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States-of-Mind

Ketamine as anti-depressant

If you’ve heard of the drug ketamine, it has likely been in the context of its use as an anesthetic or pain reliever.

You may also have heard of its illicit use as a street drug.

Interestingly, this medication, which was first developed in 1962, has recently received some attention for its potential use in the treatment of depression.

There has been some excitement about ketamine and other drugs like it as a possible alternative in cases of treatment-resistant depression.

Much more research is still needed, but studies show ketamine clearly has some anti-depressant effect.

Ketamine works differently than other antidepressant medications. It is typically given in a single intravenous dose and works by blocking NMDA receptors.

Unlike existing antidepressants it seems to have a rapid effect, providing symptom relief within 24 hours compared with several weeks for conventional medications.

A meta-analysis (published in the American Journal of Psychiatry in 2015) of studies examining ketamine use for depression gives mixed results.

It confirmed the rapid therapeutic effect, but also showed its positive effects are short-lived and it is somewhat problematic because of a potential for abuse and neurotoxicity.

Although ketamine provides a powerful and quick effect, results of seven studies show its benefit seems to wane after about a week.

Additional studies looking at ketamine used in conjunction with ECT found that it seemed to augment the anti-depressant effect of ECT at the start of the treatment, but not at the end of the treatment course.

Much more information is needed before we can confidently pronounce ketamine as a useful tool in the battle against depression. We have virtually no data on the use of ketamine on an ongoing basis, there are some real concerns about its safety, and we don’t know enough about exactly how it works.

Perhaps with more study and development, ketamine or other NMDA antagonists can be honed and may provide an additional option for people experiencing depression.

In the meantime, if you or a loved on are depressed, speak to your doctor. We do have effective medications and therapy that are proven to help many people.



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Smoking and mental illness

Rates of smoking are much higher for those with mental illness than in the general population.

One survey of psychiatric patients outpatients in the U.S. reported 88 per cent of those with schizophrenia were smokers as well as 70 per cent of those experiencing mania and 49 per cent of those with depression.

Along with increased rates of smoking, those with mental illness also tend to smoke more heavily than others (with intake increasing along with the severity of their mental illness) and have a harder time quitting.

All of this contributes to a reduced life expectancy in this group. Some estimates suggest people with severe mental illness die about 25 years earlier than the general population.

Contrary to assumptions, the increased mortality in this group is not directly caused by mental illness, but is largely due to smoking – 60 per cent of these deaths are due to smoking related illnesses such as cardiovascular or respiratory disease.

Unfortunately, those with mental illness are often not offered help with smoking cessation when they visit a health care provider.

Quitting can be difficult for those with mental illness. These smokers tend to have higher nicotine dependence, heavier smoking and chronic stress.

Other barriers might include a lack of supports, cognitive impairment or difficulty coping. Still, quitting is possible and is more likely to be successful with support from health care providers.

For those with bipolar disorder, I usually recommend nicotine replacement therapy as an initial strategy to avoid abrupt nicotine withdrawal.

Abrupt nicotine withdrawal can trigger a mood switch. 

Also, the use of Zyban (bupropion) for smoking cessation can be problematic in people with bipolar disorder as can the use of all antidepressants.

It can trigger mood switches, mania and mixed states.

Even though there are some risks in smoking cessation with bipolar disorder and with other disorders, it is still worthwhile to attempt to quit considering the health consequences of doing nothing.

If possible the time to try is during periods of relative stability and with supervision so that support and medication adjustments can be implemented as necessary.

The vastly increased mortality rate for those with serious psychiatric conditions should not simply be accepted.

If up to 60 per cent of these premature deaths and many health complications could be prevented with supported smoking cessation, it should be one of the primary goals of health care providers treating this population



Psych problems, solutions

Barriers and solutions for urgent psychiatric care

When a person is in acute psychiatric distress — having a psychotic episode, suicidal, demented or otherwise out of control, depressed or anxious to the point that they are unable to work — urgent care is necessary to stabilize the situation and prevent harm.

Unfortunately, many people who require urgent psychiatric services have difficulty accessing them.

A variety of barriers often exist that can differ depending on the condition and are not easily recognized by those not experiencing a mental health crisis.

