Jeevan*, a 57-year-old man from Bengaluru who suffered from severe depression and had extreme suicidal urges, was rushed to a psychiatrist after a failed attempt at suicide. Over the next six months, Jeevan went for regular sessions of ketamine infusions. “I saw an improvement within two months and did not want to end my life, but I still had an urge to inflict self-harm,” he said. Jeevan was put on anti-depressants because of the temporary nature of ketamine. While the ketamine produced no side effects, Jeevan said, “Going through several infusions can be difficult, I was this close to addiction.”
Once known as the notorious party drug “Special K”, ketamine is a commonly-used anaesthetic for animals. Ketamine hydrochloride was patented in 1964 in Belgium, after which tests on human and animals proved its hallucinogenic properties. Once it became legally available as Ketalar, ketamine was a commonly-consumed psychotropic substance in the 1970s and 1980s, when New Age spiritualism and raves were at their peak.
Recently, the drug (which has been documented as one of the most potent ways of reaching an altered state of consciousness – affecting perception of sight and sound, and causing out-of-body experiences) has been recognised by the World Health Organisation in a study as providing insight into the puzzles and riddles of the inner self.
Ketan Parmar, a Mumbai-based psychiatrist, described the drug’s new avatar as “a breakthrough” in psychiatric medicine. According to a paper titled Ketamine: A Light in the Darkness, authored by C Alexander Paleos and Stephen Ross, ketamine acts on a neurotransmitter system entirely distinct from the pathways which conventional Selective Serotonin Reuptake Inhibitor-based depression medication takes, involving serotonin, norepinephrine and dopamine. Ketamine, instead, works on the glutamate level. Glutamate is the major excitatory neurotransmitter for the central nervous system, and it involves all aspects of the neuronal life cycle, from migration and differentiation, to the genesis of new axons, to the survival of the neuron itself.
It has been found that depressed patients have elevated levels of glutamate in their blood and cerebrospinal fluid as compared to healthy controls, and these changes can be reversed. Under ketamine therapy, a patient receives one to five infusions, calibrated according to their receptivity. A small, harmless quantity (roughly 1 ml per kg weight of the patient) is usually given – two intravenous infusions could cost up to Rs 1,500.
For emergencies only
Doctors like Bengaluru-based psychiatrist Dr Bharat Shah advocate the treatment unequivocally, particularly for those who are suicidal. To sustain it, Dr Shah said it is necessary to continue antidepressants and therapy after infusions of ketamine have been administered to those suffering from depression, bipolar or obsessive-compulsive disorders.
“It’s a wonderful drug, agreed, and it has shown wonderful changes in patients,” Dr Shah added. “Yes, there are side effects and it is a short acting therapy, but it is ideal for patients who are in danger of taking their life and contemplating suicide. It’s an emergency drug.” As long as an anaesthetist is present along with the doctor, Dr Shah said, it is a safe option.
Whenever Shalini Mehta left from her home, she had obsessive thoughts about her children and husband dying in accidents. This left her paralysed for most of the day and she gradually had to quit her job and battle these thoughts full time. After her ketamine infusions, she only had good things to say: “It’s a very personal decision, [to opt for ] ketamine or not. It’s still experimental, and maybe we need more research.” Mehta said she is personally happy with the drug’s effects – according to her family too, there has been a remarkable improvement in her condition.
Undesirable side effects
But ketamine can also induce psychosis in healthy patients with no history of mental illness. For this reason, some psychiatrists are wary of its use. Chennai-based psychiatrist Dr Mohan Raj said the emergence of ketamine therapy was driven more by hype than evidence. “It’s a short-acting drug,” he said. “There is no sustained effect unlike SSRIs.”
At this point, ketamine therapy has not been approved by the Food and Drug Administration except as an anaesthetic. “There are possible side effects like kidney damage and high blood pressure,” Dr Mohan said.
“I’ve heard fellow colleagues who’ve had great experiences, but it’s too early to say,” said Dr Indira J, a psychologist in Bengaluru. “There are not enough studies about it. I’m worried about patients who have a history of drug addiction having the drug administered. Addicts will go as far as they can to get that fix and no doctor should enable that.”
Bruno A is a drug controller at the Chennai zonal office of the Narcotics Control Bureau. Instead of using ketamine as an antidepressant, he suggests Ayurvedic medicine, a change in diet and exercise. “For one benefit there are nine side effects,” he said, referring to the drug.
The sentiment is echoed by drug controllers across India. Ketamine is classified under Schedule 10 of the Cosmetics Act and Schedule 2 of the Narcotic Drugs and Psychotropics Act and is strictly regulated – doctors and hospitals need licences to procure it, and the licences must be renewed every two years. The quantity must not cross 10 grams, and if it does, it can result in up to 10 years of imprisonment.
In April, Mumbai resident Vishal Puri was sentenced to 10 years in jail by the Delhi High Court for being in possession of 1.195 kg of ketamine. Since then regulations have been tightened.
Bruno has heard of ketamine’s positive effects on patients of bipolar disorder and its terrorising effects of schizophrenia on healthy patients, but maintains that pills are much safer. “The drug is being manufactured in large quantities in China and used to be in India too,” he said. “From 2010, the numbers of procurement have drastically dropped, and it is currently at its lowest in the past three years.”
The dangers of addiction are also alarming to many patients, and according to Dr Ketan Parmar, a few patients have pulled out from the treatment after one infusion citing either fears of getting addicted or fears of overwhelming, consciousness altering experiences. “I had one patient named Pandurang who wanted to receive the infusions again and again. But I had to stop it because I knew he was getting addicted to the temporary feelings that ketamine induces,” he says.
Sixteen-year-old Smruti Jain* was apprehensive as she walked into the psychiatrist’s clinic. Her mother held her hand and led her to the chair, nodding at her with a smile. “Tell him,” she said. After a year of abuse and threats from her boyfriend, Jain was numb and tired of explaining her history to psychiatrists. Treatments were expensive, therapy was expensive. Her parents were clerks and barely made enough to make ends meet. But they knew she needed help, or they could risk losing their daughter.
“I was completely broken and didn’t want any help at first, but when I felt like ending my life, I knew I could use any help I could get,” Jain said. “I was about to lose hope when I saw the bills.” The Jains had finally found refuge in an inexpensive, if experimental method.
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