Ketamine ‘should be used for treating depression and anxiety’ on the NHS

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Ketamine-based medication should be used to treat people with depression in clinical settings, according to the Royal College of Psychiatrists.

A drug derived from ketamine – a nasal spray known as esketamine – is licensed in the UK for treatment-resistant depression and available in specialist clinics. It is available on the NHS in Scotland but not in England.

The college said it would now “recommend the use of ketamine in specialist settings with appropriate oversight and long-term monitoring arrangements”, but that further research is needed on other psychedelic drugs.

In new guidance, published today, the college pointed out the use of psychedelic and related substances in clinical practice has been recently approved in countries including Australia, Switzerland, Israel and Canada.

However, it added that while early clinical studies of other psychedelics have been “encouraging”, there is “concern around the difficulties in conducting adequately blinded trials, as well as regarding side effects and whether any therapeutic benefits observed are sustained over time”.

“These factors combined with questions regarding validity amongst clinical populations mean the current evidence base is limited, and it is not recommended that they are used in routine clinical practice other than where licensed.”

The college laid out its stance on psychedelic and related substances for medical use, which include pharmacological versions of hallucinogens, ketamine and methylenedioxymethamphetamine (MDMA) in a new position statement.

It said ketamine has been “the most studied in the rapid relief of depressive symptoms with evidence of efficacy including large randomised controlled trials”, and that ketamine has been used in studies involving thousands of patients to explore the effect on depression.

New treatments for depression are ‘vital’

Experts said it is “vital” that new treatments for mental health conditions are developed, but there is a risk of claims around psychedelics “jumping ahead of the evidence” and the “hype” should not be “prioritised above good clinical practice”.

Professor Oliver Howes, chairman of RCPsych’s psychopharmacology committee, said: “New treatments are very rarely developed for mental illnesses and disorders… it’s vital that that trend is reversed.

“We did some work in the last 10 years – on average, we get just one new treatment for mental disorders licensed and available for our patients, and that compares to four times as many in neurology and over 10 times as many in cancer. So there is a real gap there.”

The college said new findings are likely to emerge in the coming years and its position will require updating. The Australian government legislated for MDMA and psilocybin – a naturally occurring psychedelic compound found in certain mushrooms – to be prescribed for clinical use by approved psychiatrists from July 2023. Canada and Israel also have pathways to allow the use of psychedelics compassionately.

Studies are looking at use of LSD to treat substance abuse, anxiety and depression, ketamine-assisted psychotherapy for alcohol dependence, and MDMA-assisted psychotherapy for PTSD.

The college described the international legal status of psychedelic and related substances as “a rapidly changing area” and “it is possible these substances could soon be legalised for clinical use in various jurisdictions”.

Professor Howes said RCPsych supports the use of licensed drugs in a clinical setting, but stressed the college does not recommend people “self-medicate” in “back-street clinics”.

Professor Rupert McShane, a consultant psychiatrist at Oxford Health NHS Trust, welcomed the college’s position.

He added: “Ketamine should be available and used in NHS settings through the ECT [electroconvulsive therapy] teams, using spare capacity … Other psychedelics are years away. Ketamine costs £7 a vial, which will typically treat up to seven people in a session.”

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