Ketamine for the acute treatment of severe suicidal ideation

https://www.bmj.com/content/376/bmj-2021-067194

by hochmartinez • 4 years ago

130 112 4 years ago

I did a full 6 week course of ketamine therapy. It was really good, and I would recommend it if you're open minded. It's not for everyone, and the lasting (a year+) benefits aren't really measurable (maybe I'm different? maybe I'm not, maybe I've just gotten older). I'd like to go again and see if it can help with my obsessive existential dread.

mrwaffle• 4 years ago

Absolutely, I have a partner who has had severe PTSD and went through a great month-long program, she's overcome many longstanding fears and triggers and has made huge strides in being able to feel that she is living her life once again.

jokowueu• 4 years ago

May I recommend stellate gangelion block for PTSD .

https://youtu.be/nC2fBe6U7lg

jcims• 4 years ago

I wonder what the age limit is on stuff like this. So many young folks experiencing crippling anxieties that are impacting their ability to navigate the world at an age where it's going to have longstanding ramifications for relationships and careers.

sshine2• 4 years ago

I have a close acquaintance who uses ketamine to manage depression and Complex PTSD. My experience as a bystander is that the depressive symptoms reoccur periodically regardless of the use of ketamine. The depressive symptoms seem to be caused by the PTSD, and ketamine does not seem to alleviate the PTSD.

I'm saying this as a huge fan of the positive impact of ketamine.

There are some symptoms that seem like they need more rewiring.

hemloc_io• 4 years ago

What's the process for this like? Been curious about the current state of psych medicine.

ketamine13• 4 years ago

Not OP

I did 2 surveys and a phone consult then a baseline depression survey before my first infusion.

I go to the clinic and go in my room and they give me my IV then the doctor hangs the ketamine mix bag, hooks it up and leaves. The rooms are dark and they have colored lights or a dim light. I wear an eye mask.

I pay extra to receive talk therapy during the infusion so I have a therapist with me the whole time. We do a ceremony to start each infusion and set the intent just before the effects start.

oldstrangers4• 4 years ago

Depends on the place, there really isn't much regulation for it where I went. I made an appointment, signed all the papers and got started. It's very expensive ($400-$600 a week).

They have a head doctor and then an anesthesiologist that handles the actual infusion.

agumonkey2• 4 years ago

what about how it felt early on / during the therapy ?

what about side effects also ?

bradly5• 4 years ago

There is the "trip" side affect which lasts about 30-45 minutes. Then there is some wobbly legs and slow speech for an hour or two after. I had no side-affects besides those.

oldstrangers4• 4 years ago

The trip itself is fun. It'll get scary if you don't let yourself go, but it was really manageable. You are heavily sedated obviously, so you can't drive or do much after. Mentally its exhausting, and akin to spending all night studying. You will probably have a headache for the rest of the day.

ketamine13• 4 years ago

It immediately relieved my existential dread. I fear the next infusion will be intense, however.

oldstrangers4• 4 years ago

Ohhh that's encouraging. I was supposed to go for a "booster" session ages ago but kept putting it off.

aaaronic• 4 years ago

There are treatments for that? I've never had anyone suggest anything other than therapy for it.

after_care6• 4 years ago

Then, patients received a first 40 minute intravenous infusion of ketamine (0.5 mg/kg) or placebo 0.9% (saline solution) in addition to their current treatment.

This really shouldn’t be labeled as double blind.

1.The nurse administering knew if it was placebo or active (for safety reasons).

2. It would immediately become obvious to the subject if they were injected with salt water or ketamine.

3. Within minutes it would become obvious to everyone in the room if the patient was injected with salt water or ketamine.

Some trails are impossible to be double blind. That’s okay, there are other ways to address concerns of internal validity. Pretending like this trail is double blind does not address any internal validity concerns, and only raises concerns about the researchers understanding of experimental design.

BurningFrog• 4 years ago

Injecting some other psychoactive drug should work, at least for patients who have never used ketamine before.

But I suspect that would take many years to get through the permitting apparatus, if it was at all possible.

after_care6• 4 years ago

Injecting someone with another psychoactive drug would not be a placebo. We would be comparing the efficacy of {other psychoactive drug} and ketamine. That's not to say this experiment has no value, it's one of the many experiments we should run to help build the case for ketamine.

