Canadian woman wanted assisted suicide for depression. Then ketamine saved her 

Researchers worry ketamine may be 'easily overlooked' by doctors and people considering MAID for major depression when the option becomes legal 

Published May 17, 2023  •  Last updated May 17, 2023  •  6 minute read

Scientists began testing ketamine as a potential antidepressant for the first time in 2000, and research has found symptoms of depression can be reduced as rapidly as one to four hours after a single treatment. PHOTO BY TERESA CRAWFORD/AP, FILE

She’d lived with severe depression and near constant thoughts of suicide for more than 15 years. Nothing, not a dozen different psychiatric drugs, not electrical pulses to the brain or two rounds of shock therapy, provided more than fleeting relief.

She decided that she would prefer to die, and twice sought a medically assisted death. Then her doctors gave her ketamine.

In less than two weeks, her depression “rapidly and robustly remitted.”

“To our knowledge, this is the first report of ketamine or any other intervention yielding remission in a patient who would have otherwise likely been eligible for MAID for depression,” Dr. Kyle Greenway, a psychiatrist working at McGill University and Montreal’s Jewish General Hospital, and his co-authors are reporting.

It’s just a single case. However, the researchers worry ketamine may be “easily overlooked” by doctors and people considering MAID for major depression when the option becomes legal next March. Beyond ketamine, the case also illustrates the potential for “grave and irreversible consequences” of prematurely declaring someone’s depression irremediable — essentially, incurable — they said.

At the least, before taking an irreversible step like MAID, a trial of ketamine warrants consideration

Others cautioned that psychedelic-assisted psychotherapy isn’t an automatic lifeline for people seeking an assisted death, because requests could go in either direction. People might actually become more at peace with their decision, said Daniel Buchman.

“We don’t know how psychedelics, and especially very transformative, deep spiritual experiences even, can shift people’s attitudes towards death and towards MAID itself,” said Buchman, a bioethicist and independent scientist at the Centre for Addiction and Mental Health in Toronto.

“How might we respond to someone who says, ‘I do feel a deeper interconnection with the world, a deeper sense of well-being. I’m at peace where I’m at, and I would actually like to pursue MAID now.’

“That’s entirely possible as well.”

Right now, Canadians whose sole underlying illness is a mental disorder aren’t eligible for an assisted death. In February, the federal government introduced a bill delaying MAID eligibility for people with mental illness until March 17, 2024, a one-year extension from the original timeline to give psychiatrists more time to prepare for the change — more time to “get this right,” Justice Minister David Lametti said at the time.

A key part of granting euthanasia for mental illness will be establishing “incurability.” A government-appointed expert panel recommended incurability should be based on the number of treatments tried, though it didn’t say exactly how many, or what sort of treatments should be seen as sufficient.

“Accordingly, it is essential for clinics to have up-to-date and reliable evidence about all potential treatments,” Greenway and his co-authors wrote, including emerging ones like ketamine.

Ketamine has been around since the 1960s and is one of the most commonly used anesthetics in medicine, worldwide. It’s used in surgery, and for rapid pain relief for emergency procedures, like replacing a dislocated shoulder.

Dr. Kyle Greenway sits in the original ketamine treatment room at the Douglas Mental Health University Hospital in Montreal. There are only a handful of publicly funded ketamine clinics in Canada. PHOTO BY NATHALIE GOYETTE, RN

It’s also used as a risky and illegal club drug, “for those looking to feel a little lighter and a little loopier on the dance floor,” Vice reports.

Ketamine clinics are sprouting up across the U.S. There are more than a dozen privately operating ketamine clinics in Canada, most charging roughly $1,000 per treatment. There are only a handful of publicly funded clinics, which raises ethical and equity issues. Greenway’s team can only treat a few patients per week, which is why they focus on “ultra-refractory” cases.

Scientists began testing ketamine as a potential antidepressant for the first time in 2000. A tiny trial involving seven people with major depression found that people reported a significant improvement in symptoms within 72 hours of an infusion of ketamine.

Since then, a review of the evidence from 83 published research papers found symptoms of depression can be reduced as rapidly as one to four hours after a single treatment, and last up to two weeks.

Conventional antidepressants, by comparison, typically take weeks to months to show effects.

In the Montreal case, the 68-year-old woman, who consented to having her case reported, was referred to Greenway’s ketamine clinic at the Jewish General Hospital in December 2021. Her score on a scale measuring treatment-resistant depression was 22 out of a maximum of 27, “qualifying her as severely resistant.”

She received six, 40-minute IV infusions over four weeks, alongside weekly psychotherapy sessions. She has been receiving ketamine boosts every three to six months since.

“A lot has improved,” Greenway said. “There’s ups and downs. She had a lot of challenging life events.” She isn’t cured. She isn’t necessarily “thriving.” However, her MAID request remains withdrawn.

Greenway is cautious. He’s aware of concerns around the ketamine hype. A Canadian and American research team recently raised serious safety concernsaround the effects of repeatedly inducing an altered mental state, and limited, and often flawed, studies. The altered consciousness varies, they noted, from a fleeting, pleasant euphoria to “significant psychosis.”

Ketamine is a bit of a chameleon, Greenway said. When used as an anesthetic, “people feel a little bit strange, and they might see the room a little bit distorted.” When injected in lower doses as part of ketamine-assisted psychotherapy, and especially when blindfolds and music are added, people experience vivid and “pretty pronounced” hallucinations within 10 to 20 minutes. The hallucinations are often related to emotionally charged events in their lives. People can report feeling as if they’re dissolving, or melting into the universe, and mystical experiences. “Sometimes very emotional stuff comes up,” Greenway said. “It’s very psychedelic that way.” People then return to more or less normal after about 90 minutes.

How ketamine eases depression and suicidal thinking isn’t clear. It could be down to a neural reset, Greenway said, like electroconvulsive therapy. Some studies suggest ketamine promotes the growth of neurons, and connections between neurons. “In our hands, we’re never really sure how much is biological and how much is psychological about the experience,” Greenway said. “We think there’s a lot of both.”

But while ketamine’s anti-depressant effects come on rapidly, they often only last days, or weeks.

Greenway encourages people to use the “momentum” from the immediate effects to make life changes and engage in psychotherapy — “stuff that will help keep people well without necessarily needing repeated or weekly doses for their rest of their lives.”

Still, while it’s cheap, costing about three dollars a dose, ketamine therapy requires an infusion pump, a quiet room, a nurse and, ideally, a therapist. “That’s one of the major obstacles,” Greenway said.

The other: Not everyone responds. About 10 per cent of people receiving ketamine for depression robustly remit, he said, though there’s some evidence suggesting that the greater the treatment-resistance — exactly the sort of cases where MAID will be considered — the greater the odds of ketamine helping.

“At the least, before taking an irreversible step like MAID, a trial of ketamine warrants consideration,” Greenway said, though people do have the right to refuse a treatment they deem personally unacceptable, he and his co-authors said.

Buchman, of CAMH, who, together with colleagues, published a recent commentary on psychedelic-assisted psychotherapy and MAID, said it’s “wonderful and important” that people are able to have their suffering alleviated.

But he takes a cautious approach, “so that we’re not fuelling additional hype around some of these psychedelic medicines as an easy way, or a magic bullet to reverse MAID decisions.”

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