On the inside of her right wrist, Becca Belofsky Shuer wears a tattoo of a semicolon. It’s a symbol of solidarity with other people at risk for suicide. She chose it to give her courage to fight her dark thoughts. Shuer longed for death. But, four months later, she began a series of infusions of the drug ketamine that have kept the darkness at bay.
Shuer felt the drug “cleaning her brain,” beginning with her second treatment in January 2016. Ketamine works quickly, according to a meta-analysis published in October in the American Journal of Psychiatry. That report pooled data from 10 previous studies of IV-delivered ketamine.
Within a day of their first drip, more than half of the participants were free of suicidal thoughts for up to a week. Shuer, a warm and vivacious woman who loves books and comedy, now leads counseling workshops on clutter and hoarding with her husband, Lee. She returns for a ketamine infusion whenever she feels her mood darkening. This year, she has been able to go as long as three months between treatments. Four months ago, she began using ketamine lozenges every day as well.
“Life got really hard, but I didn’t put a period there. I put a semicolon, and I kept going,” she said.
New use for an old drug. Ketamine is a common, inexpensive anesthetic for surgery.
It’s also a top choice on the battlefield, and is still widely used by veterinarians. As with any drug, the effect of ketamine varies with the dose and delivery method. Clubbers at “raves” like Special K’s “out-of-body sensation.” They inject, snort, or smoke it and too often dangerously mix it with other drugs.
Clinics providing ketamine as an off-label (not FDA-approved) antidepressant have popped up around the country, typically headed by an anesthesiologist. The research on its antidepressant effect is almost entirely based on carefully fine-tuned IV drips. A handful of doctors spray it into the nose or inject it into a muscle. The dose is a fraction of what recreational abusers take or what you’d get in a surgery.
In 2016, the Food and Drug Administration (FDA) put a nasal spray delivering a variation called “esketamine” on the fast track for approval as a treatment for suicidal people.
Current popular antidepressants focus on serotonin or noradrenaline pathways in the brain, or both. Ketamine is more like a “reboot” on your computer. It temporarily blocks a molecule on the glutamate pathway connected to memory and seems to prompt new brain connections to spring up.
James Murrough, a psychiatrist at Mount Sinai Hospital in New York and a lead author of a favorable report in 2013 who was also involved in the recently published meta-analysis, notes that research on ketamine first revealed the connection between this pathway and depression. In low doses, ketamine is a powerful anti-inflammatory as well. Depression is associated with chronic inflammation.
Can you have a bad “trip” on the drug?
David Feifel, a psychiatrist who treats patients with ketamine in California, told a writer for the journal Lancet: “It’s exceedingly rare, usually dose related, and very transitory due to ketamine’s rapid metabolism.”
There is no research on the long-term effect of IV ketamine infusions for depression. Since it is a generic drug, Brooks points out, pharmaceutical companies don’t have a reason to invest in research in that form of delivery. But they are looking for alternatives. The goal is to find more convenient forms that don’t provide any “high” but dampen depression.
Meanwhile, patients are looking for help. The age-adjusted suicide rate in the United States increased 24 percent from 1999 to 2014. In addition, standard treatments fail a third or more of the severely depressed. “The typical patient I see is, or has been, suicidal, often has been hospitalized, and has done ECT [electroshock therapy] or TMS [transcranial magnetic stimulation], and tried different classes of antidepressants and nothing has helped,” said Glen Brooks, an anesthesiologist who treats Shuer.
He treats severe depression or neuropathic pain with ketamine in offices in New York City and Pittsburgh. Brooks usually gives new patients six infusions, separated by a day, or six in a row for patients visiting from faraway. Younger people do better. Like Shuer, patients tend to come back every four to six weeks for boosters over a year and half, he said. Brooks looks for signs of symptoms in childhood, triggered by stress or trauma at that time.
Shuer, he said, “fits the profile of pretty much all our patients. She had a history of depression beginning at age four. An abusive, neglectful mother. By age 26, she was suicidal. High school was tumultuous and she had GI distress.” Shuer’s childhood included a shock on top of a background of sadness. Her 29-year-old brother ran upstairs to save a litter of kittens during a house fire and died himself. “I worshipped him. He had always been the hero in our family,” she said. Shuer was 13. The tragedy devastated her and her parents. “I was on my own after that. They talked about death every day. They had a suicide pact, that if anything happened, they didn’t want to go on,” she said. Her mother, she guesses, already had a mood disorder. “I never knew if she was going to be happy vibrant mom or depressed quiet mom,” Shuer recalled. “When she was happy, the world was happy.” Her mother would sometimes disappear into her bedroom for a couple of days and Sheur’s father would say, “Mom’s not feeling well.” “I was a very sad child, sad for no reason. I had everything I could need,” Shuer said. Eight years younger than her nearest sibling, Shuer grew up feeling isolated, watching talk shows and news with her mother. She had asthma and she heard her pediatrician tell her parents to stop smoking, but they didn’t. In school, she was the smallest child in every class and often bullied. By high school, Shuer was drinking three nights a week, smoking cigarettes, and writing poetry about slashing herself. She picked at her face compulsively and her skin became covered with scabs. One day a teacher looked at her and said, “Becca, what are you doing to yourself?” “I was always in agony,” Shuer said. She had a constant pain in her gut. She also had migraines that were first diagnosed as “psychosomatic.” To her, the term just meant “psycho.”By the age of 26, she was thinking constantly about how to kill herself. One day she called a suicide hotline and said, “I don’t want to die, but I want to die.” The person who answered gave her hope. “She was amazingly helpful, “Shuer remembered. “She said, ‘You’re not alone. This is something that happens. There is help for you.’” Shuer began taking Prozac, which felt like magic. “The colors came on in the world,” she said.
Over the next two decades on Prozac, Shuer developed a satisfying career helping autistic children and their families, and a supportive marriage. But in her 40s, troubles hit rapidly. Within three years, her father died of smoking complications. Grief stricken, she also had to leave her job in Massachusetts to tend her mother in Florida, who was now on hospice care. Her beloved cat died. Her migraines got so bad she sometimes stayed in bed for a week. Shuer tried seven medications with the goal of treating her migraines and depression together. “They caused such a mixed bag of effects I hated them,” she said nothing worked, and Shuer again began thinking seriously about suicide. Shuer was also coping with a shortage of psychiatrists near her Massachusetts home. Two, in fact, retired while treating her. Feeling very much on her own, she hit the internet and found Dr. Brooks in New York after speaking with two doctors in Boston.
In the United States, doctors charge from $400 to $800 per infusion, reports the Ketamine Advocacy Network, which offers a partial list of providers. Some, like Brooks, aim to make it affordable for people in need. About a third of his patients, he said, receive some insurance reimbursement. You must be continuously monitored during your infusion, which runs from 40 minutes to an hour.
Some providers will stay with you and, if you choose, provide support as a kind of talk therapy. Others leave the room but monitor you. Shuer, who studied psychology at Smith College, likes to be alone during the infusion with her thoughts.
“It’s like the ketamine interrupts the horrific pain associated with the memory so you can have the memory and not feel destroyed by it in the moment,” she said.
Dr. Jeffrey Ditzell is a Psychiatrist in New York City and specializes in issues involving anxiety depression and adult ADHD. Ketamine for Depression is one of the many treatments Dr. Ditzell offers to treat a variety of mental health issues.