What’s ketamine all about? Bhekisisa recently spoke with Bavi Vythilingum, a member of the South African Society of Psychiatrists, who helped write the guidelines for ketamine use to understand more about the drug and how it works. (Wikimedia)
“To be clear, I am NOT taking drugs!” the richest man in the world announced on his social media platform X at the end of May. “The New York Times was lying their ass off.”
Elon Musk — originally from South Africa and until recently the head of the Trump administration’s so-called department of government efficiency, which cut billions of dollars in foreign aid — was responding to a New York Times investigation that reported he was using drugs, particularly the psychedelic-inducing drug ketamine, while he was on the campaign trail with President Donald Trump.
“I tried prescription ketamine a few years ago and said so on X, so this [is] not even news. It helps for getting out of dark mental holes, but I haven’t taken it since then,” he told The New York Times.
Musk also made these remarks two months ago in The Don Lemon Show.
Ketamine has been used for decades as an anaesthetic drug. But in the past few years, more and more psychiatrists have been using it for hard-to-treat depression — and not without reason. Peer-reviewed research, such as this study, which pooled the results of dozens of studies, shows that ketamine, when used in combination with other antidepressants, could help even the most treatment-resistant depression patients to lift their mood.
In South Africa, treatment-resistant depression is mostly regarded as depression in someone for whom at least two antidepressants haven’t worked.
Musk has openly talked about having occasional periods of depression, but not necessarily treatment-resistant depression.
Because ketamine causes temporary “dissociative effects”, patients should only use the drug for the treatment of depression in the presence of a health professional, who either gives it to them, for instance as a drip, or supervises them taking it when it’s taken as a nasal spray. Dissociative effects change someone’s level of consciousness or their perceptions of themselves or environment. Some patients say this feels like being “spaced out” or “dreaming”.
These psychedelic effects, and the fact that ketamine can make people feel happier, are part of the reason why ketamine is also used as a street drug, often known as “Vitamin K” or “Special K”.
Musk told The Don Lemon Show that “he gets a prescription from a real doctor”, but he didn’t confirm whether he takes the medicine in presence of doctors, as it should be, only that he takes “a small amount of ketamine every other week” with “several weeks going buy where I don’t use it”.
In South Africa, ketamine is registered as a schedule five drug with the medicines regulator, the South African Health Products Regulatory Authority, Sahpra. Schedule five drugs can’t be bought over the counter and can only be obtained with a doctor’s prescription. But in the case of ketamine, a patient can also not fetch the medicine directly from a pharmacy, because taking it for treating depression has to be supervised by a health professional.
In 2022, ketamine was approved as a nasal spray for treatment-resistant depression, but psychiatrists told Bhekisisa the spray isn’t available in the country. Some healthcare providers in South Africa are also administering the drug off label as a drip; that’s when doctors use a legally registered medication to treat an illness that it hasn’t been approved for. Off-label use is a common practice for many medicines, but it has to be done responsibly.
In the case of ketamine, the South African Society of Psychiatrists (Sasop) has published guidelines for its use for the treatment of depression. This includes that it’s only used for treatment-resistant depression, and only in drip-form, so not as an intramuscular injection or as a tablet that dissolves under your tongue. Ketamine also has to be given by an anaesthetist or a GP with a diploma in anaesthetics “in an environment where it is possible to monitor the patient and potentially resuscitate”.
But Bhekisisa’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.
Sahpra’s chief executive, Boitumelo Semete-Makokotlela, told Health Beat: “[Although off-label use] is an informed decision, on published clinical evidence, [it’s important to remember] that it means that if anything happens to a patient, they [patients or healthcare providers] then cannot hold the manufacturer responsible when it, in fact, registered the product for a different indication.”
Experts say unregulated use of ketamine 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.
In an autopsy, authorities in Los Angeles found that Friends actor Matthew Perry, who played the character Chandler Bing and wrote about his history of drug dependency, died in 2024 of what authorities called the “acute effects” of ketamine abuse, which was administered intravenously.
Mia Malan recently spoke to psychiatrist Bavi Vythilingum, a member of the South African Society of Psychiatrists, who helped write the guidelines for ketamine use in South Africa, in Bhekisisa’s May episode of Health Beat. The interview was edited for clarity.
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 to 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 to 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.
This interview appeared in a recent episode of Bhekisisa’s monthly TV programme, Health Beat.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.