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Ketamine, a Break-through Treatment for Depression?

Over the last couple days the news has been exploding with a new ‘miracle medication’ for depression. There has been a lot of attention given to this new medication, more-so than probably any other treatment for depression in recent times. So, what it is? How is it different? And what do I need to know?

What is it?

Ketamine is a medication that has been largely used as a potent anesthetic, it has also been abused as a street drug due to potential dissociative properties. Ketamine has been used off-label for some time to acutely treat depression, particularly suicidal thoughts.

Spravato is a medication closely related to Ketamine that has been approved for treatment resistant depression in the form of a nasal spray.

Why is it different?

Traditional treatment for depression has been based on the theory that depressive symptoms are a result of an imbalance of neurotransmitters serotonin, norepinephrine, dopamine, or a combination of the three. Many people don’t respond or have limited response to traditional medications for depression. Even if a person does respond to these medications it typically takes several weeks for any effect to be noticed. Our neurotransmission (the way neurons communicate with each other) is basically like one giant game of mouse trap, this lever makes that marble drop, which lowers that ramp, which makes that basket drop and catches the mouse (p.s. if anyone has successfully set up this game please let me know, three degrees and this is still an impossible task for me). It’s similar to how the neuronal transmission in our bodies work, a medication might lead to an increase in serotonin, and a higher level of serotonin leads to further downstream effects. The theory of why ketamine and ketamine-like medications work for depression and why they work so rapidly is that they immediately target what traditional medications only effect indirectly (hence the immediate vs. delayed onset of effect). In short, theoretically this new treatment basically cuts out the “middle-man.”

What do I need to know?

  1. Ketamine and Spavato certainly have demonstrable and rapid effect on depression and suicidal thoughts, however there is still more we need to learn about long-term effects. A concern with Ketamine is abuse potential because it does have dissociative properties, hence why it is used as the street drug “Special K.” It has also been theorized that there is additional effect on receptors similar to those targeted by opioids.

  2. You have to be under the direct supervision of a healthcare provider to receive the medication. The nasal spray is not something you can bring home. You can physically administer the medication yourself, but it must be directly supervised by the healthcare provider.

  3. Not every provider can prescribe/administer this medication. The clinic/healthcare site must get certified to use and administer this medication, each patient also has to enroll in this specified program.

  4. There must be a history of not responding to traditional treatments. Because this treatment is indicated for ‘Treatment resistant depression’ this cannot be the first go-to. A person must have tried and not responded to a minimum of two previous anti-depressants.

  5. It’s not used as a sole treatment. The nasal spray is intended to be used in conjunction with an oral anti-depressant.

  6. The risks of this treatment include sedation, ‘feeling intoxicated,’ disassociation, abuse/dependence, sedation, vertigo, suicidal ideation, among others.

Psychiatry, like all areas of medicine is continuously evolving and treatment is becoming more sophisticated, it’s a continual learning process for patients and providers alike. This is certainly a treatment with promise, and has the potential for great benefit for individuals with severe depression, but as with any other novel treatment long-term effects/benefit still have room for assessment.

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