This is Part 1 of a Series. You can find parts 2, 3, and 4 here.
Name an antidepressant, I’ve probably been on it. Once upon a time, I felt uncomfortable with the idea of a pill altering my brain chemistry. Then I turned twelve and got over it. Anything to feel better. I have been continuously medicated for depression for 21 years now. Of all the medications I’ve tried, ketamine has worked the best, and the fastest.
Prescribing ketamine for depression is currently legal, but with the exception of a nasal spray, it hasn’t received full FDA approval, so it’s not federally regulated. When administered as an IV, intramuscular shot, or oral lozenge, it’s considered an off-label use.
Matthew Perry’s recent death due to “acute effects of ketamine” speaks to some of the dangers of this lack of regulation. Perry was undergoing infusions for depression, but the ketamine in his system was 10-15 times the therapeutic amount. It was a dose equivalent to what’s used for general anesthesia. And then he got in a hot tub.
In the wake of the Matthew Perry news, tons of “what is ketamine?” explainers have cropped up in various news outlets, and they can provide a more comprehensive intro, but basically: it’s been approved and used as an anesthetic for animals and humans since 1970. When given at a much lower dose than what’s used for anesthesia, it can relieve serious depression – even suicidal ideation – within a few hours. It’s also used by recreational drug users for its dissociative effects.
Perry’s death should encourage conversations about the risks of ketamine treatment for people with a history of addiction, but it shouldn’t scare off people who could benefit from it.
I wish more people struggling with depression had access to ketamine. I think it is, in many ways, a wonder drug. But the lack of regulation limits its availability and increases the expense and the risks. Not all doctors administering and prescribing it are doing so responsibly – and though the FDA issued a warning about compounded ketamine in October, many online providers continue to prescribe it for unsupervised, at-home use. It’s unclear where Perry acquired the ketamine that killed him, but I know from personal experience that he wouldn’t have needed to resort to the black market.
I have been receiving ketamine for depression for the past five months – first with a psychiatrist in LA and then at a New York clinic. When I saw the headlines about Perry, my first thought was I wonder if he saw the same LA doctor as I did.
Before Perry’s death, I had classified my experiences with the first doctor as good material. I didn’t know what I’d make of it yet, but I’d recorded details and lines of dialogue in my journals and took short videos for myself in the immediate aftermath, when I felt too high to type. As in many other moments when I’ve felt a combination of discomfort, lack of agency, and disbelief of the is this really happening? variety, I absorbed it as narrative material in order to claim agency over it.
I intended to make it a funny story. Darkly comedic, absurdist in moments. But Perry’s death has prompted me to zoom out and consider the broader implications. If I were someone with a history of substance abuse issues – like Matthew Perry, for example – it is alarmingly easy to see how my story might have taken a darker turn.
I’m writing this now because when I went searching for information about ketamine for depression – in particular, for firsthand accounts – I couldn’t find much. I’ve learned through experience what the range of treatment providers is like, how important it is to find a good one, and what red flags to look out for. I don’t want Matthew Perry’s death to scare off people who might benefit from it, but I do want to arm others with information I wish I’d had going in.
(Also— forgive me, but I am a writer—it’s quite a story.)
My depression
Garden variety, nothing unique or spectacular. It feels like moving through the world encased in cling wrap, a film that sometimes slackens enough for comfort but never quite disappears. At times, it has stretched so loose that I feel free, but then, inevitably and inconveniently, there comes a choking tug, a gasping feeling so familiar that it’s easy to mistake it for fate.
The most salient quality is isolation. It is feeling both unreached and unreachable. That’s one of depression’s worst tricks, given its prevalence and the antidepressant power of human connection and a sense of community.
Over the years, I’ve shed a lot of my shame and secrecy surrounding my mental health. I attribute this to a number of things: to changing cultural norms around therapy and medication, to opening up about it with friends, to writing about mental health in my fiction. Still, I feel a lurking concern about laying too much of myself bare on the page here, even though I know how common these feelings are – even though that’s why I feel compelled to write about it in the first place.
