamine is a powerful treatment for depression but critics are waving a cautionary flag.

According to the Canadian Mental Health Association, at least eight percent of Canadians will suffer from major depression at some point in their lives. Antidepressants won't work for half of them. Now, a small but growing number are finding relief thanks to ketamine, which is now best known as a club drug.In the ER we give it to patients as a sedative and pain reliever.

The idea to use a club drug to treat depression came in part from anecdotal observations that people with depression who used ketamine for recreational purposes found their mood was lifted. Researchers at Yale University have found that ketamine works very differently than conventional antidepressants. The drug triggers blocks a receptor in the brain called N-methyl-D-aspartic acid orNMDA. That raises the level of a brain chemical called glutamate, which activates the brain by stimulating the growth of synapses or connections between brain cells.Those connections are important for helping us to cope with stressful circumstances in life.

The Yale researchers have also shown that chronic stress damages those synaptic connections. They believe that ketamine works quickly because they've observed that the drug can rapidly reverse the damage to brain connections caused by chronic stress.

The thing that distinguishes ketamine is how fast it works. Conventional antidepressants take six to eight weeks to lift your mood.Ketaminegets you feeling better in days, in some cases hours.

Treatmentis offered up in the US by a handful of anesthesiologists and psychiatrists. The drug is given by intravenous drip. Some clinics give a dose of ketamine once a week. Others treat patients daily or every couple of days until the patient feels a response and then every couple of weeks to every couple of months to keep them from relapsing. The Ketamine Advocacy Network has posted a directory of US physicians who administer ketamine for depression, PTSD, manic depression or bipolar affective disorder and other mental conditions. The Network's web site has an interactive map that directs you to the closest MD who uses ketamine. The treatment doesn't have regulatory approval and is not reimbursed by publicly funded insurance. Rarely is it covered by private health insurance. US Clinics charge between $300 and $1000 per treatment out of pocket. I'm not aware of any Canadian doctors who give ketamine for depression.

Last summer, Patrick Cameron of Toronto told the Toronto Star he paid a Manhattan clinic $3000 for six infusions of ketamine over a six day period. He said by the third day, he noticed a change in his mood. There are Canadians who self-administer ketamine bought on the street.

Critics say ketamine has not been studied extensively enough for regulators to give it their blessing. The known side effects include nightmares, hallucinations and delusions, elevated blood pressure and cognitive decline. Since the effects of ketamine wear off within days, it might have to be taken for years. Researchers don't know the long-term side effects. Given how little we know about ketamine and depression, critics say they're alarmed that ketamine clinics have cropped up in the US. They fear that these clinics are preying upon vulnerable patients who would do just about anything to get a bit of relief. They're also concerned that ketamine is being prescribed off-label or non-approve treatment for depression. A series of prescription drug scandals led regulators and ethicists to frown on that.

The problems with ketamine convince me that the drug is not the answer for people with depression. I think it's resolved by developing and testing alternatives to ketamine that work the same way but don't have the same side effects like out of body experiences. A US company named Naurex has a promising drug called GLYX-13. A trial partially completed with four hundred patients showed the drug was well tolerated. GLYX-13 is taken by IV drip, but other companies are working on a pill and a nasal spray. In the meantime, while I sympathize with patients who have depression that is resistant to conventional antidepressants, I don't believe doctors should recommend it in its current formulation.