– I actually think there would have been a possibility that I would not have lived today. In the worst case, it could have been a fact, says “Marius”. Tromsøværingen is one of the few who receive treatment with ketamine for severe depression and acute risk of suicide. news knows his identity, but anonymises him because he will now try to get back to work. But it wasn’t something he envisioned a year ago. He has been disabled for three years, and says he has tried all kinds of antidepressants, and also talk therapy. It has not had the desired effect. But now he is in a treatment facility where he receives a dose of ketamine once a month. – Immediately after the first treatment, it was as if a lid had been placed over the heaviest thoughts. They somehow didn’t get away with it, says “Marius”. Andreas Wahl Blomkvist, doctor in drug and addiction medicine at the University Hospital of Northern Norway (UNN), and author of the book “Illegal Medicine”. Photo: private Need for new methods There have been no new treatment methods in this field for a long time. Andreas Wahl Blomkvist, doctor in drug and addiction medicine at the University Hospital of Northern Norway (UNN), believes that we need new solutions, and that the drug ketamine is an example of something that can help. – Depression treatment does not help all patients. 1 in 3 does not benefit from today’s offer, says Blomkvist. Ketamine was first produced in the 1960s, and is mostly used as an anesthetic and for pain relief. Ketamine is a numbing medical drug that is often used for anesthesia or for pain relief, but which is also shown to have an effect on depression. Photo: Øyvind Sandnes / news Some people also use it in powder form to get high. And it is referred to as “horse doping”, because it is used as a sedative or anesthetic for animals. But the drug has also shown promising results for severely depressed people with and without suicidal thoughts. In 2020, it was approved as a drug against depression, but it is still not allowed as a treatment method. Blomkvist believes that the effect of ketamine treatment is sufficiently well documented, and refers to several systematic reviews and meta-studies that support what he says. But the Institute of Public Health believes it is too early to make a decision. Restart the brain The advantage of ketamine, as Blomkvist sees it, is that you do not need to use it daily, but that you can cure or relieve depression with a few doses. – Ketamine appears to promote the brain’s ability to adapt to new experiences. For patients who are stuck in negative thought patterns and behaviour, ketamine seems to help them think differently and change their behavior and perspective, says the doctor. But the treatment is controversial. Ketamine is a legal drug in Norway, but as mentioned it is mostly used for pain relief or in anesthesia. It is permissible to use approved medicines for other treatment, provided that the doctor who gives them takes a certain responsibility. This is called “off label”, and is often used where there are affordable alternatives to an expensive medicine. Before Christmas, Blomkvist treated “Marius” with ketamine, but it was stopped by the UNN management because they wanted to decide whether to allow it. So far they have not done that. But Blomkvist and his colleagues have received money from Helse Nord to carry out a randomized study on the use of ketamine in psychiatry. – I am happy that they have allocated money, and that they are investing in this type of research. But even if UNN is delaying its decision, several professionals are urging hospitals to offer ketamine for severe depression. Ketamine and addiction Helse Nord has allocated around NOK five million to carry out a randomized study entitled “Ketamin for combined depression and alcohol addiction”. The study will be carried out at the University Hospital in Northern Norway, and has been approved by the regional committee for medical and healthcare research ethics. It must now be approved by the Norwegian Medicines Agency, before they start the study during the spring. Doctor Andreas Wahl Blomkvist does not think this research will have much to say for the use of ketamine against severe depression, as this study examines the effect of ketamine in combination with substance abuse treatment. – We finance it because the patient group in question is considered a priority group in need of a better treatment offer. The project was assessed by the external assessment committee as a solid and well-worked project, which will investigate a promising treatment for alcohol addicts with depression, says specialist director Geir Tollåli in Helse nord in an e-mail. Long waiting time Only one public hospital in Norway has taken on the responsibility of treating depressed patients with ketamine intravenously. It is at DPS nordre Østfold, which is a department at Sykehuset Østfold. Here, “Marius” received further treatment for his severe depression. – We are currently the only hospital that offers this, and so far we have received approval from the authorities to continue with it. It is a choice I have made even though many in the field have been critical, says head of department Ingmar Clausen. Head of department Ingmar Clausen at DPS Nordre Østfold. Photo: Rahand Bazaz / news They get referrals from all over Norway. In April 2022, they had to stop taking in new patients, because they had no room for more. Now they have reopened, and patients are pouring in. – Those who receive an offer are welcome to wait six months, but we are currently not allowed to do anything about it. We are sorely lacking in resources to reduce the waiting time. It cannot be done with just a pat on the back, says Clausen. Their experience, after treating between 150 and 200 patients, is that small doses of ketamine have a rapid effect on more than half of all who received the offer. The treatment is very effective, while having few side effects, says Clausen. In this room at DPS emergency room Kalnes, which is part of Sykehuset Østfold, patients receive ketamine treatment for 40 minutes. This is the only offer in the public healthcare system in Norway. Photo: Sykehuset Østfold This agrees with the research in the field. Clausen is now encouraging other hospitals to offer this treatment method, in order to reduce waiting