“Special K” for Depression

The past few weeks the news has been inundated with celebrity suicides. First Avicii, then Kate Spade, and now Anthony Bourdain. New data published by the Centers for Disease Control reveal that suicide rates are increasing and are up 30% since 1999. Clearly, something needs to be done.

While traditional psychiatric medications can help alleviate depressive symptoms, these medications can take weeks to months to have their full effect, and do not work for everyone. Depressed patients are left struggling while they wait for the medication to kick in. We need something that can rapidly reverse suicidality and bring comfort to suffering people.

Interestingly, a club drug, in the same class as phencyclidine (PCP) and dextromethorphan (DXM), may be the answer. Ketamine (also known as “K2”, “Special K”, or more interestingly “psychedelic heroin”) has been used for over 50 years in the medical field. When PCP was first being tested as an anesthetic in humans, it was noted to cause an intense and prolonged delirious state (unsurprisingly). Ketamine, with its reduced potency and shorter half-life, was just the solution. It continues to be used as an anesthetic for children and as a rapid induction agent for anesthesia in emergency departments.

Once it came on the market in the 1970s, ketamine began to be diverted for its dissociative properties. Noted to cause feelings of being detached from reality with changes in sensory perceptions and the sense of floating, ketamine became used on the club scene. One Reddit user describes ketamine as “there’s uppers and there’s downers; get ready to be sideways for once.”

Newer research has delved into ketamine’s application as a rapid reliever of suicidality and as a fast-acting antidepressant. Studies have demonstrated that a single IV or intranasal dose of ketamine (at doses lower than those that would cause anesthesia) can produce antidepressant effects in patients with treatment-resistance depression. Furthermore, and perhaps more importantly, ketamine has also been shown to cause rapid resolution of suicidal ideation 1.

The antidepressant effects of intranasal esketamine (the S-entantiomer of ketamine) occur within hours. While perceptual changes occur for only 2 hours after dosing, antidepressant effects may persist for at least 8 weeks after a period of treatment 2. Furthermore, the intranasal formulation was remarkably well tolerated – the most common side effects were dizziness, nausea, and dissociative symptoms 2.

Ketamine has excited the psychiatric world. Patients may no longer need to wait weeks for an antidepressant to work and may be able to alleviate some of their depressive symptoms within hours of seeking treatment. For those suffering from suicidal ideation, this drug may be life-saving.

While longer term data is needed on the neurological effects with continued use, esketamine (the intranasal formulation) may be available in the U.S. as early as 2019. Ketamine IV infusion clinics have already starting appearing across the world, though insurance does not frequently cover this treatment.

Perhaps in the future, when a depressed patient presents to the emergency room with suicidal ideation, they’ll be given an IV infusion or intranasal dose of ketamine before being sent to the psychiatric ward. Their recovery will be hastened and their suffering eased.

Sources

  1. https://www.ncbi.nlm.nih.gov/pubmed/28969441
  2. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2666767

Holiday Blues? Not so much. Trends in Psychopathology over the Holidays.

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The idea of “holiday blues” or “holiday stress” has been discussed extensively in popular culture and in the psychiatric literature. Interestingly, the majority of these articles presume its existence, yet do not cite data. Most of the literature comes from case studies or psychoanalytic teachings (as opposed to higher-quality research papers). As early as 1955, a psychiatrist described a “holiday syndrome” characterized by feelings of “helplessness, possessiveness, and increased irritability, nostalgic or bitter ruminations about the holiday experiences of youth, depressive affect, and a wish for magical resolution of problems.2 Not a small number of articles inundating my newsfeed are about how to “cope” with the added stress of holidays instead of how to enjoy a lovely season. Suggestions for how to manage this stressful time include living in the present (Oprah via HuffPo), making a budget and focusing on your breathing (US News), and just shaking it off (Today).

shake-off

You’d think that with all of this stress surrounding the holidays, psychopathology would increase. People would be visiting the psychiatric emergency room more frequently, people would be committing suicide, and there would be higher rates of depression, right? Wrong.

This is what we know from research: though your mood may worsen, overall utilization of psychiatric services goes down. There are fewer visits to the Psychiatric Emergency Room in the days and week before Christmas. The psychiatric wards are emptier, suicide rates go down, and people engage in less self-injurious behavior (i.e., cutting and face-picking).1

Theories abound as to this apparent discrepancy. Perhaps the hope inherent in the Christmas season leads to the belief that problems will be fixed.2 Perhaps increased contact with family members bolsters social support, which is protective against psychopathology.2 Or, perhaps there needs to be a greater distinction: demoralization, disappointment, and merely revisiting intrapsychic conflicts do not a disorder make.3

Maybe the idea of Christmas blues is merely that, “blues,” and most people cope appropriately.

My first impulse when researching holiday stress was to assume that people struggle and that there would be increased utilization of psychiatric services. I was pleasantly surprised to find that the majority of people tolerate the holiday season and many even fare better during the month of December than other months of the year. Older adults, those who are single or widowed, people who struggle with alcoholism, and those who have had traumatic past holiday experiences may be at increased risk of having a difficult time during the holidays. Furthermore, those who have a prior or current diagnosis of depression or other mental illness may experience shame when surrounded by [presumably happy] family members.4 If you’re a member of one of these groups, I encourage you to seek out appropriate supports in the form of family, friends, or a trusted therapist or psychiatrist. [You can also take a look at this infographic from Happify, which did actually have some great suggestions for coping with holiday stress.]

The take home? While the holidays might be tough for some, in general mental health pathology and utilization decrease. Though people may feel intermitently blue, let’s allow the hope of the season to seep into our psyche, and let’s enjoy the season as we continue to show each other love and compassion.

References:
1. The Christmas Effect
2. Holiday Blues as a Stress Reaction
3. What is it About the Holidays?
4. A Season of Hope