Can We Stop Suicides?
In May of 2017, Louise decided that her life was just too difficult, so she would end it. In the previous four years, three siblings and a half-sibling had died. Close friends had moved away. She felt painfully, unbearably alone. It would be the fourth time Louise (I’m using her middle name to protect her privacy), then 68, would attempt suicide, and she was determined to get it right.
She wrote a letter with instructions on where to find important documents and who should inherit what. Then she checked into a motel, put a plastic sheet on the bed, lay down and swallowed pills with champagne. A few days later, she woke up in a psychiatric ward. The motel maid had found her. “I was very upset I had failed,” she said. She tried to cut her wrists with a bracelet — unsuccessfully.
Suicide is now the 10th leading cause of death in the United States, according to the Centers for Disease Control and Prevention. And yet no new classes of drugs have been developed to treat depression (and by extension suicidality) in about 30 years, since the advent of selective serotonin reuptake inhibitors like Prozac. The field of psychiatry needs new treatments for patients who show up with a stomach full of pills. Now scientists think that they may have found one — an old anesthetic called ketamine that, at low doses, can halt suicidal thoughts almost immediately.
Depression ran in Louise’s family. Prozac had helped her for a time, but stopped working in the late 2000s, as it sometimes does. No other drug seemed able to lift her dark moods. After her suicide attempt, Louise’s psychiatrist suggested ketamine.
She agreed, and received an infusion intravenously. Within hours, her sense of well-being improved. The hospital discharged her. Back home, she discovered that going to the market was no longer a “herculean task.” Getting her car washed wasn’t an insurmountable chore. “Life was better,” she said. “Life was doable.”
Using ketamine to treat depression and suicidality is somewhat controversial. Small studies suggest it holds promise, but it is only now being tested in placebo- controlled trials with hundreds of patients. It is also popular as a club drug. Like morphine, it may operate on the opioid system, and it can induce feelings of euphoria. But ketamine abusers can develop brain damage.
Nonetheless, if proven safe and effective in small doses, ketamine stands to transform how doctors deal with suicidal patients and depression. Sedation and physical restraint aside, doctors have few ways to quickly stop suicidal ideation. Current antidepressants can take weeks and sometimes months to work, if they work at all. They may also, paradoxically, increase suicidality in some patients. Therapy takes time to help as well (assuming it does).
Researchers at Yale University discovered ketamine’s potential as an antidepressant in the late 1990s, and scientists at the United States National Institute of Mental Health confirmed it in the mid- 2000s. Numerous studies followed suggesting that the drug helps patients for whom nothing else works. It does not work for everyone in this group, but when it does, it works within hours.
Because ketamine is already approved by the United States Food and Drug Administration, doctors can prescribe it “off-label,” for uses other than that for which it has been approved. Meaning that it is theoretically available.
Ketamine works differently from other antidepressants. The prevailing theory is that it affects the brain’s glutamate system, which scientists now realize may be involved in depression, rather than the serotonin pathway used by drugs like Prozac. Animal research suggests that partly blocking certain glutamate receptors increases brain plasticity — the ability of the brain to make new neuronal connections — and corrects some of the abnormalities that result from chronic stress. These effects on the brain have inspired a flurry of research. Drugs are in development.
But ketamine has what many view as a flaw. It can produce dissociative and hallucinatory side effects. Patients can feel as if they have left their bodies or that they are dying. Louise described her first ketamine experience as being like Picasso’s painting “Guernica” — disjointed and unpleasant. But subsequent treatments, she said, were “wonderful.”
Questions also remain about the safety of long-term use. Depressed patients often have to return for “booster” treatments (Louise finds that she needs an infusion once a month). The drug is considered safe when given once, but no one is sure how repeated doses may affect the brain. And it can be addictive, too.
Nonetheless, dozens of clinics have opened offering ketamine infusions as an off-label treatment for depression. Views on these clinics include concerns about profiteering and acknowledgment that they may be helping desperately ill patients.
Dr. Samuel Wilkinson, a Yale psychiatrist, worries that patients’ suicidal impulses could seem to disappear after ketamine treatment, leading to discharge from the hospital, but then rebound.
The deeper issue here is one of weighing the risks of a treatment that has unclear long-term side effects against a condition whose main symptom is the urge to kill oneself.
The most ringing endorsement of ketamine may come from the emergency room. I met Louise through a friend, Lowan Stewart, who works at the emergency room in New Mexico where she was admitted.
Emergency room doctors are often familiar with ketamine. With research revealing its potential to stop suicidal impulses, he thinks doctors should offer it to suicidal patients in the emergency room. “We could help so many people,” he said.