We and others have reported on the misuse, abuse, and dependence associated with the illicit use of ketamine. Ketamine is not new, it entered to public consciousness as “Special K” in the late 1990s at the onset of the Rave movement. However, it is important to keep in mind that although ketamine can be abused as a result of its dissociative properties, it has numerous indications and uses in anesthesiology, dentistry, and veterinary medicine.
Primarily, ketamine has been used in anesthesiology for nearly 50 years. But recently, important research has shown that ketamine hydrochloride can rapidly change mood, reverse suicidal thinking, and produce persistent antidepressant effects in patients with persistent depression, mood and anxiety disorders. Most clinical trials and case reports available have centered on the use of infused ketamine, via IV solution at a dose of 0.5mg/kg per 40 minutes for individuals with treatment resistant depression or anxiety disorder.
Why Does This Matter?
Despite not being an FDA-approved treatment for treatment resistant depression or anxiety, increasingly psychiatrists are using ketamine as an “off-label” treatment for depression and suicidality. As a result of the reported success associated with symptom reduction, The American Psychiatric Association (APA) has recently issued guidelines for clinicians who wish to use ketamine for this purpose.
Guidelines-From the APA
- A comprehensive diagnostic assessment should be completed to establish current diagnosis and evaluate history of substance use and psychotic disorders.
- Assessment of baseline symptom severity should be completed to allow later assessments of clinical change with treatment.
- A thorough history of antidepressant treatment should be collected and documented to confirm previous adequate trials of antidepressant treatment.
- A thorough review of systems should be performed to evaluate potential risk factors associated with ketamine treatment.
- Decisions on the specific physical examination and laboratory screening assessments should be made according to established guidelines and advisories issued by the American College of Cardiology Foundation/American Heart Association and the American Society of Anesthesiologists and should be based on a patient’s individual clinical characteristics.
- A careful review of past medical and psychiatric records and/or corroboration of the past history by family members are strongly encouraged; all current medications and allergies should be reviewed, including histories of opiate and benzodiazepine use; the use of a baseline urine toxicology screen is strongly encouraged to ensure the accuracy of the reported substance use and medication record.
- An informed consent process, including discussion of the risks associated with the treatment, the limits of the available information pertaining to the potential benefits of the treatment, the fact that this is an off-label use of ketamine, and a discussion of alternative treatment options should be completed; this discussion should be complemented with written materials and the patient should provide written informed consent before initiating treatment.