Ketamine treatment for individuals with treatment-resistant depression: longitudinal qualitative interview study of patient experiences

Abstract

Background Ketamine has recently received considerable attention regarding its antidepressant and anti-suicidal effects. Trials have generally focused on short-term effects of single intravenous infusions. Research on patient experiences is lacking. Aims To investigate the experiences over time of individuals receiving ketamine treatment in a routine clinic, including impacts on mood and suicidality. Method Twelve fee-paying patients with treatment-resistant depression (6 females, 6 males, age 21–70 years; 11 reporting suicidality and 6 reporting self-harm) who were assessed as eligible for ketamine treatment participated in up to three semi-structured interviews: before treatment started, a few weeks into treatment and ≥2 months later. Data were analysed thematically. Results Most participants hoped that ketamine would provide respite from their depression. Nearly all experienced improvement in mood following initial treatments, ranging from negligible to dramatic, and eight reported a reduction in suicidality. Improvements were transitory for most participants, although two experienced sustained consistent benefit and two had sustained but limited improvement. Some participants described hopelessness when treatment stopped working, paralleled by increased suicidal ideation for three participants. The transient nature and cost of treatment were problematic. Eleven participants experienced side-effects, which were significant for two participants. Suggestions for improving treatment included closer monitoring and adjunctive psychological therapy. Conclusions Ketamine treatment was generally experienced as effective in improving mood and reducing suicidal ideation in the short term, but the lack of longer-term benefit was challenging for participants, as was treatment cost. Informed consent procedures should refer to the possibilities of relapse and associated increased hopelessness and suicidality.

Holding on or letting go? Patient experiences of control, context, and care in oral esketamine treatment for treatment-resistant depression: A qualitative study

“…Consistent with other qualitative studies on ketamine treatment (26)(27)(28)(29), respondents were often overwhelmed by the "side effects" of esketamine. Using this specific terminology for the acute psychoactive effects of ketamine implied that these are 10.3389/fpsyt.2022.948115 undesirable, reducing the likelihood for patients to recognize and interpret such experiences as potentially therapeutic, and of sharing their experiences with staff afterward, particularly since some participants in our study suggested their subjective experiences were therapeutically valuable.…”

“…Recently, a number of qualitative studies investigated the experiences of patients undergoing IV ketamine treatment of alcohol use disorder (AUD) (16), suicidal ideation (26), major depressive disorder (MDD) (15, 17), and TRD (27)(28)(29). Most described the phenomenology of ketamine's acute effects; other themes included adverse effects (26)(27)(28)(29), perceived therapeutic mechanisms (16,26,29), patient attitudes, motivations, expectations (16, [27][28][29], and barriers and facilitators of (es)ketamine treatment (16,29). With one exception (ketamine treatment of AUD) (16), most qualitative studies did not capture in detail how patients experience the ketamine treatment and which conditions facilitate optimal outcomes.…”

Maintenance ketamine treatment for depression: a systematic review of efficacy, safety, and tolerability

“…24,53 We included 11 controlled and uncontrolled trials, case series, and case reports on maintenance oral ketamine treatment, including 199 unipolar (approximately 93%) and bipolar (approximately 7%) patients with treatmentresistant depression. 11,12,25,28,31,32,34,35,37,43,52 Duration and frequency of treatment varied widely, from 6 weeks to 3 years and from 3 times a day to once a month. In some studies frequency was individually tailored, in some dosing was individually tailored, and in some both were.…”

“…Two controlled trials, one uncontrolled trial, and six case series and reports presented results of maintenance treatment within the first 6 months after initial response. 12,25,28,32,34,35,37,43,52 Although the RCTs were not designed to study maintenance treatment, in both studies ketamine treatment was offered for more than 4 weeks, therewith meeting our intervention criteria. In the first RCT, including 40 patients, antidepressant effects were superior for ketamine versus diclofenac after 3 weeks of treatment when measured by the Hospital Anxiety and Depression Score (HADS).…”

The Downstaging Concept in Treatment-Resistant Depression: Spotlight on Ketamine

“…They should also consider patients’ perspectives; therefore, patient report outcomes should be measured. Particularly interesting would be how patients perceive the treatment and its short- and long-term effects, as well as what their hopes and fears are [ 89 ]. The downstaging concept is presented in Figure 4 .…”