MAID-Accessing Depression - and Potential Alternatives

"To our knowledge, this is the first report of ketamine or any other intervention yielding remission in a patient who would have otherwise likely been eligible for MAID [Medical Assistance in Dying/Euthanasia] for depression."

"Accordingly, it is essential for clinics to have up-to-date and reliable evidence about all potential treatments."

"A lot has improved. There's ups and downs. She [patient] had a lot of challenging life events. [She is not cured, not necessarily] thriving [but her MAID request remains withdrawn]."

"In our hands, we're never really sure how much is biological and how much is psychological about the experience. We think there's a lot of both."

"At the least, before taking an irreversible step like MAID, a trial of ketamine warrants consideration."

Dr. Kyle Greenway, psychiatrist, McGill University / Jewish General Hospital, Montreal

"We don't know how psychedelics, and especially very transformative, deep spiritual experiences even, can shift people's attitudes toward death and toward MAID itself."

"How might we respond to someone who says, 'I do feel a deeper interconnection with the world, a deeper sense of well-being."

"I'm at peace where I'm at, and I would actually like to pursue MAID now."

"That's entirely possible as well."

"[It's] wonderful and important [that people are able to have their suffering alleviated]."

"[Caution is required] so that we're not fuelling additional hype around some of these psychedelic medicines as an easy way, or a magic bullet to reverse MAID decisions."

Daniel Buchman, bioethicist, independent scientist, Centre for Addiction and Mental Health, Toronto

 

In a single case of a suicidal woman who had tried psychiatric drugs, electrical pulses to the brain, shock therapy, none of which provided her any relief from her severe depression, which led her to apply for medically assisted death, her life suddenly turned around when her doctors gave her ketamine. Her depression in the space of under two weeks "rapidly and robustly remitted".

 

This single success has led researchers to be concerned that ketamine may be "easily overlooked" by people considering MAID for major depression, along with their doctors, when medical assistance in dying becomes an available option for people suffering acutely from depression. This case study illustrates the potential for "grave and irreversible consequences" of prematurely declaring an individual's depression to be irremediable; incurable.

There are responses of the study on the careful side cautioning that psychedelic-assisted psychotherapy may not be an automatic lifeline for those seeking assisted death, since requests could conceivably be in either direction, with some people becoming more at peace with such a decision. At the present time, Canadians whose underlying illness is a mental disorder are not eligible for assisted death. 

However, the federal government introduced a bill delaying MAID eligibility for people with mental illness until March 17, 2024, an extension from the original timeline to allow psychiatrists additional time to prepare for the change, in response to outcries of consternation that assisted death be available to people suffering ill mental health. Even as it would be critical in granting euthanasia that "incurability" be established.

Ketamine, available since the 1960s, is one of the most commonly used anesthetics in medical use worldwide, for surgery and for rapid pain relief in emergency procedures such as replacing a dislocated shoulder. It is also a risky and illegal club drug "for those looking to feel a little lighter and a little loopier on the dance floor". Across the United States, ketamine clinics are opening -- with more than a dozen operating privately in Canada.

The charge is about $1,000 per treatment. Dr. Greenway's team is able to treat only a few patients weekly. In 2000, scientists for the first time began testing ketamine as an antidepressant. One very small trial with seven subjects suffering major depression found a significant improvement in symptoms reported by people, within 72 hours of a ketamine infusion. Following that, a review of evidence from 83 publications found depression symptoms can be reduced within one to four hours after a single treatment, lasting up to two weeks.

A Canadian and American research team raised serious safety concerns recently on the effects of repeatedly inducing an altered mental state.  Dr. Greenway, operating out of a ketamine clinic at the Jewish General Hospital, is cautious. The findings are that altered consciousness has a range from a fleeting, pleasant euphoria to "significant psychosis". When used as an anesthetic "people feel a little bit strange, and they might see the room a little bit distorted". 

People experience vivid and "pretty pronounced" hallucinations within ten to 20 minutes when injected in lower doses, part of ketamine-assisted psychotherapy, noted Dr. Greenway. People report variously feeling like they're dissolving, or melting into the universe, as a mystical experience. "Sometimes very emotional stuff comes up. It's very psychedelic that way", explained Dr. Greenway. After about 90 minutes there is a return to normal.

It is unknown how ketamine eases depression and suicidal thinking. There are studies that suggest ketamine promotes the growth of neurons and connections between neurons. People are encouraged by Dr. Greenway to use the "momentum" from immediate effects of ketamine to make life changes and take to psychotherapy -- "stuff that will help keep people well without necessarily needing repeated or weekly doses for the rest of their lives."

Ketamine is inexpensive, about three dollars each dose, requiring an infusion pump, a quiet room, a nurse and a therapist. And not everyone responds; about ten percent of those receiving ketamine for depression remit robustly, though some evidence exists suggesting the greater the treatment-resistance, the greater the odds of ketamine helping to avoid MAID  requests.

All drugs have side effects. When someone is suicidal or severely depressed, possible benefits may outweigh possible risks.

Ketamine given by infusion may cause:

• high blood pressure
• nausea and vomiting
• perceptual disturbances (time appearing to speed up or slow down; colors, textures, and noises that seem especially stimulating; blurry vision)
• dissociation (sometimes called out-of-body experiences); rarely, a person may feel as if they are looking down on their body, for example.

Generally, any changes in perception or dissociation are most noticeable during the first infusion and end very quickly afterward.

Harvard Health