Ketamine, which has been used for decades as an anaesthetic, can be legally prescribed in South Africa under certain guidelines but the novelty of its treatment as a fast acting counter to depression has made it popular as a recreational drug as well.  

There are three SAHPRA registered ketamine products available as Schedule 5 medicines and the regulator says it is aware that ketamine treatments are becoming more available in South Africa and the market is largely unregulated.

The Bhekisisa Centre for Health Journalism says ketamine treatment has caught on in South Africa for the treatment of depression, but is also being widely misused in that as a cure for other conditions as well. It says not only is this a problem within the health care industry, but in society at large where it has gained notoriety as the recreational drug of choice on the celebrity party scene.

The Centre’s Mia Miller says the ketamine craze appears to have hit South Africa and the organization’s TV programme, Health Beat, found many “cowboy clinics” where unqualified workers give ketamine to people with depression and for conditions, such as attention deficit and hyperactivity disorder, for which there isn’t credible evidence that it works. 

In South Africa, ketamine drip infusions, which are popular internationally, haven’t been approved yet by SAHPRA , but doctors can prescribe and treat ketamine for two conditions:

-      As an anaesthetic compound to be used with other products;

-      For treatment-resistant depression,

It’s the treatment-resistent depression angle that has taken off. Specialists warn that ketamine therapy requires expert training and monitoring and that its unregulated use is not only risky, it can be deadly, because if someone takes too much of it, it can raise their blood pressure, make it hard to breathe and, among other things, cause seizures. 

Sahpra CEO Dr Boitumelo Semete-Makokotlela told Health Beat: “There is increasing use of ketamine for the treatment of depression and I anticipate that we will start to see more applications coming to us for treatment.”

Mia Malan recently spoke to psychiatrist Bavi Vythilingum, a member of the South African Society of Psychiatrists (Sasop), who helped write the guidelines for ketamine use in South Africa,

Mia Malan (MM): Why are psychiatrists talking about ketamine right now?

Bavi Vythilingum (BV): It’s probably the first completely novel antidepressant that we’ve had for a long time. So with antidepressants, it usually takes about, say, two to three weeks for it to work. With ketamine, you can get a response within two to three days, and sometimes, as we give the infusion, patients feel better.

MM: Why does it work so fast? 

BV: We’re not 100% sure, but we think that it’s because it’s working on the glutamate receptor and causes very big neurodevelopmental changes very rapidly, and that’s what gives you that rapid onset of action. 

MM: What is a glutamate receptor? 

BV: Glutamate is a brain neurotransmitter like serotonin and noradrenaline. Glutamate is situated throughout the brain and ketamine works on that receptor. 

MM: So it’s something that helps you feel good? 

BV: If you’re taking ketamine, for example, for drug use, it would produce an altered state of consciousness, which can make you feel good, but can also be unpleasant. But certainly, for depression, it seems to work for a lot of people. 

MM: So who gets ketamine? Is it people who need to be helped immediately, and then you wean them off it? Or how does it work? 

BV: So there are two groups of people who would get ketamine. People who are extremely depressed, extremely suicidal and a danger to themselves, where we need a very rapid onset of action. And the second group of people are what we call treatment resistant, where they have failed what we call an adequate trial. So that’s a trial at a high enough dose for a long enough period of time of two standard antidepressants.

MM: And if you then put such a patient on ketamine, explain to us what happens. 

BV: Most people who have ketamine will have what we call a non-ordinary state of consciousness where they may feel they are not in their body, which is what we call dissociation. They may experience reality in different ways. They may see complex shapes and colours. They may feel sounds as being colours. It can be a beautiful experience, but it can also be an anxiety-provoking experience. 

MM: And for how long would that last?

BV: For as long as we give the infusion. So usually about 40 minutes. Then they go home and they come back after two to three days for a total of about six infusions. 

MM: And what happens after that? 

BV: There’s no internationally recognised standard of maintenance. We’re still trying to understand how we should do it. But there are definitely some people who get very well on ketamine and don’t get well on other stuff. And for them, we need to top up. So initially we would top up every week to two weeks, for about four weeks, and then reassess. There are some people who need monthly ketamine, but we do that with caution, and we do a constant reassessment of a patient to see if we still need to give it. 

MM: What about addiction? 

BV: We have to assess somebody very carefully for previous substance use and current substance use. So if somebody is an active substance user, even if they’re not using ketamine — say they’re an alcoholic — you’d be very cautious about giving ketamine. 

MM: Who can give ketamine? We have heard of many clinics that give it where it’s not psychiatrists giving it, where a GP gives infusions. Is that legal? 

BV: It is technically not illegal, because any doctor can give any medication. That’s a Health Professions Council of South Africa regulation. But you have to be within the scope of your practice, which means you have to be able to prescribe and you have to be able to manage the [possible drug] complications.

Sasop’s position is that only psychiatrists can prescribe ketamine because it is for either emergencies or treatment-resistance situations. But we follow the principles of the South African Society of Anaesthesiologists, in that people must have an anaesthetic qualification. So I, as a psychiatrist, will prescribe, but I don’t give ketamine. My anaesthetic colleagues are the people who give the ketamine.

MM: What does ketamine treatment cost? And do medical aids pay for it? 

BV: You’re looking at about R2,400-R2,500 per infusion. The big cost of that is around personnel because you need an anaesthetically trained doctor and a nurse. 

MM: Do medical aids pay? 

BV: Medical aids are starting to pay. So your top-tier medical aids will pay for ketamine upon motivation, but the medical aids are reluctant to pay. And a big cause of the reluctance is all these so-called cowboy ketamine clinics. The medical aids are saying, quite rightly, that they don’t know if ketamine is going to be given safely.

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