Until recently most of what I understood about ketamine was in the context of it being a party/club drug. I remember trying it in college the first time. Apparently I did too much and went into a “k-hole”. I was stuck on the couch. The world seemed far away, I couldn’t move, and couldn’t process even a simple thought. I was only vaguely aware of what was going on around me and couldn’t interact. It felt like I had been frozen in the space-time fabric of an adjacent dimension to our normal experience of reality. One of the strangest experiences of my life. Recently I had been seeing articles about it as a depression medication. Then, on March 5th of this year, the FDA approved Spravato: an antidepressant nasal spray with the active ingredient esketamine, a ketamine derivative.
Ketamine is used in veterinary medicine as an anesthetic. It was tested on humans back in the 60’s and was approved for medical use in 1970. As an anesthetic in humans it is considered a very safe option because it has less of an effect on breathing and heart rate than other drugs do. It has been in use in operating rooms for about 50 years. Soldiers carried ketamine on them during the Vietnam War for emergencies and it is still used in the military. Last year when the Thai soccer team got stuck in the caves, rescuers administered ketamine to the boys to keep them from panicking during the risky extraction. The drug is also useful in pain treatment and as an anti-inflammatory agent.
Many doctors are calling ketamine as an antidepressant the most important advance in depression treatment in decades. For many years the go-to medications for depression were selective serotonin reuptake inhibitors (SSRIs) like Prozac, Zoloft, or Lexapro. Serotonin is a neurotransmitter that affects mood and SSRIs block its absorption back into the neuron to keep more of it available. There are a few drawbacks to these drugs. Many people don’t respond to them, some sources say as much as a quarter or third of patients who try them. It can take several weeks for the relief of depression symptoms to be felt and there has to be a constant level of medication in the body.
Ketamine works differently. The exact causes of depression are not fully understood but more recent research has showed that two other neurotransmitters, GABA and glutamate, play an important role in mood and stress levels. Ketamine triggers the production of glutamate. Doctors at Yale University, where a lot of ketamine research has been done, also say that it’s more about how the brain reacts to the drug then the actual action of ketamine. Unlike SSRIs, ketamine works fast and the effects can be felt within hours. Symptom relief has also been reported in the last weeks after administration.
Ketamine studies have shown it to be successful in treating alcoholism, PTSD, and eating disorders. It also seems to produce positive self-reflection and introspective clarity which helps with addictive behaviors in general. With most people, side-effects have been minor and short-lived. Children have even been tested with it. It helps reduce suicidal thoughts and because it acts quickly, doctors hope it can save lives.
Because it is such a new treatment, there is a lack of study on long-term side effects but the research on Spravato is encouraging and doctors are cautiously optimistic. So far it has been especially effective in conjunction with other antidepressant medication.
Esketamine is not as psychoactive as ketamine but there is still potential for abuse and Spravato treatment has many restrictions. It is only available in nasal spray form from a certified clinic. Patients can’t pick it up at the pharmacy, it has to be administered at the clinic under observation from the doctor. Doctors can only pick up Spravato from specialty pharmacies. Furthermore, patients have to be on another antidepressant medication and have to have previously tried two others that were unsuccessful.
Depression is a tough condition to tackle. The lack of a full understanding of the biomechanics behind it make it difficult to treat. It can also be difficult to measure and quantify. Everyone feels down at some point. Breakups, losing a job, financial problems, whatever. Where are the lines between temporary, frequent, and clinical depression? With addicts especially, many turn to drugs because of depression and addiction also causes depression. What came first, the chicken or the egg? In recovery I’ve heard people talk about how on an individual level, we are not “terminally unique”. We’re not the only ones to have the feelings that we have. We all have anxiety, depression, anger, and insecurities and it’s not more or less than anyone else. I get that but at a certain point, you are more depressed or anxious than the people around you and you may not be doing something about it when you should be because you’ve been told you’re not “terminally unique”. Like many things in recovery, that kind of judgment call has to come from honest self-appraisal but we can’t always see how deeply things are affecting us.
I don’t believe that I’m chronically, clinically depressed but I have experienced extended periods of depression and have entertained suicidal thoughts before. I’ve been on SSRIs and they made me feel worse. I’m not a doctor but there are people in my life who I believe suffer from chronic depression and it’s heartbreaking to see someone you care about going through that. Many of them have also been on SSRIs with no success. That’s why I am also cautiously optimistic about ketamine for depression. Doctors are calling it the most important advance in depression treatment in a long time but we’ll have to wait to see if it lives up to the hype.
In general I am fascinated by the medicinal potential of drugs that are often abused. Not so much meth or heroin but things like DMT, psilocybin, or MDMA. Being in recovery, that feels a little strange sometimes but just because something is abused doesn’t mean it is all bad. Millions of people suffer from depression. Some people have genuine chemical imbalances and the fact that a drug that can help correct that will be used by other people to get high doesn’t take away the usefulness. People who can’t help their depression should be able to have the same opportunity for happiness that anyone else has. I think we should continue to pursue scientific and medical progress. In order to do that, we need to be able to look at certain drugs objectively, not just as inherently bad or evil. My hope is that profit motive was not the main driving factor behind Spravato like it was with OxyContin and Purdue and that treatment results will continue to be positive without unforeseen complications.