The classic gold standard is to randomly assign subjects to groups. Then give one group a sugar pill, give the other group the treatment pill. Neither to patient, the person administering, or the person recording the results know who got the treatment who got the placebo. This is not possible with ketamine, psilocybin, MDMA, LSD, etc. That's fine, we can still build a strong body of experimental evidence of their efficacy. It bothers me when clearly non-blind non-mask experiments are labeled as double-blinded, which we see often in this body of research, this study included.

AdamH121132• 4 years ago

My psychiatrist administers IV ketamine treatments for depression. (I don't use those; regular antidepressants work for me.) I'm not sure what dosage she uses, but from what she's told me, it's not a drug trip, and a lot of people don't feel any different during the treatment.

[Edited to clarify.]

sandworm1012• 4 years ago

You might be in her placebo group.

chimeracoder4• 4 years ago

My psychiatrist does IV ketamine treatments for depression. I'm not sure what dosage she uses, but from what she's told me, it's not a drug trip, and a lot of people don't feel any different during the treatment.

At 0.5mg/kg intravenous, there's no way that people wouldn't feel anything. It's not necessarily a "drug trip", but pretty much anybody can tell the difference between that large of a dose of ketamine vs. a saline solution.

For trials in cases like this, it's common to use a group which receives either a smaller dose of the drug or a drug that is intended to mimic some of the subjectively observable side effects.

bradly5• 4 years ago

Does is dependent on weight (and gender?) if I remember correctly.

hadmatter6• 4 years ago

I’m sorry but you are strongly over exaggerating the (side) effects of i.v. ketamine. It’s not a dose that sends you in a K hole. It’s way less than that. Some get sedation and some do get dissociative symptoms which can unmask the study arm of the patient. Approximately one out of ten got at least one of those side effects. Sedation can be mimicked with midazolam, so if you use that as placebo, you get 90 % of the patients that are not obvious, which medicine they got. I do agree that a better ”placebo” would be good to use.

The problem with ketamine and suicidality studies is that suicides - thankfully don’t happen very often - so we have no direct evidence that ketamine prevents suicides. Of course if it would only alleviate suffering and wouldn’t increase the rate of suicides, that would be a win too.

chimeracoder4• 4 years ago

I’m sorry but you are strongly over exaggerating the (side) effects of i.v. ketamine. It’s not a dose that sends you in a K hole. It’s way less than that.

0.5 mg/kg intravenous. For frame of reference, a small recreational dose is between 5-25 mg (insufflated[0]), and a larger recreational dose (for people targeting a "k-hole") is more like 50-100mg. For clinical depression (ie, not this study, but for a similar purpose), the fixed dose is 84mg (not weight-based).

So assuming a 75kg individual, that would be a 37.5mg intravenous dose, which is definitely going to provide a noticeable effect for any ketamine-naive user (ie, someone who does not already have a tolerance for the drug from recent prior use).

The problem with ketamine and suicidality studies is that suicides - thankfully don’t happen very often - so we have no direct evidence that ketamine prevents suicides.

That's not really a problem - suicidal ideation is a strong enough predictor for suicidality and mental health that it's common to use as a biomarker. In other words, nearly anything that reduces suicidal ideation is presumed to reduce suicidality (on a large scale) - it's not necessary to wait months or years to see what happens (and in fact, depending on the specifics of the study, it can be considered unethical to do so).

Source: former clinical researcher and drug counselor

[0] bioavailability when insufflated is significantly less than other means of ingestion

after_care6• 4 years ago

I don't think I am exaggerating the noticeable effects of i.v. ketamine. Patients given i.v. ketamine are advised not to operating an automobile hours after administration. This level of impairment would be noticeable to the patient and the staff administering the treatment.

encoderer• 4 years ago

Have you had it?

A friend of mine did it last week and he described it as the most intense experience of his life. He’s 40 and he has experience with other drugs.

I think possibly you don’t know what you’re talking about?

dataisfun• 4 years ago

Umm…ketamine IV at these doses is most certainly a unique and insane experience, speaking as someone who’s done it about a dozen times for anxiety.

bradly5• 4 years ago

Inter muscular ketamine treatments were the only thing that helped my severe treatment resistant depression that included suicidal thoughts. They definitely had strong side affects. Complete disconnection, loss of the concept of humanism, I've gone inside a rainbow, held hands with my brain, etc..