lists. – We have good contact with several hospitals and researchers across the country. We have a kind of missionary work going on, to get more people to offer this. Because it is a burden that patients have to travel all the way from Tromsø, when they could get it close to where they live, says Clausen. He also hopes that project funds will be announced this year from the health organisations’ research fund KlinBeforsk to carry out a national project on the use of ketamine against depression and acute suicidality. An undertreated disease In a recent chronicle under the title “Why do patients have to wait for ketamine”, ask among others Ingmar Clausen and Lars Lien, head of the Norwegian Psychiatric Association: “Is it an unconscious discrimination against patients with mental disorders that means that the Norwegian authorities do not approves the use of ketamine for suicidal thoughts and depression?” To news, Lars Lien elaborates, and believes that there is differential treatment among patients in Norway: – If there had been a drug that was so cheap and effective against cancer, I think it would have been approved a long time ago, says Lien. He believes depression is a serious problem in society. And that it is under-processed. – Many do not recover from the treatment we receive today. So we need something when everything else has been tried, he believes. Lars Lien is a psychiatrist and professional adviser for the National Competence Service for concurrent substance abuse and mental illness. He is also the leader of the Norwegian Psychiatric Association. Photo: Thomas B. Eckhoff / The Norwegian Medical Association Must wait a year for the Decision-making forum for new methods, which orders and decides which new medicines are to be introduced in Norway, is not satisfied with the research and the results that already exist. The Institute of Public Health has surveyed what is available, but believes it is too early to carry out a method assessment before 2024. – Since we know that there is a lot of research on the way in the near future, it is reasonable to await the results of this in order to get the best possible basis for decision-making , says special medical adviser Michael Vester. – But why is more research needed, when a lot already exists? – There is still limited research, some of it is out of date, and both the interventions and the target groups vary. It is considerable work to carry out a complete method assessment, says Vester. Both the Directorate of Health and the Norwegian Medicines Agency refer to the Norwegian Institute of Public Health and the Decision Forum’s decision to wait. Medicines without a patent Usually in discussions about whether medicines should be used, it is the supplier, i.e. the one who has the patent, who has the obligation to provide documentation. – But when a medicine has gone off patent, the industry has less incentive to research alternative areas of use, says senior physician at the Norwegian Medicines Agency, Sigurd Hortemo. When using “old” medicines in new ways, other professional environments (for example the Institute of Public Health) often have to collect the necessary documentation and show that the priority criteria are met and patient safety is safeguarded. Source: Decision-making forum for new methods and the Norwegian Medicines Agency Cheap and effective Lars Lien of the Norwegian Psychiatric Association describes the feedback from the Decision-making Forum as untimely. – If you read the latest research, it shows that this has a good effect. I find it difficult to say that we have to wait even longer, says Lien. He believes we already know that ketamine is safe to use in treatment, because it is used in larger doses in anaesthesia. – The risk of addiction is small, and it costs little to carry out a treatment. I would have understood if it cost NOK 100,000 per dose, but this is cheap, and has a good effect for many, says Lien. The nasal spray esketamine Ketamine in the form of a nasal spray, esketamine, is approved by the Norwegian Medicines Agency for use against treatment-resistant depression in adults. But this has been rejected several times by Beslutningsforum, partly because the price is too high and because you cannot adjust the dose. “Marius” hopes more people will get the same opportunity as he has. Back at work “Marius” had had a few suicide attempts behind him before he was allowed to try ketamine. It has worked so well that he can now concentrate on working on getting rid of anxiety, which he also struggles with. Because even though UNN in Tromsø stopped his treatment, he was referred to the hospital in Østfold for further follow-up. He has had few side effects, just a little dizziness just when he wakes up after the treatment, and a little nausea. He is happy that he has received this treatment in public. He had not had the finances to make use of the private market to recover. And he believes ketamine has been vital. – I have periodically struggled with suicidal thoughts, and have a few attempts behind me. The situation today is different, he says. – I have just been in contact with NAV, and would like to try my hand at work during this year. It is not only good for me as a person, but also for society. It is socially beneficial, says “Marius”. Need someone to talk to? If you need someone to talk to, you can use one of these low-threshold services: Church SOS: Call 22 40 00 40, or write to soschat.no or meldinger.kirkens-sos.no The Red Cross’s service Cross on the neck is for you under 18 years. Telephone: 800 333 21. Write or chat on the website korspaahalsen.rodekors.no Mental Health Helpline: Call 116 123 or write to sidetmedord.no Parental support: Call 116 123 (key 2) Student telephone: Call 116 123 (key 3) Mental Health Youth . Aimed at young adults aged 18-36. Online chat service Monday to Friday from 18.00-21.00: www.mhu.no. The emergency telephone for children and young people. A free phone for children and young people who are exposed to violence, abuse and neglect. Telephone 116 111. Acute risk of suicide? Call 113 when it is urgent and your life is at stake. Call the emergency room on tel. 116117 for immediate assistance. You can also talk to your GP.
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Asking more hospitals to use it – news Troms and Finnmark