I want to say that I’m describing something I struggled with in the past but have triumphed over now. You can come closer, it won’t rub off on you. I’m not a mess. I’m not just fine, I’m great! In that impulse lives a fear of judgment, a lingering suspicion that depression is best spoken about once transcended if you don’t want to risk revealing yourself as broken and unlovable.
The truth is, I am fine, mostly. My depression has been milder, more fully managed, in my thirties than in my twenties than in my teens. I have worked hard on my mental health – harder than on anything else in my life. It has been over twenty years of work. Sometimes, though, the cling wrap pulls taut and I find myself in an airless space more frightening for its familiarity. I do all the things I know to do: I exercise, I journal, I talk to my therapist, I make plans with friends – and still I feel stuck.
It was in one such period that I turned to ketamine.
Let’s call him Dr. K.
When he gave me a ride home from my third ketamine session in his blue Thunderbird convertible with the busted mirror, he encouraged me to call him by his nickname, but that came later, and I also never took him up on it, so let’s go with Dr. K.
He came as a referral from my mother’s psychiatrist, who I’ll call Dr. S. In a setup that was never fully explained to me, Dr. K sometimes practices out of Dr. S’s office, and the two doctors share an assistant. Dr. K has an MD from a good medical school and an affiliation with a university hospital.
I was in LA visiting my family when my mom met Dr. K and scheduled treatment with him. She said he seemed legit, offered me his contact info. After getting the thumbs up from my longtime psychiatrist, I made an appointment.
I’d read a bit about ketamine as an experimental depression treatment and had received targeted Instagram ads from telehealth startups offering ketamine through the mail. It struck me as equal parts intriguing and terrifying. My experience with psychedelics was limited. I took acid once, in my mid-twenties. It was…fine, I guess. I looked at my reflection in the bathroom mirror and thought, with sudden clarity: I understand cubist portraiture! It was an experience I never felt compelled to repeat.
Dr. K arrived for my consultation 50 minutes late with his shirt misbuttoned. Not ideal, but I assumed the rules were different with non-traditional treatments. I felt a little transgressive. Like I was trying to get away with something of dubious legality. Like I was trying to…well, to do drugs.
Dr. K brought me into Dr. S’s office, which was decorated with dark wood bookshelves, a couch and leather armchair, and an alarming amount of cat décor. Stuffed cats of varying degrees of verisimilitude peeked out throughout the room, on bookshelves, under tables, one lounging on top of a glass case enclosing a geisha figurine.
“It’s stupid how well it works,” Dr. K said. He told me a single dose of ketamine can eliminate suicidal ideation, that some hospital emergency rooms have started giving it to suicidal patients because it works right away. It creates a sense of hope that quickly.
I asked if he’d been administering ketamine for a long time.
“I count by how many needles I’ve ordered,” he said, “I get them from Amazon in boxes of 100, and I’ve ordered 18 boxes.”
Maybe it was fine to get needles from Amazon. What, like he had to get his medical supplies from a medical supplier for this to be kosher? He was a doctor, right? So it shouldn’t matter where the needles came from. And yeah, ok, it was weird that he’d answered this way, instead of saying, I’ve been doing it for X years. But regardless: 1800 injections was a lot. I asked about side effects. None, he said. Stupid how effective it is.
A full course of treatment was six sessions, usually spread out over a two week period, to be followed with periodic booster sessions; the effects wane over time.
He called prescriptions in to a local compounding pharmacy. I felt odd showing up and saying I was there for ketamine, but the pharmacist acted like it was as prosaic as Prozac. She handed me a paper bag containing a glass vial and a package of lozenges.
I went back to my mom’s house and looked for information online about therapeutic ketamine, in particular what to expect from the trip itself. The most I could find were threads on Reddit from people who’d had transcendent experiences and visions – ego dissolution, sudden insights and broadened perspectives, stories that sounded similar to what I’ve heard people say about ayahuasca, minus the vomit.
But the way ketamine alleviates depression isn’t through the trip itself – although it’s easy to see how broadening of perspective and euphoric aha moments would help a depressed person. Ketamine works on the brain regardless of what you feel during the trip, though there is no way to take a clinically effective amount without the side effect of a psychedelic trip.
It works by…actually I can’t remember, I should look this up. To be fair, I don’t know exactly how SSRIs work either.
