Finding Hope: A Depressive’s Ketamine Experience
Sometimes it gets ugly when your brain turns against you.
We all have an internal monologue that keeps us company in our waking hours, an inner voice that keeps up a fairly constant stream of thought and analysis. We all have periods where that voice turns negative, sometimes telling us things that we know aren’t true: that we are worthless, unloved, a failure. During a depressive episode the voice can get even uglier; aggressive and persistent.
Sometimes depression sneaks up on you. Cruel as it can be, sometimes you’re the last to know. I’d been in an invisible downward slide for some time without really realizing it as yet another combination of meds slowly, gradually lost its effect. Then one morning it all came into sharp focus when the crash came as it does these days: sudden and violent. I lay in bed until the afternoon, drifting in and out of sleep as the inner voice went on, and on, and on about suicide.
You should do it. No one will miss you. You’re a burden on everyone. You’ll be better off. Just get it over with. No more pain. Do it.
I know none of that is true; I knew it even then. But it wears you down, that voice. You can ignore it at first, maybe push it aside, but in a depressive episode it gets to you as minutes turn to hours turn to days — months, even — and it just doesn’t stop. Coincidentally it happened to be the day that Anthony Bourdain died; my phone suddenly joined the chorus in my head with news alerts that seemed to come in every half hour. Suicide, suicide, suicide. Read the details. Read them all. You’ll need them later. Let’s plan this. Look, another story. He was so brave, much braver than you.
I was between doctors, my excellent psychiatrist had left his practice. But we’d talked about it. I’ve fought depression on and off for thirty years or so and it would be fair to say that it is treatment resistant; I’ve been on so many medications I forget the names. We knew my combination of medications was likely to lose efficacy eventually and we’d talked a lot about my next move. I had three major options available.
I was (and am) saving electroconvulsive therapy (ECT or “shock treatment”) until I am out of options. Despite the long track record of efficacy it scares the bejesus out of me, nearly everyone I’ve met who’s had ECT struggles with memory issues. There was also transcranial magnetic stimulation (TMS), which uses a powerful electromagnet to reduce depression, but it would require 20 treatments or more over a period of at least a month before I knew if it would work or not; I wanted something faster and less time consuming.
This left ketamine infusion, an experimental off-label treatment for depression that my doctor first mentioned about a year ago. I dismissed it offhandedly at first — the club drug, the veterinary sedative? — but he encouraged me to read up on it and to take it seriously. It turns out that ketamine has shown efficacy of up to 70% in some studies in reducing serious depression; that’s an absolutely unheard of, off-the-charts response. Best of all, you are likely to know if it will be helpful for you or not within one or two treatments. I made an appointment for an evaluation with a local ketamine infusion clinic that specialized in the treatment of depression, one of the first to open in the United States in 2012, and buckled in to wait it out and resist my inner voice.
I read everything I could get my hands on, a pile of articles on the ongoing research into ketamine and its miraculous properties as an antidepressant. I delved into scientific papers far above my station hoping to understand the mechanism that researchers are just beginning to figure out. There’s just not much out there on how the effects are actually felt in people, and I have a hard time reconciling what I would later discover to be a very, very specific action with explanations I read of receptors and proteins and cells.
After my evaluation, I was cleared for my first treatment, each being an intravenous infusion that lasts about an hour. Just before I went in for the first infusion, the doctor stopped me outside the door of the treatment room; there was something he’d forgot. “Oh, you know that inner voice? The one that tells you that you’re nothing, that you’re shit? We’re going to take care of that today.” I was a bit surprised, this wasn’t something we’d discussed. I think I gave him a wan smile in return and said something like “If you say so.” I didn’t really buy into it.
That’s what it does. That’s the major effect of this therapy — for me, at least, and for others I’ve talked to. When the bleariness wore off and my head was once again clear I realized that the twisted version of the inner voice representative of the demon of depression that has so tortured me on and off for thirty years was gone. Not shoved to the side or muted or beaten down like some SSRIs or SNRIs or antipsychotics can do over a period of weeks (if you’re lucky enough to get a response), but gone, in hours, with no side effects whatsoever the morning after treatment. I still HAVE an inner voice, of course, it’s just that it’s the normal one.
It’s not perfect. For one thing, that’s not all that depression is; for another there are years of built up habits to unlearn, new ones to try to instill. There is still a dark mood sometimes. Even then, with that demon gone I retain powers that I would not otherwise have. I can read, write, concentrate, focus. It’s still early in the treatment. But it’s a very, very powerful, very fast acting tool in the toolbox.
Given the power and the efficacy, I don’t see why this isn’t better known. The clinic I went to has been in operation since 2012, somehow I did not hear about it or realize that it was a real treatment available right now until around a year ago. As a drug that has long been generic and is being used off-label for an unapproved purpose, I get that there is no money in it for the drug companies. They would much rather have you on the Next Big Pill that has to be taken on a daily basis instead of a generic drug administered every 6 weeks or so. No one will ever bring a generic drug through trials for this new treatment since there is no pay-off in the form of a patented blockbuster, but there is a derivative of ketamine called esketamine currently in trials for FDA-approved treatment of depression. Given the power of ketamine as it exists I don’t understand why it’s not known by every doctor in America, why it’s not the very first thing considered when someone has uncontrollable, repetitive, self-destructive thoughts and needs immediate help.
Nearly every mass-market article I’ve read on ketamine seems to feature a section on ketamine’s side effects, those being the reason recreational users use this drug. This seems to be viewed as a Big Deal. It is not. In decades of psychiatric medication I have certainly experienced far worse. For the hour I’m in an infusion I am dizzy and disassociated with visual distortions, perhaps geometric patterns; it’s not unlike an extended nitrous oxide experience without the auditory effects. Music gets very interesting and you get absorbed in tiny details; my doctor recommends you do treatment with headphones on and play some of your favorite happy music, which has been very pleasantly engrossing. Some people get nauseous from the visual effects, I haven’t had an issue. It’s not unpleasant but probably not something I would necessarily seek out. Once the infusion is over it takes a few hours for a feeling of drunken dizziness (though with clear thinking) to subside, and then that’s it. No further side effects. When I compare that to 30 years of daily, ongoing side effects from SSRIs and other psychiatric medication… pass the ketamine.
The other thing that every mass-market article seems to feel the need to mention is ketamine’s history of abuse as a club drug. This doesn’t bother me much either — there are many therapeutic medications that hold the potential for abuse, and infusion treatment is always given intravenously under medical supervision in a medical setting, it’s not like you’re taking anything home. Ironically the history of abuse contributes mightily to the safety data, we have a very good idea of the unwanted effects of constant, repeated doses far higher than I will ever experience.
I’m done with my initial treatment, which consisted of 6 infusions over 12 days. Now I’ll have a single maintenance infusion every 4–6 weeks over the course of a year, and in the second year we’ll try tapering that down. Hopefully after the second year I will only need a very occasional maintenance treatment.
It’s not perfect. It’s an experimental treatment with some unknowns, and individuals would be wise to research it carefully to make sure they’re comfortable with the process and the risks. Insurance frequently will not cover the cost, which for me in the New York City area is $425 per infusion. But this is the biggest improvement I’ve had in a long time, and I’m praying it has a lasting effect. If you have treatment resistant major depressive disorder, this is a treatment worth a long, hard look.