Physical Harm From Recreational Drugs Chart

After putting it off for too long, I had another dreaded colonocopy screening done recently. Chugging the salty "prep" is usually the worst part of these procedures, but this time I had a different clean out drink --- it required drinking only two liters (in two divided doses) instead of the usual gallon, and was much more tolerable, in terms of taste and results. 

During my pre-procedure anesthesia conference, I mentioned that I have obstructive sleep apnea (OSA), and so I received a milder than a "total knock out" dose of proponol,  so as not to compromise my breathing -- in the form of a "cocktail" of proponol and ketamine.

The ketamine induced some mild, colorful pattern-like hallucinations, and was very pleasant.  Although a child of the fifties and sixties, I have taken a hallucinogen before, and at a low, monitored dose the visual effects were quite striking, and my overall mood was highly elevated. The "doors of perception" were opened a bit. From earlier reading, I recalled that low doses of ketamine are sometimes used to treat severe depression and suicidal ideation. 

When I researched ketamine online, I found out that it is often used as an animal tranquilizer, and also has long been used and abused as a "recreational drug" by dance and light show ravers and clubbers -- with results somewhat similar to Ectasy. I can understand how ketamine use could become addictive. Apparently, a tolerance to the drug is quickly built up, and the addiction becomes much, much harder to feed. Here are some charts from a Wiki entry on Ecstasy (MDMA) on the comparative risk factors of the various "recreational drugs."

From Wiki:

Comparison of the perceived harm for 20 popular recreational drugs from a poll among medical psychiatrists specialized in addiction treatment. Ecstasy is ranked the 16th most addictive and 12th most harmful of 20 popular recreational drugs.

Enjoyable as it was, I think I'll wait the recommended five years for my next go-around to experience it again. Still and yet, it made for a much more interesting procedure.

Ketamine 'Exciting' Depression Therapy

By James Gallagher, Health and Science reporter, BBC News

Ketamine offers an avenue of research into a field that has struggled to find new treatments for depression.

The illegal party drug ketamine is an "exciting" and "dramatic" new treatment for depression, say doctors who have conducted the first trial in the UK.

Some patients who have faced incurable depression for decades have had symptoms disappear within hours of taking low doses of the drug.

The small trial on 28 people, reported in the Journal of Psychopharmacology, shows the benefits can last months.

Experts said the findings opened up a whole new avenue of research.

Depression is common and affects one-in-10 people at some point in their lives.

Antidepressants, such as prozac, and behavioural therapies help some patients, but a significant proportion remain resistant to any form of treatment.

A team at Oxford Health NHS Foundation Trust gave patients doses of ketamine over 40 minutes on up to six occasions.

Eight showed improvements in reported levels of depression, with four of them improving so much they were no longer classed as depressed.

Some responded within six hours of the first infusion of ketamine.

Lead researcher Dr. Rupert McShane said: "It really is dramatic for some people, it's the sort of thing really that makes it worth doing psychiatry, it's a really wonderful thing to see."

He added: "[The patients] say 'ah this is how I used to think' and the relatives say 'we've got x back'."

Dr McShane said this included patients who had lived with depression for 20 years.

The testing of ketamine has indentified some serious side-effects

The duration of the effect is still a problem.

Some relapse within days, while others have found they benefit for around three months and have since had additional doses of ketamine.

There are also some serious side-effects including one case of the supply of blood to the brain being interrupted.

Doctors say people should not try to self-medicate because of the serious risk to health outside of a hospital setting.

"It is exciting, but it's not about to be a routine treatment as where we need to be going is maintaining the response... it's not about to replace prozac."

However, it does offer a new avenue of research into a field that has struggled to find new treatments for depression.

'Something chemical'

David Taylor, professor of psychopharmacology at the Maudsley Hospital, London, told the BBC: "In these kinds of patients, spontaneous remission almost never happens, people going to these clinics are at the end of the road."

"It shows that depression is something chemical, that it can be reversed with chemicals, it dispenses for once and for all that you can just pull your socks up."

"What restricts it is the potential for disturbing psychological adverse effects and the route by which is given - intravenous - does restrict it to a small number of people."

He said in the future drug companies would develop a chemical that had the benefits, but without the side-effects, and that could be taken by something such as an inhaler.

The Home Office is reclassifying ketamine in the UK to be a class B drug, although it is already used in medicine for the treatment of back pain and as an anaesthetic.

BDNF Theory of Depression



Ketamine is a drug used in human and veterinary medicine, primarily for the induction and maintenance of general anesthesia, usually in combination with a sedative. Other uses include sedation in intensive care, analgesia (particularly in emergency medicine), and treatment of bronchospasm. Ketamine has a wide range of effects in humans, including analgesia, anesthesia, hallucinations, elevated blood pressure, and bronchodilation. Like other drugs of its class such as tiletamine and phencyclidine (PCP), it induces a state referred to as "dissociative anesthesia" and is sometime misused as a recreational drug.


Uncovering the Biology of Depression

by Jonathan Hwang, Yale Scientific, 2011

Professor of Psychiatry and Pharmacology Director at Yale University, Ronald Duman studies depression, a serious issue that affects approximately 17% of the U.S. population and is estimated to cost as much as $83.1 billion for our economy.

There is a general consensus in the scientific community that low levels of monoamine neurotransmitters are a major contributor of depression. From that belief, antidepressants are designed to increase levels of neurotransmitters in the brain. They block reuptake or breakdown of different types of neurotransmitters in order to maintain higher levels in the brain.

