Ketamine and Psychiatry in Australia

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Hi folks, Professor Colleen Loo from the Black Dog Institute in Sydney, published this latest editorial in the MJA

Is ketamine ready to be used clinically for the treatment of depression?

It suggests caution with ketamine for depression and promotes more research . Thats a reasonable opinion but it has some inconsistencies that need to be pointed out in the article. Firstly Professor Loo states there are no controlled trials showing safety and efficacy of ketamine in depression treatment. Then she later describes 8 RCT of ketamine in treating refractory depression! Secondly she cites a case report of ketamine addiction of a nurse who self administered stolen ketamine from a hospital for treating depression. This is basically a case of recreational abuse of ketamine and was not medically supervised nor prescribed. Addiction is possible but thats the same with drugs like morphine or benzodiazepines. I am not aware of any reported cases of medically prescribed ketamine addiction, so far. Thirdly Loo states we have only long term safety data of ketamine use from recreational use studies. Thats not true. Pain medicine specialists have been using chronic ketamine prescriptions for years and we have good safety data from their specialty.

I asked Dr Stephen Hyde, Psychiatrist from Tasmania, to comment on this editorial . Here is his response:

Comment  to MJA editorial on ketamine for depression

It is correct that to date placebo-controlled trials on the use of repeated doses of ketamine to help those with treatment resistant depression are yet to be done.

The main reason for this is that ketamine is long off-patent so there is no incentive for pharmaceutical companies to invest the time and money required to do full scale, multicenter, double blind, placebo-controlled trials. It is pleasing to know that Professor Colleen Loo et al at the Black Dog Institute have recently been given a grant to extend their research in Australia but this will take several years to be completed and reported.

In the meantime people are suffering and dying prematurely from treatment-resistant depression – on average those suffering from chronic psychiatric illness die 20 years before their peers, some by suicide but most through the illnesses that will kill us all in time, cardiovascular disorders and cancer.

350 million people worldwide experience major depression.

With our current treatments one third have good responses, a third partially respond and a third do not respond at all to a full range of counseling and medication approaches and even ECT.

The use of ketamine in this treatment-resistant population leads on average to a 70% response rate and around a 30% remission rate in this very hard to treat group. Ketamine has helped people whether given orally, sublingually, subcutaneously, intranasally, intramuscularly and intravenously.

Short-term side effects are well described and easily managed.

Longer-term side effects are also known from the experiences of recreational users around 5% of whom can develop tolerance, dependence and addiction with the associated urinary and hepatic problems appearing in those who take very large doses  [3-5 grams] on a daily basis for years on end.

Ketamine has been used over the past 50 years by millions as an anaesthetic, [it is currently the most widely used anaesthetic in the world] by hundreds of thousands for pain relief including those who have had repeated continuous infusions for the treatment of burns and CRPS, and now for thousands of people with severe depression [Dr. Angelo De Gioannis and colleagues in Brisbane have now treated over 600 patients with oral ketamine over the past 3 years with a 70% response rate – results of his trial will be published shortly}.

It is noteworthy that with the extensive use of medically prescribed and monitored ketamine  over the past 50 years that there have been no reports of dependence or addiction as a consequence. For every one recreational user there are a thousand who benefit from the responsible medical use of this agent.

Our colleagues in pain medicine have demonstrated over the past 20 years that ketamine can be safely and effectively used in therapy e.g Varun Jaitly who has been treating patients with chronic pain using sublingual ketamine for over 15 years now. Some of his patients have been taking ketamine at home on a daily basis for 15 years with no indications of physical or psychological problems nor any evidence of dependence or addiction.

So a psychiatrist faced with a patient with a severe life-threatening illness has the option of discussing with them the risks and benefits of trialing ketamine. The RANZCP has just released a clinical memorandum describing ketamine as a novel, innovative treatment to be used with caution and appropriate safeguards in patients with treatment resistant depression. I believe this is a considered and humane response to the suffering our patients endure.

Further opinion amongst Australian doctors was reported here in MJA Insight :

Ketamine decision “premature”

 

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