Exploring patients’ and carers’ views about the clinical use of ketamine to inform policy and practical decisions: mixed-methods study

Abstract

Background Only one-third of patients with major depressive disorder achieve remission. One new and promising treatment, ketamine, may prove challenging to implement because of its abuse potential. Although clinicians' views have been sought, we need patients' views before large scale roll-out is considered. Aims To explore patients’ and carers' views to inform policy and practical decisions about the clinical use of ketamine. Method We carried out a mixed-methods study using data from 44 participants in 21 focus groups in three sessions and an online survey with patients, carers and advocates during a consultation day. Focus groups explored participant's views about ketamine as a form of treatment and the best way for ketamine to be prescribed and monitored. The qualitative data were analysed by two patient–researchers using an exploratory framework analysis and was supplemented by a survey. Results The ten themes generated were monitoring, information, effect on daily life, side-effects, recreational use, effectiveness, appropriate support, cost, stigma and therapy. Participants wanted better evidence on the safety of ketamine after long-term use and felt that monitoring was required. Collecting this information would provide evidence for ketamine's safe use and administration. There were, however, concerns about the misuse of this information. Practical issues of access were important: repeated travelling to clinics and a lack of sufficiently informed medical staff were key barriers. Conclusions Clinicians have some similar and some different views to those of patients, carers and advocates, which need to be considered in any future roll-out of ketamine. Declaration of interest R.M. has had UK National Institute for Health Research grant funding to study ketamine, is participating in trials of esketamine, runs a clinic that provides ketamine treatment, and has consulted for Johnson & Johnson and Eleusis.

Ketamine treatment for depression: qualitative study exploring patient views

“…Participants were asked for details of their history prior to being accepted to attend the focus groups and were remunerated for their time at each focus group, as well as travel expenses. Each focus group lasted between 60 and 90 min and was facilitated by two service-user researchers, using a topic guide based on the results of a public consultation day 15 (Appendix). To ensure a shared understanding, a summary of ketamine treatment for depression was provided (supplementary data, section 1 available at https:// doi.org/10.1192/bjo.2020.165).…”

“…11,12 Despite this, the National Institute for Health and Care Excellence (NICE) recently made a preliminary decision against its recommendation for several reasons including its cost-effectiveness and concerns over stopping the treatment. 13 Positive experiences of ketamine for treating depression have been reported by patients, carers and advocates 14,15 but more information is required prior to its widespread roll-out as it poses challenges that come alongside the benefits. These include the potential for misuse, dependence, tolerance, withdrawal symptoms and physiological side-effects (for example urological/bladder problems), [16][17][18] as well as the potential for illegal diversion to street markets or illegal access if a prescription is refused.…”

Ketamine treatment for individuals with treatment-resistant depression: longitudinal qualitative interview study of patient experiences

“…These suggestions have also been made by patients. 18 Some individuals in our study identified a need for closer monitoring and, with regard to psychological input, one participant thought that it should be provided soon after treatment-related dissociative and psychotomimetic effects have worn off because, in their experience, receptiveness will be optimised at this point because of improved mood and openness to the possibility of change.…”

“…28 A minority of our participants thought that there might be a possibility of dependency on ketamine occurring over time. Dependency has not been identified as an adverse outcome of ketamine treatment, 27 although concerns about misuse potential have been raised, 18,[29][30][31] including risk of illegal procurement. One individual in our study referred to a possibility of purchasing street ketamine to self-medicate because it was cheaper and more locally accessible than therapeutic ketamine treatment.…”

“…16,17 Concerns have also been expressed about the impact on patients where the treatment fails, an initial impact reverses or when patients have to cease therapy because of insufficient funds to cover the cost. 18…”