Very valid points. But keep in mind that ketamine therapy is generally considered a treatment of last resort, for refractory depression, often after even treatments like ECT have failed.
Here's the thing, the SSRI didn't work out for me, now I'm going to try another medication, another 6 weeks before it's fully effective (It's not an SSRI though). I don't know if I can wait that long.
I still haven't gotten to other tiers of treatment in terms of medication - Antipsychotics, rMAOIs, etc.
Point is: I'm not sure a tiered approach for medication works well for everyone with depression, it's too time sensitive.
First line treatments like sertraline and fluoxetine are used because they take time to work and have generally tolerable side-effect profiles. E.g. in the case of patients with undiagnosed bipolar disorder, you run a lower risk of triggering a manic episode.
If the doctor didn't listen to, or at all believe at least half the the stuff the patient actually said, and didn't need to.
If others had leg amputation performed and the leg grew back and on top of it we had evidence that leg amputation caused long-term damage when performed for other reasons. (Ketamine has long been used as an anesthetic precisely because the data we have suggests no long term damage from that dosage.)
If the patient had suicidal ideation and intent, because something hurt so much and we had no way of doing anything other than leg amputation, then why shouldn't we?
Until humanity manages to develop and deploy brain scanners that can actually see how much physical and emotional pain a person is actually in, then the leg amputation analogy is lazy and unhelpful because we simply don't have the same tools to address mental health because it's largely invisible.
Most doctors are still humans who negatively judge patients who drink heavily, who frequently miss appointments, who can't manage to get lab work done, who self-medicate with street drugs; those patients are judged as degenerates, not deserving of their help because they can't manage to take a pill, that doesn't seem to work for 6-8 weeks.
I mean, it's great that a hospital's ethic's board has reviewed the situation and determined that the best course of action is for people to suffer because they don't want the liability of, in this analogy, leg amputation, but in the meanwhile, people are being discarded by the mental health profession.
Traditional drugs are often a crapshoot anyway, and there's been plenty of harm from them. In the end, it should be the patient's choice in what path to take.
And, in the end, it is the patient's choice, within a certain circumscribed set of options. A good doctor works with the patient's needs. But it would be a very poor doctor that jumped to riskier options and less proven options first. The level of patient choice you're suggesting implies a level of informed patient that is frequently not the case. I rigorously research every single treatment option, discuss each one with my doctor, and we arrive at a course of treatment. But my doctor has indicated that I am, unfortunately, in the small minority in this respect. Your level of patient choice would invite all sorts of bad prescriptions to patients ill informed and, often, self diagnosed incorrectly-- a frequent issue leading patients to skew their conversations with doctors towards that incorrect diagnosis. In theory, in a perfect world, what you propose is fine. But we don't live in that place.
Secondly, it's ridiculous to suggest we're underprescribing antidepressants. Completely the opposite. Mental health disorders require complex treatments involving therapy and lifestyle changes as well as medicines, but doctors will completely ignore that in favour of just writing a prescription after a 5-minute conversation. I say this with a lot of experience of mental health treatment: doctors hand out antidepressants far too easily.
> Dr. Michael Grunebaum, a Columbia psychiatrist who studies ketamine, thinks the drug should no longer be relegated to a last-line treatment.
Maybe I’m just being cynical, but if the standard treatments were effective perhaps we mental illness wouldn’t be so prevalent.
Of course, it’s complex and multifactorial, and there’s societal and cultural issues, and generational issues, we need to address too.
It's a safe drug with a low incidence of serious side effects that could help a lot of patients. Researchers have shifted much of the research to Ketamine metabolites.
Their reasoning is that these metabolites have a lower side effect profile than the parent compound. It has been almost 20 years of small scale ketamine trials for depression with not much to show for it. Now, they would like to explore a diversion that may be less safe than a drug with a long history of safety.
I think there are a few reasons for this: 1) Depression isn't seen as a serious disease like cancer and 2) Ketamine is a cheap drug.
SSRI are hugely problemmatical because they take time to ramp up and flush down. Mental health sometimes needs a course correct not a long-term hand on the tiller.
MDMA and psylocibin likewise: brief, sharp reset goal.
(That's what I read)