Here are a few of the common barriers to accessing services:

  • To see a psychiatrist, a referral is required from a general practitioner. There may be some exceptions to this for psychiatrists who are not paid on a fee for service basis, but these are in the minority. Referrals require access to a GP and can also often involve wait times for availability with both the GP and then the mental health professional.
  • Most mental health professionals require a booked appointment. Many people with even moderate degrees of mental illness have difficulty making and keeping appointments. Once a couple of appointments are missed, the patient may not be offered another.
  • If experiencing a moderately severe mental illness, the patient will likely be given a medication prescription. These can be expensive and the patient may not be able to afford it. There are some programs in place to cover medication costs, but many people don’t know what they are or how to access them.
  • Financial support for food and housing may be needed. Even if eligible for social assistance, the patient may not know how to apply for it. Some qualify for provincial or federal disability pensions, but the required process needs to be followed and can take up to six months — a completely unacceptable timeline when dealing with a mental health crisis.
  • People experiencing moderate or serious mental health symptoms can find disability applications almost impossible to complete. It can be very difficult to explain problems verbally or in writing.
  • In order to stabilize a mental health crisis, it is important to find suitable and affordable housing and be able to follow the rules. Again, daunting when in the midst of a crisis.
  • Even those being seen by salaried case managers at government-funded institutions may have difficulty keeping appointments, getting and taking medications and looking after activities of daily living.
  • Often, homeless people miss out on disability pensions because they cannot get the required information together to apply.

I believe many of these issues could be much better dealt with than they currently are. Here are a few ways we could ease the situation for vulnerable individuals:

  • Service facilities need to be easily identifiable, well known and available without an appointment.
  • A facility should have all the necessary professionals in one place i.e. social services, employment counsellors, social workers, alcohol and drug counsellors, nurses, pharmacists, psychologists, doctors and psychiatrists.
  • Patients should be able to access their medications on site free of charge without delay.
  • Help should be available to complete whatever paper work is necessary (it should be kept to a minimum). Basic information should be electronic and accessible so people don’t have to repeat the same database to several different people and institutions. Contact information and provincial health care number should be readily available to all necessary health care providers.
  • Ideally, a facility like this would be available seven days a week to reduce visits to the ER.
  • Overnight observation availability would also be helpful in many cases.
  • More affordable housing units are needed — both independent and supportive.

A clinic like this would be provincially funded and available in large and mid-sized municipalities. As it stands, all of these services are already available, but are not easily accessible or well coordinated.

Not only would it save the system money to coordinate them and make them more accessible to those in need, it would likely also go a long way toward eliminating homelessness.

I can’t tell you how amazing it would be to be able to actually discuss a patient’s needs with the other professionals involved rather than filling out a form and sending it to someone you will never meet and from whom you will never hear.



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Picky eaters and anxiety

For parents with toddlers and small children, meal-time food battles are common.

Rare is the family whose children will gladly ingest unfamiliar dishes without at least some suspicion.

As common as it is for kids to avoid one or two foods or ingredients, there are some who seem to take it to a whole other level.

Everyone likely knows at least one particularly picky eater. These kids are the ones who insist they can only eat a certain colour of food, whose peas can’t touch their carrots, who can only enjoy things with smooth textures, or noodles with no sauce.

A study from Duke University and published by the American Academy of Pediatrics, associated extremely picky eating with an increased likelihood of anxiety, depression and ADHD.

Perhaps not surprisingly, the symptoms worsen with the severity of pickiness.

Researchers in this study examined eating habits of 3,400 children between 2007 and 2010. They then narrowed it down to just over 900 picky eaters between the ages of two and five who were not on the autism spectrum (associated with very picky eating).

More than one in five of these kids demonstrated moderate or severe selective eating and those in the severe category were more than twice as likely to have a diagnosable psychiatric condition and twice as likely to have behaviour problems outside the home.

In the moderate group, children had increased rates of ADHD and separation anxiety.

Both groups had 1.7 times increased likelihood of generalized anxiety disorder.

Of course, picky eating does not necessarily mean your child is anxious or depressed, but if picky eating is interfering with your child’s social functioning or if you are concerned, it may be a good idea to seek professional advice about it.

When a co-existing psychiatric condition is present, getting help early can prevent the condition from worsening, and can also minimize its negative effects on a child’s life.

Often, early education and work with a child can help them to cope with difficult feelings and situations so he or she is able to continue taking part in daily activities.

It is not well understood exactly what causes extremely picky eating. Several theories exist and most scientists now believe it is the result of a combination of neurology and environment. There has not been a lot of study yet into how best to introduce new foods to these children.

Although more longitudinal research is underway, we don’t yet have data on how many picky children continue on to be picky adults or how many continue to develop more serious psychiatric symptoms.

Parents can be comforted to know that extreme picky eating is not typically a result of poor discipline or permissive parenting. 



More States of Mind articles

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About the Author

Paul Latimer has over 25 years experience in clinical practice, research, and administration.

After obtaining his medical degree from Queen's University in Kingston, Ontario, he did psychiatric training at Queen's, Oxford and Temple Universities. After his residency he did a doctorate in medical science at McMaster University where he was also a Medical Research Council of Canada Scholar.

Since 1983 he has been practicing psychiatry in Kelowna, BC, where he has held many administrative positions and conducted numerous clinical trials.

He has published many scientific papers and one book on the psychophysiology of the functional bowel disorders.

He is an avid photographer, skier and outdoorsman.

Like us on Facebook: facebook.com/oktrials

Follow us on Twitter: @OCT_ca



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The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet does not warrant the contents.

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