As we focus on mental health this October, it’s important to remember that of the many crises plaguing South Africa, depression is one of them. A 2022 study by Wits highlighted key findings: South Africans suffer higher rates of depression and anxiety than other countries. Only a quarter of those ever receive treatment. And, since treatments are subject to costly long-term psychologist visits or psychiatrist prescriptions, some people are turning to unconventional treatments. Among them, there’s a noted rise in people treating their symptoms with psychedelics. Now, there’s an increase in ketamine use to treat depression in cases where other medication has failed. Amazing, right? Not so much, say experts.
Per experts, using ketamine for depression a revelation (more on this below). However, the misuse as a party drug and the mounting unsupervised use as a treatment for depression is problematic.
“The anaesthetic drug can bring life-saving hope for people suffering treatment-resistant major depression or at severe risk of suicide. But unsupervised use or excessive dosages hold addictive and even lethal risks,” warned the South African Society of Psychiatrists (SASOP) in a recent press release.
So… what is ketamine?
Ketamine is an anaesthetic, originally used in animals since the 1960s. In humans, it’s been used to treat pain since the 1970s. It’s listed in the World Health Organization’s List of Essential Medicines as an anaesthetic. It’s also registered in South Africa for induction and maintenance of anaesthesia. If you were to break a bone, a doc might use ketamine instead of full anaesthesia.
When it’s used recreationally, K produces dissociative sensations and hallucinations. Users report feeling relaxed, dream-like and nauseated. In its newest era, K is a breakthrough treatment for depression, with others claiming it works for other mental health conditions too.
How does ketamine help with depression?
Ketamine is available for off-label use. This means that regulations allow doctors to use it for purposes other than pain management. Studies have shown that it’s a viable treatment for depression and suicidal urges, especially in cases where other medications haven’t worked.
“There is good evidence that ketamine in low doses, administered under controlled conditions with the necessary medical supervision, is an effective treatment for treatment-resistant major depression,” explains SASOP spokesperson, psychiatrist Dr Bavi Vythilingum. “It is also effective in acute cases of suicidal ideation, rapidly reducing the risk of life-threatening thoughts and acts.”
How does it work?
Per Dr Vythilingum, K improves the production and functioning of the neurotransmitter glutamate. This plays a role in mood, thought patterns and cognition.
Ketamine has a different mechanism to traditional anti-depressant medications. And, it’s why medical researchers believe it to be at least part of the reason for its effectiveness where other treatments have failed. Unlike conventional antidepressants like SSRIs, which take weeks to work, the effects of ketamine are rapid. It also doesn’t work on the same brain receptors.
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How is ketamine for depression administered?
To use ketamine for depression, you’re meant to head to a treatment facility. There, you’d be given a dose via I.V. It takes about 40 to 50 minutes, and there’s extra time to recover afterwards. After the treatment, you’ll need someone to take you home – no driving until after they have had a full night’s sleep.
But you’re not A-OK after just one session. The initial treatment takes place in six sessions over two to three weeks. The treating psychiatrist may prescribe maintenance treatment on a case-by-case basis.
The dissociative state (the trip) caused by ketamine can produce feelings of a trance-like state or hallucinogenic experience, feelings of an “out-of-body experience”, feelings of unreality, visual and sensory distortions, and euphoria or “a buzz”.
“For this reason, it is important that the setting is safe, meaning that it is quiet and private, that treatment is medically supervised, that the patient is not left alone during treatment and recovery, and that the facility is equipped to manage any adverse side effects,” says Dr Vythilingum.
While the dissociative side-effects can also be positive in improving depressive symptoms, she said other negative side-effects could include nausea and vomiting, raised blood pressure, respiratory depression (slowed breathing), sedation and unconsciousness.
But… ketamine can also be lethal
While the treatment is a game-changer for many, there are significant risks. “Ketamine is a powerful anaesthetic agent. A too-high dose can cause sedation and loss of consciousness and in very high doses, may cause dangerously slow breathing and the risk of death,” explains D Vythilingum. “Even at lower doses, if administration of ketamine is not adequately supervised and the person is not in a safe, controlled setting they may become confused and inadvertently harm themselves. Ketamine is also potentially addictive and open to abuse.”
Added to this is the rising number of “independent” clinics offering ketamine treatment for depression and other mental health conditions. SASOP is concerned about these facilities: whether they’re correctly diagnosing patients and using ketamine as the appropriate treatment. The treatment also has to be carefully monitored for harmful side effects.
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Ketamine’s side effects can be dangerous
Long-term use of ketamine at high doses can cause bladder, kidney, liver and stomach pain or toxicity, as well as addiction demanding increasingly higher, life-threatening, doses. Plus, while some claim that ketamine is effective in treating other mental health conditions, such as post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD), SASOP cautions that there is limited scientific evidence for this.
How to stay safe in treatment
If you choose to pursue ketamine for depression, it’s totally legal. Just make sure you’ve picked a facility that dots its i’s and crosses its t’s.
Find specialists
“Ketamine for psychiatric treatment must be prescribed by a psychiatrist. Only a psychiatrist can diagnose that depression is treatment-resistant,” explains Dr Vythilingum. “That diagnosis is made following at least two courses of conventional antidepressant medication with no improvement in symptoms.” She also made clear that only a doctor can administer the meds “and both physical and psychological safety are paramount during administration of ketamine.”
SASOP advises that the guidelines issued by the South African Society of Anaesthesiologists (SASP) should be adhered to. These guidelines state that the medical doctor administering ketamine must be an anaesthesiologist or registered sedation practitioner who is qualified in advanced cardiac life support and resuscitation.
Check the facility
“Ketamine must be administered in a facility equipped for physiological monitoring (blood pressure, pulse rate, oxygen saturation), with medication, equipment and qualified personnel to manage adverse physical or neurological events, including hypertension, cardio-respiratory events, airway management and resuscitation.
“The administering clinician or member of the team should also have expertise in mental health and managing patients who may become agitated, anxious or otherwise distressed. A psychiatrist should be available in case of a psychiatric emergency,” Dr Vythilingum said.
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It’s not for everyone
Ketamine is not considered safe for patients diagnosed with schizophrenia or for those with a history of substance abuse. Dr Vythilingum also cautioned that while there is clear evidence for the off-label use of ketamine in treatment-resistant major depression, more research was needed on the drug’s long-term effects, side effects and safety as a psychiatric treatment.
