Ketamine may offer hope to those with treatment-resistant depression.
Oxford University and Oxford Health NHS Foundation Trust consultant psychiatrist Professor Rupert Mcshane is calling for ketamine to be used as an option for those patients with severe or very treatment resistant depression being considered for Electroconvulsive Therapy (ECT). Prof. McShane leads the Oxfordshire ECT and ketamine services and runs the memory clinic.
Depression is a long-term condition and long-term treatment is often needed for those with the most severe illness. ECT remains the most effective antidepressant available, especially for those with severe depression, with 70% of UK patients treated with ECT reporting significant improvement of their condition after treatment. Despite these encouraging statistics and refinements in the treatment since it was first introduced, stigma surrounding ECT means that very few patients feel comfortable with the idea of receiving ECT, this lack of enthusiasm is further exacerbated by reported side effects of long-lasting memory loss in some ECT patients.
Prof. McShane has made the call for ketamine to be used as an option for these patients based on the results of a new US study (1) carried out on patients without psychosis confirming that ketamine has fewer long lasting side effects than ECT and works as well as ECT.
An earlier Swedish study (2) concluded that ECT remains the better option for the elderly and those with psychotic depression, however a standard dose of ketamine is preferable for younger patients without psychotic depression.
It is known that when used frequently in high doses without medical supervision ketamine is addictive and causes severe bladder damage raising the fear of a “ketamine epidemic”.
However, in low doses and under medical supervision this does not happen indicating that NHS Trusts could start to use ketamine off-label now; however, many are reluctant to do so without ‘authorisation’ from NICE whose guidelines on treatments for depression make no reference to ketamine.
A WAY FORWARD
A new, innovative route round this problem has been set up by the Medicines & Healthcare products
Regulatory Agency (MHRA) , National Institute for Health and Care Excellence (NICE), National Institute for Health and Care Research (NIHR), NHS England (NHSE) and Department of Health and Social Care (DHSC) through the NHSE Medicines Repurposing Programme. With enough data, scientific review of studies carried out in this area and incentives offered to drug manufacturers to apply for the licence, NICE could then restrict NHS use to intravenous use of ketamine in specialist clinics for those patients being considered for ECT.
Across the NHS, there are 93 ECT clinics accredited by the Royal College of Psychiatrists. This infrastructure would be well suited to the administration of IV ketamine.
Prof. McShane said:
“The proposed highly controlled use of IV ketamine in specialist clinics treating the most severely ill, coupled with experience from the Oxford Ketamine Clinic makes me confident that this use, controlled by the NICE restriction, would be safe and may appeal to some patients as an option.”
Prof. McShane presented this proposal at the British Association Psychopharmacology conference in Manchester on 23 July.
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Published: 24 July 2023