“Ketamine saved my life,” a patient told me.
We are still learning about ketamine, an anesthetic that has been repurposed for use as an antidepressant, which has action over minutes—not weeks, like the standard treatments, such as serotonin- and serotonin-norepinephrine-reuptake inhibitors. Ketamine has already been shown to deliver remarkably rapid relief of depression and suicidal thinking for treatment-resistant patients, many of whom have already tried numerous medications and therapies to little effect.
Ketamine is believed to work by releasing a lot of glutamates, the most abundant excitatory neurotransmitter in the vertebrate nervous system, by way of NMDA receptor blockade with AMPA receptor activation, rapidly improving neuronal connections in the brain. Ketamine has been shown in laboratory animals to grow more dendritic spines and neurons, hence increasing connections between cells.
This is happening from ketamine’s effect on cells’ release of brain-derived neurotrophic factor, or BDNF, a protein critical in brain development and functioning. Mood and thinking are likely improved as a result of this process. Ketamine appears to strengthen communication between neural networks in severely depressed patients.
While ketamine has been used by psychiatrists in recent years as an intravenous infusion for severe, treatment-refractory depression in doses much lower than for anesthesia, it also may be used via other routes of administration, such as intranasal spray.
From the perspective of a clinical psychiatrist, this novel use of an existing medication is extremely exciting, since we’ve employed the same kinds of antidepressant treatments for decades. Ketamine is indeed a unique treatment, and the rush to treat must always be tempered by known risks as well as the possibility of unknown risks. Needless to say, ketamine must be utilized cautiously and treatment tailored for qualifying patients. From the perspective of a current patient, receiving ketamine as antidepressant treatment is not just exciting; it’s life-changing.
As such, I asked a few questions of my patient, who gave me permission to publish their responses on Mind Tapas. Needless to say, the following is one experience only, and reflects neither a guaranteed nor a representative response to this drug.
Why did you begin ketamine?
I had been on almost every SSRI [Selective Serotonin Reuptake Inhibitor] there was. I did ECT [Electroconvulsive Therapy] for five years. I tried TMS [Transcranial Magnetic Stimulation]. At the point I started ketamine, I was already on an MAO-I [Monoamine Oxidase Inhibitor], and nothing had worked. I was suffering tremendously, and it was exciting that there was an option out there we hadn’t explored.
It was a last resort.
How did it go?
It was wonderful. Of all the treatments I’ve been on, it has the fewest number of side effects. Unlike SSRI antidepressants, it didn’t affect my sexual functioning. Unlike ECT, there are no memory issues. And unlike MAO-Is, there are no dietary restrictions.
While it’s more time consuming and less pleasant to feel dissociated, it has been enormously helpful and allowed me to live independently, which I had not been able to do prior to ketamine.
What should other severely depressed people know about ketamine?
No treatment is perfect. No treatment is going to work immediately, nothing is a magic bullet, but for me, ketamine has been life-changing. I lived with my parents until my late 20s, because I was too mentally ill to live with roommates or live alone. I have been able to be financially independent and live independently, and a large part of that has been because of the ketamine treatment.
Would you recommend ketamine treatment to other depressed people?
Have you had side effects?
When I’m taking ketamine, it’s not safe to drive or write emails, but the effects go away after about an hour, and there are no other side effects that I have experienced.
Can you take ketamine nasal spray safely at home?
Yes. I find that it’s best to take it about an hour before bed, so there’s enough time to be awake and process the effects, but it does not interfere with my day. It sometimes helps to have bland music on, so I’m in the right headspace, and it’s after I’ve done everything I need to do during the day. I would not recommend using it just before having an important conversation, for example. It’s helpful to have someone else there as a safety net.
But even when I lived alone in a studio apartment for a year and did not know my neighbors, there was never a time it wasn’t safe to take.
Are the dissociative effects manageable?
As someone who does not use drugs recreationally, this experience was not something I would have sought out. I certainly had warm feelings and happiness that I hadn’t experienced in a decade. Was it deep and profound? No. Was it joy for the very first time? Yes. And that was, I guess, profound in itself.
We, physicians, are very cautious, especially when it comes to making treatment recommendations. It’s helpful that you, as a patient, are very level-headed. Is ketamine a safe drug for you?
Here’s the thing, every medication has potential side effects; this is so much safer than so many other drugs. I don’t have to worry about liver disease or it frying my brain. This is so different than other drugs. It’s something we have stigmatized and has been made to seem a lot scarier than it is. If something can have so many positive effects for so many people and is safe, we should be able to benefit from it.
Are you addicted to ketamine?
No. Ketamine gives you a really nice feeling. I’m a very cautious person, likely more than other people are. I don’t drink, don’t do drugs, and as far as substances go, ketamine is a lot safer than others.
You’ve had experience with intravenous infusions and sublingual ketamine. What is it like using the ketamine nasal spray for regular use?
It’s not as intense as the intravenous. It is far more effective than sublingual treatment. The side effects don’t last as long as they did when I was taking it sublingually. The dissociation doesn’t last as long.
Thank you for your helpful insights.