Ketamine: Balancing the risks and life-saving applications

Initially identified in the early ’60s for its anaesthetic properties in veterinary use, ketamine is now on the World Health Organisation’s List of Essential Medicines.

It has also been abused for its properties over decades – but with a balanced view and cautious approach, ketamine can have potentially life-saving applications in psychiatric medicine.

Ethical ketamine treatment

Psychiatrist Dr Bavi Vythilingum practises at Netcare Akeso Kenilworth and Ukukhanye Wellness, a psychiatrist-led ketamine clinic that focuses on evidence-based ethical ketamine treatment.

She emphasises its usefulness for certain patients but also warns health care practitioners and the general public about misinformation and the inappropriate use of the drug.

“Ketamine is a pharmacologically novel treatment with proven efficacy in major depressive disorder.

“It is one of the first non-monoaminergic treatments, which means not involving the balance of hormones, such as serotonin or norepinephrine.

“There are major safety concerns when it is used irresponsibly or illegally, even in controlled, licensed psychiatric settings,” says Vythilingum.

“It is essential that it is only ever administered in line with the clinical guidelines to appropriate patients where all else has failed to bring relief to treatment resistant depression or bipolar depression, suicidality, or post-traumatic stress disorder.”

Vythilingum says fewer than 15% of people with treatment-resistant depression achieve remission with mainstream antidepressant therapies.

“When there is suicidal intention, particularly, the threat that it poses to life may, for some individuals, require novel therapies such as ketamine to be considered.

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The dangers of ketamine

“However, it cannot be over-emphasised that there are dangers and potential for adverse risks and, like any medication, in the wrong hands it can be potentially life-threatening.

“Ketamine stimulates the heart to beat faster and can increase blood pressure which may trigger heart attacks in predisposed individuals.”

Over time, ketamine use is also associated with adverse symptoms affecting the lower urinary tract and genitourinary toxicity, such as potential kidney damage.

It is also not safe for use during pregnancy or breastfeeding.

“When ketamine is clinically indicated for a specific patient, and administered by a suitably qualified medical professional, it is important to monitor the person’s cardiovascular status and ensure advanced cardiac life support is on hand in case of an emergency.”

The patient should also be professionally supported by a suitably trained and experienced psychiatrist as there is a low risk of psychosis.

At higher doses, sometimes used for anaesthesia in emergency settings, dissociation may occur.

“It is interesting to note, however, that dissociation is not necessary to achieve the antidepressant effects of ketamine.

This is supported by a growing body of international psychiatry research,” Vythilingum says.

Although it is short-acting, the person’s cognitive functions may be impaired, and they should not drive until the following day – hence transport must be arranged for after the treatment.

“Ketamine’s recreational use for its psychedelic effects raises pertinent concerns about its risk for abuse.”

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