Ok: it’s not just me, apparently – according to Harvard, “it’s not entirely clear how ketamine works.” It probably targets receptors that increase the amount of a certain neurotransmitter that then activates connections in another receptor, and together that leads to the release of new molecules that help create new neural pathways, and this process likely affects thought patterns and cognition.
*
I turned my bag of ketamine over to Dr. K, and he ushered me into a narrow blue room next to Dr. S’s office that contained just a couch and two filing cabinets. A framed photograph of a street sign reading DREAM was propped on the floor against a wall. Out the windows, silhouettes of palm trees, stark against the sunsetting sky. The couch was covered with a bedsheet.
Dr. K pulled down the blinds and handed me two lozenges. They tasted strangely chemical and took a while to dissolve. I felt my mind slowing down, getting fuzzy. It felt sort of like nitrous oxide at the dentist. Dr. K kept chatting with me like all was normal. He mentioned a ketamine paper in a scholarly journal he thought I might like to read, given my literary bent. He offered to send it to me. I’m feeling it, I said. I think I’m feeling it. Finally he told me to lie down and close my eyes. He hovered close to me as he guided me in a meditation, encouraging me to imagine myself at the top of a set of beautiful ornate staircase, and when you reach the bottom step, you find yourself on what seems to be a dark empty stage, with a bright spotlight shining down on you, and this spotlight represents something positive and good, your well-being or something, and you can always come back to this…A remote pinch in my arm, sound of gongs and voices chanting in the distance, and I began to dissolve.
It was like being in a kaleidoscope. No, it was like being a kaleidoscope. There was no I. First person dissolved. There were colors and shapes and they changed and changed, and it was flat but not. It was like discovering that the world as I’d thought it to exist was a mere simulation, that there is a grid underlying everything, something separate and sophisticated and beautiful and two-dimensional, and I had a sudden godlike access to it.
Of all the ketamine trips I’ve been on, this one remains the most intense. Maybe because it was the first and I had no frame of reference, though it also may have been a giant dose.
At a certain point, I remembered that there was an I. I remembered that I had a body. I felt capable of opening my eyes, and I did so. My vision was wavy, doubling. I was alone and uncertain not just whether I should move, but whether I was capable of movement. The door was closed. I called out hello, then hello again.
Finally I stood, stumbled out to the reception desk area: empty. The waiting room: also empty. The only other door led to Dr. S’s office. I opened it to find an unfamiliar man sitting in the armchair. “I’m on ketamine,” I said, by way of introduction and apology. I was surprised to hear that my voice sounded normal, though the words felt far away. “I’m looking for Dr. K.”
“How long has it been?” Dr. S said.
“I don’t know,” I said. I looked down at my naked wrist, as if a watch might appear. (It had been two and a half hours, I’d later learn - an unusually long time for a ketamine trip.)
Dr. K returned, said he’d been in the bathroom. We went back into the little room; I sat back down on the couch. “I feel high as a kite,” I said.
“You sound very articulate.”
“I can only think of one thing at a time,” I said. He seemed untroubled by this. “It’s not usually like that,” I added.
“Do you deal with intrusive thoughts?”
“I just think of them as thoughts.”
*
The next day, I was completely flattened. So tired I couldn’t get out of bed, more tired than I could ever remember being. A depleted drug hangover kind of tired. (My mom wasn’t nearly as tired after her first session. She also couldn’t remember anything about the trip itself, aside from purple. Different brains, different reactions.)
I returned for my second session trepidatious and still tired. I told Dr. K how hard it hit, asked if that was normal. “After the year you’ve had, I’d be tired, too,” Dr. K said. No, this level of exhaustion was not common, but maybe I had a slow metabolism for ketamine.
I didn’t want to be knocked flat again. I also didn’t want to be left alone in the office. I told Dr. K as much. He brought me into Dr. S’s office this time. I lay down on the sheet-covered couch and accepted a sliver of a lozenge – a major step down from the two lozenges he gave me the first time. Because I wasn’t nearly as out of it this time, I felt the shot in my arm. It hurt more than a regular shot. I stayed awake, altered but not entirely gone. Dr. K chatted with me some. I didn’t feel conversational, but I also didn’t know how to articulate that. Each time I thought of something to say and endeavored to make the words emerge from my mouth, it felt like a major achievement. I couldn’t follow all of what Dr. K was saying to me. He said he’d sent me the journal article he mentioned. “Where did you send it?” I asked. He read out a phone number.
