Why Not Make Ketamine a First-line Treatment?

July 25, 2017
Rakesh Jain

In this new, occasional feature on Psych Congress Network, members of the Psych Congress Steering Committee answer questions asked by audience members at Psych Congress meetings.

QUESTION: Why not make ketamine a first-line treatment rather than reserve it for treatment-resistant depression cases?

ANSWER: Ketamine is rapidly emerging as one of the important treatment options in refractory major depression. While it is quite effective, it is not yet appropriate to make it first-line treatment. There are several reasons why this might be the case.

First of all, the database on ketamine is in its infancy and we still don't have a great understanding of the long-term benefits and side effects. Secondarily, the effects of ketamine seemed to wear off rather rapidly. This of course is a problem with a disorder like major depression that tends to be chronic in nature. Additionally, the route of administration of ketamine can be a limiting factor. Ketamine has its own set of side-effects that include the potential for hallucinations, psychosis, and potential addiction. It behooves us clinicians to keep our eyes closely on the ketamine literature but at the moment reserve it for (off-label) use in refractory patients, rather than use it first line.

Of course, as the evidence base expands, treatment guidelines change, and our thinking on this most likely will be modified. I am personally quite enthusiastic about the role of ketamine and its analogues in the treatment of depression. But let me reiterate at this moment ketamine treatment is best reserved for resistant depression as we simply don't yet know enough information/evidence to consider it as a first-line treatment.

— Psych Congress cochair Rakesh Jain, MD, MPHClinical Professor, Department of Psychiatry, Texas Tech Health Sciences Center School of Medicine, Midland

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