A diverse range of antidepressants exists. However, current antidepressants are still ineffective and have low response rates: only 1 in 3 respond to the first antidepressant treatment, and 2 in 3 ever respond after repeated treatments. Beyond knowing that antidepressants block or inhibit particular neurotransmitters, most scientists are still not sure which pathways these antidepressants influence and thus the types of mechanisms that contribute to depression. Duman’s work investigates these unknown pathways.

Neurotrophic Theory of Depression

The bulk of Professor Duman’s research has led to the formulation of the neurotrophic theory of depression, which states that neuronal growth factors contribute to the onset of depression. In 1995, Duman published a landmark paper relating increased brain derived neurotrophic factor (BDNF) levels with antidepressant effects, setting the foundation for the neurotrophic hypothesis of depression.

Since then, subsequent research has clarified the pathways leading to the expression of BDNF. Professor Duman’s research suggests that BDNF is expressed through the cyclic adenosine monophosphate (cAMP) signal transduction pathway, which is regulated by serotonin.

In this pathway, cAMP is first activated, and this leads to activation of cAMP dependent protein kinase, which regulates cAMP response to element-binding protein (CREB). Additionally, Duman found that long-term antidepressants increase levels of CREB mRNA and protein in the hippocampus, further supporting the link between antidepressants and the cAMP pathway. CREB seems to regulate a set of genes in the hippocampus producing antidepressant effects.

Stress reduces the complexity of density of dendrites (top) as compared to normal dendrites (bottom). Image courtesy of Duman.

The Role of BDNF

BDNF is a vital neurotrophic factor in the brain. Previous studies have shown that exposure to BDNF in the hippocampus can lead to increased strength in some synaptic connections. BDNF’s role in neurogenesis was of particular interest. Duman discovered that upregulation of neurogenesis was the result of several antidepressants, suggesting that antidepressants reverse the atrophy of neurons that occur during depression.

Other studies confirming Dr. Duman’s work have found that increasing levels of BDNF in specific areas of the brain, such as the hippocampus, leads to antidepressant effects. The hippocampus has been implicated in mood disorders and its connections to amygdala and the prefrontal cortex are important for the function of cognition and emotion. Additionally, studies by Duman also revealed the converse: loss of BDNF contributes to depression. Stress, a precursor of many mood disorders, also decreases expression of BDNF.

The approaches Professor Duman took to clarify BDNF’s role were varied. One was by using a viral vector to overexpress BDNF, which produced a behavioral phenotype typical of antidepressants. Antidepressant behavior was tested using the forced swim tests and learned helplessness models.

Another approach involved infusing recombinant BDNF into the brain region, which also produced a
similar antidepressant behavioral response. Duman also tested mice with a heterozygous deletion of the allele for BDNF. Although their phenotype appeared normal, they displayed a depressant-like phenotype once exposed to stress. This follows the widely held belief that a combination of environmental and genetic factors contributes to the onset of depression.

The mechanism regulating the expression of BDNF. Image courtesy of Duman.

A Faster and More Efficient Pathway

In August 2010, Duman’s lab discovered a completely new pathway, a major breakthrough for the field of depression. In ketamine, Duman addresses a pressing need in the field for “a more rapid, more efficient drug” to treat depression. In his paper published in Science, Duman lays the foundation for further understanding of this novel pathway.

Ten years ago, ketamine was preliminarily tested at the Connecticut Mental Health Center as an antidepressant in low doses. The subjects were patients who previously resisted all other forms of treatment, but over two thirds responded positively to ketamine. These results were confirmed in later studies. Much more remarkable about ketamine’s use as an antidepressant was how quickly the patients responded; antidepressant effects took place within two hours of treatment and lasted more than seven days.

“The story is in the pathway,” Duman explained. Unlike traditional antidepressants, which are generally neurotransmitter inhibitors, ketamine is a N-methyl-D-aspartic acid (NMDA) receptor antagonist.

It operates on an entirely different pathway from those of traditional neurotransmitters. Studies conducted by graduate student Nick Li demonstrate that ketamine activates the mammalian target of rapamycin (mTor) pathway. mTor is a ubiquitous protein kinase involved in protein synthesis and synaptic plasticity in a process called synaptogenesis.

Synaptogenesis restores the synapse connections in the brain that may deteriorate under stress and depression. The study also found increases in the levels of synapse proteins usually regulated by the mTor pathway. To physically confirm synapse formation, in collaboration with George Aghajanian, Professor of Psychiatry at Yale, two-photon imaging was used to observe increased spine density. Further supporting the link between the mTor pathway and antidepressant effects, Duman blocked the mTor pathway with rapamycin, leading to inhibition of ketamine’s antidepressant effects.

Ketamine is such a “magic drug” because it produces antidepressant effects in people who have resisted most other forms of treatment and its speed of response acts in days rather than weeks.

However, the key disadvantages of directly using ketamine as an antidepressant are its use as a street drug and its toxicity from repeated dosages. Despite these shortcomings, knowing the mechanisms of ketamine’s antidepressant effects will further benefit drug designs for immediate antidepressant effects.

Duman’s lab continues to further investigate factors and pathways for depression. One future direction is to deepen understanding of what stress does on a molecular scale and its link to depression. Other directions include studies to reveal more details about the mechanisms underlying Duman’s neurotrophic theory of depression. Professor Duman’s discoveries today could be the basis of depression treatments tomorrow.

Two-photon microscopy of neurons after treatment with ketamine (bottom) as compared to control (top) shows increased density. Image courtesy of Duman and Aghajanian.

About the Author

Jonathan Hwang is a Chemical Engineering major in Saybrook College.
Acknowledgements

The author would like to thank Professor Ronald Duman for his time and assistance over the course of writing this article.