VyperCard2• 4 years ago

I get the used dosage every three month and I can assure you, it is very noticeable.

However, I have no idea how other sedations feel, so who knows if they are a good placebo. Could be.

boomboomsubban2• 4 years ago

1.The nurse administering knew if it was placebo or active (for safety reasons).

I read it as the nurse preparing the IV's knew if it was a placebo, it doesn't really say that the same nurse administered the IV's.

btach2• 4 years ago

The nurse administering it is most certainly liable for what s/he administers. It is a very big no-no to blindly administer a medication of which you cannot reasonably verify what it is. To push a syringe or start a pump of something that "could be ketamine, or could be NS" is walking an uncomfortable line for your license to practice nursing. Right patient, right medication, right dose, right route, right time. If you as a nurse cannot attest to all of the above when you push something, it is in error to push it.

PragmaticPulp• 4 years ago

0.5mg/kg spread out over 40 minutes wouldn’t be as dramatic as you’re suggesting.

3. Within minutes it would become obvious to everyone in the room if the patient was injected with salt water or ketamine.

I think you’re mistaking IV infusion for injection. The dose is given slowly over 40 minutes, not as a rapid injection. The patient would barely have any of the drug in their system in the first few minutes. Given the short duration of action, it wouldn’t produce peak levels anywhere near what recreational users experience.

dwaltrip2• 4 years ago

My personal experience suggests otherwise.

In the sessions I had with IV ketamine, it is very, very noticeable and fairly trippy. The eye mask and the music certainly help, but the ketamine is inducing some crazy sensations.

I don’t remember the exact dosages I received, but I remember it being in line with what I saw others reporting online from their experiences at a clinic.

sonicggg2• 4 years ago

Your second point does not invalidate it as a double blind. But I agree that the person administering should not be aware.

fsckboy• 4 years ago

2. It would immediately become obvious to the subject if they were injected with salt water or ketamine.

this is not part of the definition of double blind. There maybe drug effects and there may be placebo effects. If you don't know and the person administering it doesn't know, then the effects you report or measure are what is being studied over the group of people in the study.

3. Within minutes it would become obvious to everyone in the room if the patient was injected with salt water or ketamine.

also not part of the definition of double blind.

archhn2• 4 years ago

Christianity without tears?

ketamine13• 4 years ago

What do you mean?

archhn2• 4 years ago

That's the description of soma in bnw.

Terry_Roll2• 4 years ago

Some vets use Ketamine as part of a multi stage protocol for euthanising animals, other vets just use a single drug protocol but I havent established what that drug is, but it just seems all a bit refined butchery to me!

Ketamine is supposed to be a disassociate drug, which I'm guessing is perhaps like an out of body experience or something. But I cant see how that can help with depression when people dont understand depression can actually be lots of things, but it has one overriding common element which is people remembering.

So unless people get something like dementia where recent memories seem to fade first and the earliest memories come back, I fail to see how K can help treat depression.

As for suicide ideation, well look around at what constitutes 1st world medical care! If you dont buy into the smiley faces because you might have grown up around medical professionals and heard the back office chats you might think twice about the authenticity of so called medical professionals! Not only that, its just a job for most, leave it at the door when your shift finishes, which is easier said than done especially if a dying patient seemed nice and innocent compared to an unpleasant angry dying patient.

I really dont know why we dont have legal euthanasia because being experimented on in the name of science is not something I'd let others do to me if I can help it, I am aware that some argue it would be a direction towards eugenics, but that goes on already in stealth with some medical procedures.

amelius• 4 years ago

Isn't morphine overdose the best (friendliest) possible euthanizing method?

Terry_Roll2• 4 years ago

Morphine/Heroin is supposed to physically cause respiratory depression so you stop breathing and I guess the CO2 builds up past the 30% blood saturation point by which stage it takes about 2 mins for the body to shut down. As the CO2 levels reach that 30% blood saturation point, the body becomes increasingly stimulated which is why you see people thrashing around when drowning or asphyxiating. Having done sea rescue to stop someone drowning in rough sea's, you can say goodbye to all the training water rescue people get taught and just hope the panicking person isnt as strong as you and hope your lungs are better than theirs, because they will force you under and you will ingest lots of water so you have CO2 build up which spurs you on to shore ironically.

