Today I want to enter into a not widely appreciated topic which is on the face of it very controversial, the use of an abused drug/medication for intractable psychiatric depressions. This drug poses some very unique dilemmas for the psychiatric health care systems in the western world. First, it is in certain circles, e.g., the goofy idiotic rave club culture and its offshoots, an abused drug whose extent of use now may not really be known; but a few years ago it was getting enormous play in the 24 hour media and one would think that every young adult between 18 and 39 who danced in clubs or went to concerts was high on this stuff, getting raped and jumping off buildings, or going psychotic and “never coming back.” Second, it is a generic drug having passed of branded status decades ago and now cheap and offering the pharmaceutical companies no real inducement to develop as a new drug unless they blatantly did what they do with “me too” drugs as I call them: develop a known medication for a new use, bring it out under a new name and charge an unjustified sociopathic gazillion dollars a dose because it is able to patented and sold under a new idiotic name for a different indication or illness. Such is how our drug development system is perverted these days of hypercapitalism. Third, this drug has been used for a legitimate use and crucially and responsibly so for a few decades.
What is this drug/medication you may ask? It is ketamine, a dissociative anesthetic that many or most persons who have routine cataract surgery have given to them for their brief, safe, cataract removal and synthetic lens implant. All my elderly extended relatives had ketamine as far as I know for the last 20 years or longer for correction of their cataracts. Their surgery was brief, not traumatic, painless, and their recovery times were minimal, never more than a few hours, for this truly routine outpatient surgery that restored the acuity of their vision and restored enormous enjoyable segments of their lives to them. And they did not die by the scores, they did not go psychotic and suffered almost no complications. In my now forty years as a psychiatrist who has always practiced “consultation psychiatry,” seeing medical/surgical/pediatric hospital patients who develop psychiatric issues, I have never seen a patient for psychiatric issues after ketamine facilitated cataract surgery.
But this drug has surfaced in the last nearly decade in the clinical off label world of psychiatry in which a drug approved by the FDA for one use, is found to be effective often by happenstance after its release to the market to be of benefit in another condition no one dreamed of. Ketamine, this object of great ambivalence, suspicion and puzzlement has been found to work in patients with intractable depression. It has been quietly prescribed by psychiatrists brave enough to try it for patients they have usually followed for years who have suffered from what is described as “treatment resistant depression,” and who have been tried on almost every antidepressant older and newer ones, had courses of electroshock therapy, had vagal nerve stimulators placed surgically, had various forms of “transcranial magnetic stimulation,” with no lasting benefit. These persons are by no means uncommon. It is common knowledge that after roughly 60 or so years of use of the antidepressants that 60% and usually far less, i.e., perhaps as low as 30% of patients with depression respond to antidepressants. ECT is for some of the most severe forms of depression, life saving and truly extremely effective, but like the newer forms of “magnetic stimulation,” temporary and often requires ongoing continuation or “maintenance ECT.”
Enter ketamine with a solution to one of the most vexing problems about depression. It often takes 3 to 8 weeks of taking an antidepressant before it works–in those persons in which they work. Keep in mind that most insurance companies now require that depressed patient be discharged in less than 10-14 days, often weeks before an antidepressant ‘takes hold’ and ushers out the disabling depression. Ketamine, on the other hand, was found to work within hours, the same day, when given intravenously!
But ketamine was known in its early days more than 30 years ago to be able in some people to be able to induce schizophrenic like psychotic states with high enough doses, fortunately far higher than those utilized to induce 30 minutes of dissociative anesthesia for brief surgeries such as cataract removal. But this knowledge was enough to cast a decades long pall upon it reputation as potentially a very bad drug. And that capability which is now partially understood from partial knowledge now of its actions in the brain in the dopamine system, that it became a favorite of the rave set. The same crowd who favored LSD, DMT, Ecstasy more recently gravitated predictably to ketamine.
I will not bore or overwhelm the reader with a pedantic exposition of how ketamine works in the brain, but is likely to be a precedent setting drug that opens new research doors and spawns new families of antidepressant drugs as it works on the glutamate system. That alone will teach us much more about the complexities of depression and many psychiatric thinkers on the research and clinical scenes nationally predict we will in the not too distant future learn that there are many different kinds of depression that work and are effectively treated by different mechanisms.
So here we have it: a drug of mixed heritage and reputation, that is showing the way toward new and likely more effective treatments but whose handling and development merits a new approach than the current model of all the drug companies competing to bring out some molecular variant of it under new ridiculous brand names, advertising them all relentlessly on television and the other media like presidential candidates and charging prices that represent profit margins in the thousands of per cent of ROI (return on investment). Or its potential for abuse may cause the establishment to balk at permitting organized rational research and it and more predictable chemical cousins, and cause the loss of a potentially valuable tool in the armentarium of medical tools to control those cursed with chronic depression.
Here is the link to the fairly well done article on ketamine in Forbes: http://onforb.es/1te3Np1. I could have offered many other links but for something to make it Forbes, it means it really has gotten noticed.
Pen and Psychiatrist 