>> Don't do drugs. We've been told that for a long time.
In research into party drugs suggests the public messaging might need some revision.
With us for more from his office at Toronto western hospital Dr.Roger McIntyre professor
of psychiatry and pharmacology at the University of Toronto.
And head of the mood disorders psycho pharmacology at the health network.
How are you, doctor?
>> Great to be with you.
Thanks for covering this very important topic.
>> Nam: One of the party drugs that I just mentioned that we grew up being told not to do
party drugs and one of those party drugs is something called special K also known as
ketamine.
What is ketamine?
>> Well, it's a good question.
And you are right it has quite a history.
It was in fact and still remains in some parts of the world including ours a drug of misuse
and frankly abuse.
Ketamine is a drug that was first in 1962.
Back in 1970 the United States food and drug administration approved ketamine as an
anesthetic.
The short answer is it began as an anesthetic but in the last 50 years we have learned in
addition to being an anesthetic it's also an analgesic t helps pain.
It's an anti-inflammatory and more recently we have learned it's an anti-depressant.
What's so unique about ketamine only discovered in the last decade is that in contra
distinct to the anti-depressants we have had for seven decades it no, about one to two days.
It's called a rapid acting anti-depressant.
>> Nam: I am assuming that would be very important for someone who might be suicidal.
But how did the idea emerge to use ketamine to treat depression?
>> It's a fantastic question.
It's a really interesting longer discussion but really the short discussion is that we have
learned through our research in molecular contributions to depression and trauma and stress
as well as some of our ability to look at animal models of stress that in the brain there
is something wrong with what we call plasticity.
In other words the ability--the ability of the brain to adapt and to form new
brain connections, new brain cell connections.
The observation was made that in depression and related conditions there is something
wrong with this fundamental process.
At the same time what we have learned is that ketamine is able to remedy this process.
It is able to target key molecules, neurochemistry that initiates a cascade of events
that correct this problem not in two weeks not in six weeks but within hours.
And this provided us the impetus for the U.S. government to actually develop ketamine for
depression to begin studies and demonstrate that it works and the FDA in the United States
declared ketamine and depression a big breakthrough for people who have depression.
>> Nam: Can anyone qualify for treatment with ketamine?
>> Not at all.
Ketamine is a drug that should only be given under supervision of health care professionals who
have the expertise not only in mental health broadly but mood disorders more narrowly and also
individuals who have expertise in the implementation of ketamine.
What we need to emphasize as swell is that ketamine comes in different formulations in
different delivery methods.
What we do-- >> Nam: Why is that important to sentencing.
>> Well, because we know that ketamine has been shown to be safe and effective in only a
couple of formulations and roots.
Not all formulationings and roots have been shown to be safe and or effective.
For example intravenous ketamine has been shown to be effective in people with treatment
resistant depression.
Secondly, what is called the F ketamine which is a part of ketamine has also been shown to
be effective as an intranasal delivery.
There's emerging evidence that ketamine might be helpful a lot evidence is still a work in
progress but other routes of delivery like topical or injection those are still not
recommended.
The key point here is it should only be given by people with expertise in delivering the
treatment.
Final point around that is not everyone is eligible.
For now the persons who are eligible are people who just haven't had a good outcome of
conventional treatment.
We usually deliver that to two prior treatments and more recently in the United States
the U.S. FDA has updated the monograph or one of the formulation of ketamine to
include reducing [indiscernible].
There are very specific criteria, specific skill sets people should have and very
specific premise that we should be implementing.
>> Nam: Once it is determined that someone qualifies for this treatment can you walk us
through what that looks like?
>> The person has to be assessed by mental health care provider that's the key area.
Once they are deemed eligible and they understand the risks and benefits typically what we
do at our centre, the Canadian rapid treatment centre is what we do is we give them between 4
to 6 infusions over a period of two to three weeks typically and what they do they come to the
treatment centre they receive an infusion just shy of an hour 45 minutes or so and then they head
home with a loved one or family member.
It's a bit like going for a medical procedure so to speak.
After four to six treatments we then sit down and say I guess you could say where are we.
Have we had some benefits f the benefit is there what are the next steps.
Not everyone benefits.
Many people do.
And much more than as a responding to our drugs that we have.
On a separate note but related sustained type of medication to treat depression for seven
decades.
Mid-1950s when we had the first of the so-called drugs for depression.
And we have really been in a cul-de-sac quite frankly.
Some people do very well with these medicines but most people don't do well enough.
We felt the clarion call was now.
We need to do things differently.
People with mental illness deserve to have their health back now.
And so we said this is a new direction we will take.
It doesn't help everyone but certainly helps many people.
>>> Now for most people we see what we have also encouraged them is to consider
psychotherapy or counselling.
The best practices and depression is not just about giving a medicine; it's often
the case that we can identify skills, identify tactic strategies to improve our
quality of life by integrating talk therapy.
That's after the treatment not during.
