Ketamine II

I posted recently about my experience of taking IV ketamine to intervene in disabling depression that at that point had persisted for over two years. All in all I found it to be a boutiquey experience, a fix for desperate members of the middle class that was financially out of reach for the low-income and depressed.

At the end of this experience I felt that dollar for dollar it made a lot more sense to snort street ketamine than to pay a rich doctor $500 a pop for something that didn’t have a significant duration of effect, or any effect at all in plenty of cases. It is ironic that the recent embrace of psychedelics for the treatment of mood disorders has materialized as remarkably expensive riffs on easily accessible drugs.

Despite the inadequacy of this treatment regimen, after another two years of misery I had occasion to revisit the experience. I made an appointment for a consultation with a treatment resistant depression specialist practicing out of a large state university.

It is my experience that becoming a new patient of a psychiatrist is almost always miserable. The requisite discussion of my life history is punishing. They ask you about all the things that are impossible when living with a serious mental illness- employment, education, relationships, dental hygiene. That shit goes out the window when you spend your days in what is essentially a state of existential horror, and to revisit how little I’ve done with my life as a diagnostic exercise makes me nostalgic for the time I got tested for chlamydia.

Looking at these things makes me feel endangered. I am always glancing down the ladder I climb, hoping to create some distance between myself and the realistic miseries of group homes, homelessness, institutionalization and antipsychotics that threaten all of us with serious mental illness. No matter how fast I climb the tide continues to come in. 

So I went to this consultation. I have been through several psychiatrists and there is almost always a rote response to my suffering, which is a change in medications or simply another pill loaded on top of the existing cocktail. It feels decidedly imprecise because it is. What is insulting and upsetting about this approach is that there is no acknowledgment that they are throwing stones in the dark, trying to hit a shadowy and amorphous phenomenon that they know little to nothing about. 

Regardless, there was no threat of new drugs as I had an NP prescribing for me. This was a relief. I’ve been fending off the advances of medical professionals who are essentially acting as extensions of pharmaceutical sales reps for years now. And before the reader renders judgement on me for failing to jump on every possibility for relief, know that many psychiatric medicines come with severe and ofttimes intolerable side effects. If you doubt me do some reading on akathesia. Try to imagine living with it. 

To my surprise and pleasure there was no exhaustive psychosocial history taken. They did ask me about illicit drug use which is a funny thing. So many psychiatric medications are worse for you than the drugs that people take for fun. So I lied a bit. It’s not unusual for me. I’ve taken bucketloads of acid, mushrooms, DMT, weed and ecstasy and don’t regret any of it, but it’s generally not a good idea to express your enthusiasm for recreational drugs to psychiatrists, social workers or psychologists. They’re quick to regard this not just as a problem but the problem.

After rattling off the long list of psychiatric drugs I’ve been on in the last five years of my life the doctor drew a little graph. It depicted the likelihood of response to new medications. As the number of medications trialed increases the likelihood of response diminishes until you reach no fucking chance at all. I could have told him this, but it was nice to be validated. Then he said that the first thing he’d like to do was administer ketamine twice a week for two months. 

I went home with a bunch of pamphlets. What I was to begin taking was not the ketamine of Vietnamese battlefields and veterinary sedation but a derivative of it, altered so that a pharmaceutical manufacturer could make money. This was esketamine, sold under the brand name of Spravato.

The ad men of big pharma have an uncanny ability to choose stupid names for chemicals, names that sound upbeat, that try to evoke something of the promised effect. I’ve been on abilify, lexapro, prozac, wellbutrin, effexor, seroquel and zoloft and every time I picked up a bottle I felt pandered to. 

Reading up on Spravato I was skeptical. I’d taken ketamine before to little effect, or at least little antidepressant effect (I definitely got high). From what I could find about ‘non-responders’ I was likely to be one of them. Apparently a history using benzodiazepines is a predictor of a lack of response and I’ve been taking between one and four milligrams of clonazepam for five years. And while I truly wanted relief tripping on ketamine seemed like a pretty good consolation prize.

For two months this past winter I somehow made it to my appointments. There were many times that I felt disappointed. Not only was the depression somehow worse but the Spravato wasn’t producing the fucked-upedness I was hoping for. It comes in very streamlined looking two shot bottles. I started out on one and ended up at four. This quickly took me over the limit set by the insurance company and suddenly I found myself snorting regular racemic ketamine. 

The first dose rocked my world. I saw a herd of wild horses fording a river and a beautiful girl with red hair in a field. I saw legions of people at some point in the distant past, marching with spears. Then hazy colors bloomed and I experienced the strange but pleasant experience of being folded, elongated, compressed and rotated that seems unique to ketamine. I walked out of the office like a newly birthed colt, shakily walking into the future.

I am still taking ketamine under the care of this doctor. He thinks it’s working. For myself I can’t tell. There are too many variables in the equation. I’m on a new antidepressant and have gone through a month and a half of transcranial magnetic stimulation in addition to the ketamine. I’m a bit better than I was. I still experience searing anxiety in the morning but eventually it lifts. The automatic self-hatred and fear of the indubitably terrible future has softened. I don’t lay on the couch, conscious and hating it, for hours at a time. I don’t sob uncontrollably.

Of course I live in fear of descending to those depths again and this is an uncomfortable way to live. I examine my feelings, pouring over them in search of the reemergence of crippling misery. I pan for them. I am a depression prospector, and I always find a shiny nugget to obsess over, but it is too small to bother with. I toss it over my shoulder, sit in the shade for a bit and then return to the creek.

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