Obviously (going off things like trainspotting and peoples accounts), opiates are supposed to give you a warm fuzzy feeling as you slip into a deep sleep or unconsciousness I guess but not to sure, never done it not even in an operating theatre.

MAOI's the old style anti depressants are quite sudden in that they are like an on off switch for the brain, you dont remember or feel nothing and I think they were popular with people who wanted to end it, but SSRI's have replaced them as the new anti depressant treatment but their problem is you dont sleep properly on them so they introduce their own problems, but I'm not aware of any end of life properties in SSRI's other than they ruin your sleep and send you off the rails slowly.

But all the while, these chemicals still dont address the fundamental problem with depression which is remembering stuff that causes depression. Maybe depression should be treated more like PTSD, because depression seems to be an ego thing, where as talking to other people, PTSD seems to be more like what people associate as depression.

For bloke's I think the bio mechanical properties of testosterone would help many with PTSD, cant comment for women though, but the risk the police and medical lot dont want is some hulk losing it so the idea isnt entertained AFAIK.

Self preservation of institutions comes before everything else!

Edit: I should add, once CO2 blood saturation exceeds 30% it has a noble gas effect on the body, so anyone who remembers the periodic table should remember what noble gasses are and its why compressed gas companies go to great lengths to not enable pure noble gases getting into the hands of the public.

Biology and chemistry is just the mammalian equivalent of computer hacking.

ketamine13• 4 years ago

Hello! Throwaway account for obvious reasons.

I just started IV ketamine infusions at .5 mg/kg for depressions.

I am not finished with my treatment yet.

Ask me anything if you would like.

glerk• 4 years ago

Any issues with your bladder? Have doctors mentioned anything about the potential damage to the urinary system? This seems to be the scariest side effect.

chimeracoder4• 4 years ago

I'm not OP, but I have some relevant professional (clinical) experience here.

Any issues with your bladder? Have doctors mentioned anything about the potential damage to the urinary system? This seems to be the scariest side effect.

We're lucky because ketamine has been used for decades in inpatient settings at much, much higher doses than what is being used now for psychiatric purposes, so we have a good sense of its safety profile already.

Urinary tract and bladder issues are noted for long-term and frequent recreational users of ketamine, but not really for anesthetic use. The dosing schedule for psychiatric use is closer to anesthetic use than it is for recreational use.

The effects also are reversible if detected early and use is ceased, so periodic but infrequent treatment is unlikely to result in long-term damage, both because it's not frequent enough to accumulate, and because you can stop if it becomes a problem.

rootw0rm• 4 years ago

This is part of the reason MXE was developed. Love me some MXE.

ketamine13• 4 years ago

No issues (yet).

I am a man and it did immediately reduce my libido. Not in the same way SSRIs did. Will be curious to see if that is a lasting effect or not.

VyperCard2• 4 years ago

Good luck to you. It helped me a lot. I refresh it every three to four month with a single session and a 2 day of vacation away from everything in another town.

ketamine13• 4 years ago

Did you have any particularly bad sessions? I am waiting on the other shoe to drop

tayo42• 4 years ago

do they do anything for motion sickness? the one time i tried i spent the hour trying not to throw up

ketamine13• 4 years ago

Yes. Zofran on request.

I was only nauseous for maybe 1 minute but I can see it being terrible for folks with motion sickness.

sshine2• 4 years ago

This suggests that ketamine is beneficial for people who are suicidal to prevent them from killing themselves. The claim that is generally made about ketamine and depression is that it can have a short-term resetting effect of someone's depressive symptoms (not necessarily at a suicidal level), making it possible to escape the black hole that otherwise can take weeks, months, years to come out of.

https://www.nih.gov/news-events/nih-research-matters/how-ket...

kuhewa• 4 years ago

For bipolar or other disorders, not much of a discernible effect for depressives

vmception• 4 years ago

Its the turn it off, turn it on again treatment, for the brain

mattkrause• 4 years ago

I'm not sure if you're kidding or not, but I do halfway-seriously subscribe to this idea. A lot of things that seem to have anti-depressive effects, ranging from sleep deprivation to TMS and ECT, seem to basically give the brain a whack in the hopes of having it recover into a "better" state.

mabbo• 4 years ago

The primary outcome was the rate of patients in full suicidal remission at day 3, according to the scale for suicidal ideation total score ≤3. Analyses were conducted on an intention-to-treat basis.

