Monday, March 24, 2014

Ketamine - A Professor Writes

For the past six months, I've fielded increasingly more questions about ketamine.
My patients: "Will ketamine help me?" 
My colleagues: "Is ketamine safe for my patients?"
Ketamine is an FDA- (Food and Drug Administration) approved drug for anesthesia during surgery and for pain relief -- in adults and children. Several studies (including one report published recently) have shown its rapid, positive effects in depression as well as rapid effects in obsessive-compulsive disorder (OCD) -- a persistent and often disabling disorder in which individuals have repetitive thoughts and behaviors.
Because ketamine has FDA approval, it can be prescribed legally by any physician. In fact, there are multiple private clinics advertising ketamine infusions, for a fee. But ketamine is still in an early stage of development for depression and OCD. I have my concerns and we need more evidence for its safe use in individuals suffering from these mental illnesses.
As a clinical researcher, my goal is to find new treatments that are fast-acting, effective and safe. I often feel frustrated that treatment of OCD with the usual drugs, serotonin reuptake inhibitors (SRIs), takes a long time (two to three) for symptom relief, and even then, roughly half of patients will experience only minor symptom reduction. Imagine taking your brother to the doctor after he has broken his wrist and being told he will need to take pills for eight to 12 weeks, and if he is lucky, the pain will slightly lessen. This is not acceptable for any illness, no less one that significantly impairs functioning, produces great emotional pain, and costs the U.S. economy more than $2 billion annually. Yet, this is what I have to tell my OCD patients. We need better and faster acting medications for OCD and other severe mental illnesses.
My research involves glutamate, the main chemical transmitter involved in the communication between brain cells. There is increasing evidence that glutamate plays a significant role in OCD symptoms. And... ketamine changes levels of glutamate in the brain.
In the very first clinical trial of ketamine compared to placebo in people with OCD, we found that a single low dose of ketamine caused an immediate decrease in OCD symptoms -- in all participants. In some, this rapid benefit lasted up to one week. One participant, with this positive response to the infused ketamine, told me "I feel as if the weight of OCD has been lifted... I want to feel this way forever."
This is very exciting for patients, families, researchers, and clinicians since there have been no new treatments for OCD since the 1980s. Ketamine's different mechanism of action (glutamate not serotonin) also opens up new avenues of research for treatments.

Seeing first hand the suffering of individuals with OCD and seeing the promise of rapid acting treatments in a small group of patients, I understand what could be a great rush for ketamine, in private (and public) clinics. At the same time, I believe that ketamine is not ready for safe general use -- at this time.
Ketamine has abuse potential, as demonstrated by its use as a club drug called "Special K." Ketamine also has side effects during use, including feeling dissociated (e.g., a floating or unreal sensation) and nausea, which we reported in our study. Less is known about the lasting benefits and long-term side effects. The study of ketamine, as well, is in highly monitored research settings, and other settings may not carefully screen patients for abuse potential or have the medical backup to respond in case of emergency. These are serious concerns that urge all of us to find about more, scientifically, about ketamine before we routinely use it for treatment of depression and OCD.
We need to know more about how ketamine works in the brain. This may open doors to other drugs that act in the same way, and perhaps with fewer side effects. Ketamine could be a tool to help us learn more about the links between brain and behavior.
If you or a loved one want to participate and partner with researchers looking to answer these questions, and other questions, you can find research studies There is tremendous need and I have high hopes for new treatments to reduce the symptoms of OCD and depression. It is an exciting time for the field of psychiatry, and working together, we can produce safe, rapid and effective treatments that provide relief to individuals suffering with mental illnesses.
Carolyn Rodriguez, M.D., Ph.D.
Assistant Professor
Medical Director, Translational Therapeutics Program
Columbia Psychiatry

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