You can't really meaningfully engage psychotherapy in the moment while you are getting
ketamine but it's after the treatment once their depression is significantly improved.
>> Nam: If we are wondering what it feels like one patient to describe their experience
after a series of ketamine sessions as not a temporary change but a shift in who I am,
how I approach the world and my feelings towards my own emotions.
Do we understand what is happening in a patient's brain or body that is creating this
change?
>> It's a really exciting new development in psychiatry.
What we have now learned is in the brain of people who are experiencing depression there is
something that's not quite right with what we call the functional connectivity.
As a metaphor think about the mother board on your personal computer your PC a group of
networks and circuits.
Your entertain no different.
The brain is wired connected through circuits and network.
It is a brain of people with depression there is something wrong with the microanatomy as
well as the functional interaction of these circuits.
What's so interesting is some of these circuits are responsible for our ability to think
clearly, our ability to look forward to the future, our ability to think positively as
we engage our lives.
Some of these circuits which is so interesting have been the key target of ketamine and related
products.
What's so interesting is it's now been shown that when you benefit from a treatment like
ketamine in the very near term that is within a couple of treatments that abnormal brain
circuit connectivity resets.
Resetting your PC, your computer.
And then the person who is experiencing depression at the same time says you know I feel
less depressed.
I feel less negative.
I don't ruminate as much.
My mind is much more clear.
So it really is about resetting the circuitry and the networks symptoms of depression.
We didn't have this technology 20 years ago.
The MRIs, the imaging kits we have to sus all this out.
It's not only informed the academic's understanding but informing new treatments.
We are looking at other new treatments that also can reach reset these circuits in
A rapid way ma'am nam for people living with anxiety and depression day-to-day events are
challenging.
Mendel Caillin explaining how psychedelics can help people with depression and mental
suffering.
He describes think of the brain as a hill covered in snow and thoughts of a sled guiding down
that hill as one sled goes down the hill a small number of main trails will appear in the snow
and every time a new sled goes down it will be drawn into pre-existing trails almost like
a magnet.
It becomes more and more difficult to glide down the hill or any other path or in a
different direction.
Think of psychedelics as temporarily flattening the snow.
The deeply worn trails disappear and suddenly the sled can go in other directions exploring new
landscapes and literally creating new pathways.
Is it a feeling that ketamine can help people get out of those well worn trails?
>> That was so beautifully written by the author and really resonates because what I have
heard over 20 years from people who suffer from depression thousands and thousands of
people that I have met is exactly what that author was getting at.
People are stuck in this reel, this rumination, this vicious cycle that they just can't seem
to break and they feel very helpless.
They feel very hopeless about that.
What we have now learned is that's not just some psychological phenomenon.
That is the result of the abnormality something wrong in that brain circuit that you and
I depend on to control our thoughts, to have executive control of our thoughts.
What we call in the business cognitive flexibility.
What happens when you take ketamine in the near term you get a correction of the circuit
and the person feels a greater sense of agency a greater sense of control over that cognitive
flexibility.
>>> So we always have-- everyone has negative thoughts but when you have the ability to
turn it off.
We have the ability to engage other ways of thinking and relating and that very human
function depression and what happens when you give people ketamine they gain that control
sense of autonomy over their thinking and we hear this repeatedly from people.
I think that is the case.
Moreover that's not just helping people in the near term getting depression lifted but also it
helps to engage in psychotherapy, engage in their lives.
It's very difficult to engage in your life if you are held ransom to this very negativistic
process.
Medications for depression are not happy pills but what they do is reset the circuits and the
networks which allows the individual to engage other parts of the brain this they would
need to engage at a more positive more virtuous with cycle going forward.
>> Nam: I still remember watching a video in high school this is your brain this is your
brain on drugs and we were told drugs like ketamine or MDMA or psychedelics could ruin your
life.
Now they are being used in clinical set togs potentially save lives.
How should we understand this shift toward using things like MDM parks and psychedelics to
help us to be well?
>> I think the message is that every drug is potentially harmful.
Placebo is potentially harmful.
I cringe when I hear people say to me oh, there is this new medication for such and such it
has no side-effects.
That's interesting placebo has rate of side-effects approaching 50 to 75%.
How is it so magical.
Everything has side-effects and safety concerns.
The first job of medicines don't hurt anybody.
Our job in clinical medicine and clinical research is to find out whether there is a benefit that
can overshadow the risk when implemented under appropriate circumstances.
So I strongly recommend people don't use ketamine for depression unless they are
taking it as a centre that specialized in doing it.
That being said, we know that many drugs have hazards and drugs like ketamine does have
hazards if it's not used accordingly.
You receive sage advice at your school.
Obviously you went to a good school and your school gave you great advice.
That advice still sticks.
But the take-away is is there a benefit that can overshadow the risk and for each individual
patient that the different calculation.
>> Nam: Dr.McIntyre, thank you for spending time with us.
We appreciate your insights on this topic.
>> Great to be with you.
Thank you.