“That’s almost my mom’s cell,” I said. It was one digit off.
He asked for my number. I was cogent enough to think: this is weird. But also, what was I supposed to do about it? I had to focus hard to recite the numbers.
He said he wanted to send me some music. Something called the Mystic Knights of the Oingo Boingo, which I have only just now looked up for the first time. It’s a surrealist musical theater troupe founded by Richard and Danny Elfman. The clip I watched on Youtube features an accordion, an inflatable dragon costume, and a harmonica playing man wearing a rocket ship. I have absolutely no idea why this came up or what it had to do with anything, only that he repeated it enough that I made a note of it later.
The next day, I had less of a hangover. I noticed I was treating myself with more tenderness than usual. A certain internal gentling that allowed me to recognize the unreasonable height of the standards to which I usually hold myself.
Session 3: back in the blue room, a higher dose this time, a trip that felt like being inside Fantasia. Dancing lights, motion conducted by the melody of the music playing. Dr. K came in at the end and crouched on the floor. He said he’d looked me up online, had read my breakup essay. “You weren’t lying about the year you’ve had,” he said.
“Why would I lie?” I said, though what I wanted to say was more along the lines of, “You thought I was lying?” He asked if I was in touch with my ex. He mentioned a woman’s name, a feminist writer, asked if I knew her. I barely knew my own name.
And then he offered me a lift. But he did it stammeringly, with the execution and clarity of a tongue-tied teenager, and at first, I thought he was offering to call me a Lyft – my mom said he had done that for her, after her session. Only after I said yes did I understand that he was offering to be my lift back to my mom’s house, about a mile from the office.
He led me to his blue Thunderbird convertible, one of the only cars left in the building lot. There was a brown fedora on the gear shift, and it smelled strongly of cigarettes. The right rearview mirror was missing. In its place, a small circular mirror was taped in. I noted with curiosity that I was too stoned to feel social anxiety.
“What happened there?” I asked. A question I probably wouldn’t have asked sober.
He repeated the name of the feminist author he’d asked me about earlier. Her husband did that, he said.
I imagined an angry man with a baseball bat. “Why would he do that?” I could think of only one reason, and zero reasons why he would mention it to a patient. “Turn left here.”
“He’s not a very good driver,” Dr. K said. Slowly, he clarified. This man was a friend of his who stayed with him sometimes when he visited LA, and he had borrowed his car.
I reminded myself that Dr. K was a real doctor.
“This is the house,” I said. “Thanks for the ride.”
When I got to my mom’s front door, I was too gone to operate my house keys.
The following day, I noticed more of a difference in my mood. It felt like an inch of air had been injected between the cling wrap and me. Just an inch, but a meaningful inch. Instead of absorbing the running chorus of mental admonitions, I was able to deflect the barbs and replace them with more charitable thoughts. I realized with a shock that though I’d tried positive affirmations for years, until then, the positive words had never pierced my skin. Now: pinpricks. A start.
The fourth session was more colors and shapes, dancing fractals and a bodiless feeling. I woke up alone not just in the room but in the office. I waited fifteen minutes. I texted Dr. K. He didn’t respond. I waited fifteen more minutes. As I waited, I looked around the room and noticed that the top of the filing cabinet by the door was littered with open vials of compounded ketamine liquid and scattered packages of ketamine lozenges. They all had different patient names on them. One of them was mine. There were also a few ketamine prescription labels that had been peeled off bottles and adhered onto the cabinet’s side.
My first, drug-addled thought was: this must be just because he’s in the middle of a session, he must be planning to clean up. That didn’t account for multiple open bottles, or why he’d paste patients’ prescription labels onto the filing cabinet, but it was all I could come up with. It struck me as disorganized. That it was downright dangerous didn’t occur to me until later.
I texted him one more time. Then I slipped the package with my name on it into my bag and left.