Question: does reducing suicidal ideation reduce suicide? I mean, it sounds like it obviously should, but we've been wrong about this before. Many heart medications to reduce cholesterol worked great at reducing cholesterol without reducing heart disease!

All that said, reducing suicidal ideation is a worthy goal itself, even if it doesn't reduce suicide. I'm a full supporter of seeing this treatment move more mainstream.

datavirtue• 4 years ago

Doctor prescribed anti-inflammatory for a pinched nerve I have...cured mine.

olliej2• 4 years ago

I've been getting intramuscular ketamine weekly for my severe & treatment resistant depression while working on making progress towards actual recovery. As with participants in this study I wasn't one of the lucky "I did ketamine a few times and my depression was cured" folk, but it has a huge reduction in frequency and intensity of ideation, as well as pretty much completely removing self harm.

That said it's not a long term solution (because honestly its frustrating due to losing a few hours during the work week, inability to drive, etc) so I'm working with Drs to actually resolve things without regularly being stabbed :D

standardUser• 4 years ago

I wish the gap between clinical treatment and recreational use was bridged, and you could use a nasal spray on your own time a couple evenings a week instead of a daytime injection.

olliej2• 4 years ago

The nasal spray is less effective according to the clinical trials, and is patented minor variation on ketamine so is super expensive (though "hilariously" because ketamine is technically being used off label for treating depression insurance may decline coverage of the cheaper, more effective original)

There's also lozenge form which I believe some clinics allow you to take at home, but not sure of the effectiveness

intenex• 4 years ago

The truly amazing thing here is how powerful the placebo control was, even despite the fact that as someone who's done ketamine IV treatment before, it's pretty obvious when you're on ketamine and when you're not.

"At week 6, remission in the ketamine arm remained high, although non-significantly versus placebo (69.5% v 56.3%; odds ratio 0.8 (95% confidence interval 0.3 to 2.5), P=0.7)."

after_care6• 4 years ago

The truly amazing thing here is how powerful the placebo control was

1. The "placebo" received standard treatment for suicidal ideation.

2. We should expect a natural regression towards the mean. The vast majority of humans do not experience suicidal ideation in a particular day. People with suicidal ideation tend to move towards the standard human experience of not having suicidal ideation over time.

aarontait2• 4 years ago

FYI: Johnson & Johnson patented the S(+) enantiomer of ketamine and sells it as a nasal spray called Spavato. It's been FDA approved for depression since 2019. Although Spravato costs more on paper than regular ketamine, it's often less expensive for patients since it is covered by insurance (regular ketamine treatments are considered an off-label use and are usually not covered).

blurbleblurble• 4 years ago

It's pretty awful though for a lot of people. Researchers outside of the US have published studies showing that s-ketamine has higher risk of dependency in animal experiments and lower long term efficacy for depression, like on par with placebo. If I'm remembering right there are a number of reasons for this and one of them is that r-ketamine seems to simulate neuroplasticity better, something related to BDNF in certain parts of of hippocampus I think?

While it probably works for some people, it's likely dangerous for many others.

Kenji Hashimoto and others have published numerous papers about this. It's not exactly under-researched. The incentives in the US are horribly misaligned.

Quite honestly it's upsetting that spravato even exists and there ought to be a huge class action lawsuit about this.

A few papers: https://pubmed.ncbi.nlm.nih.gov/32224141/ https://pubmed.ncbi.nlm.nih.gov/26327690/

aarontait2• 4 years ago

Yea, I agree. I wish there was some kind of organization that would seek FDA approval for racemic ketamine treatment of depression. It's cheap, and widely available. Unfortunately, without the incentive for a patentable product, it's unlikely to ever happen.

Ketamine for the acute treatment of severe suicidal ideation

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