What does a physician think of ketamine smoking in Netflix’s Russian Doll?
With the second season now dropping three years after the first in 2019, it’s time to take a look at how Netflix’s popular TV show Russian Doll incorporated the idea of using psychedelics and psychotherapy to work through major mental health issues. Of course, the show requires a fair amount of suspended disbelief: the protagonist is caught in a time loop where she must repeat the same night over and over again until it plays out ‘correctly.’
Every episode, and sometimes multiple times per episode, the main character attends her ill-fated 36th birthday party and dies. Dying leads to waking up and repeating the whole sequence with some minor differences as she struggles to grasp the situation and its implications. She tries various strategies to change the events, although with little success.
At first glance, it’s hard to see how the show intersects with ketamine therapy for mood disorders. Still, the cycle of death and rebirth is actually a widespread metaphor for patients working through traumatic memories. Many patients have relayed stories of feeling like they needed to ‘kill off’ their old lives or needed to ‘die’ in order to be ‘reborn’ into a new life. Processing trauma and breaking out of depressive tendencies can feel like a violent experience at times.
Nadia, the show’s protagonist, is shown to unknowingly use ketamine and experiences its hallucinogenic and calming properties which helps her focus and combat the stress and anxiety she feels. In real life, ketamine would need to be prescribed by a licensed doctor and not slipped into your marijuana joint by your best friend’s creepy drug dealer from down the street. Ketamine assisted therapy also utilizes a calculated dose based on your weight which is a much smaller total dose of ketamine that will help calm you but won’t cause you to hallucinate.
Nadia starts the show by smoking a joint from her friend. It’s only supposed to contain marijuana and cocaine, but when she dies and relives the same evening, Nadia suspects more drugs are involved. She tracks down the dealer and learns that the joint was also laced with ketamine. The dealer comments that ketamine is a new drug to help people with depression.
Of course, the drug dealer is only partially correct. Ketamine is not a “new thing.” It was first synthesized in the 1960s and approved by the FDA in 1970 as an anesthetic drug to be used during surgical procedures. In more recent years, scientists have been looking at ketamine to understand how it may be used to help treat PTSD, anxiety, acute suicidality, and depression.
The FDA recently approved esketamine (a form of ketamine) to be used for acute suicidality in patients who are at imminent risk of hurting themselves. Other studies have shown that subdissociative doses of ketamine for all types of mood disorders, PTSD, and even chronic pain are effective. Subdissociative means exactly that. At these doses which are about 1/10 of what is used during surgical procedures, ketamine creates a calming sensation, increases awareness, and allows the patient to focus, but doesn’t cause a mind/body dissociation or hallucinations. 
The dosage for any medication is key and a TV show following a protagonist who is happy to use illegal street drugs won’t spend screen time focusing on such minutiae. Considering that the opening scene shows her smoking a joint from an unknown drug dealer who later admits to secretly lacing it with ketamine, it’s fair to say that no one in the show is overly concerned with medical concerns.
People who abuse ketamine and use it recreationally have often reported that they experience vivid hallucinations, even ones mimicking the cycle of death and rebirth. Though that may sound therapeutic and helpful for people experiencing major depression, there can be many adverse effects of recreational ketamine use, including increased blood pressure, salivation, and psychosis. In addition, Ketamine is illegal to possess and use outside of a doctor’s prescription.
In the show, Nadia smokes Ketamine when it is placed in her marijuana joint. Ketamine can be smoked, snorted, swallowed, or injected. Each way will lead to absorption of the ketamine but the amount will vary greatly so the user often cannot gauge how much ketamine they are getting, leading to potential overdoses. The most studied ways to administer ketamine are intravenous (giving it through an IV), then intranasal and then orally. There is good data for all three methods of administration to guide the amount given to patients. For Nadia, it’s impossible to quantitate the amount she absorbs when she smokes the joint.
Recreational use may also lead to psychological addiction and put the user at risk of overdose. Recreational users are also at risk for using other drugs which may have been mixed in with the ketamine, as Nadia experiences.
Although the show doesn’t focus on Nadia’s usage of ketamine, since she realizes by episode 3 that she isn’t hallucinating at all and she is dying and reliving the same day, it does follow her taking advantage of the situation to come to terms with deep-seated trauma, anxieties, and suicidal tendencies. These are the same issues that many people with major depression describe: feelings of being stuck in a rut and living out the same day repeatedly with no success at escape. By the end of the show, when she realizes that to save herself, she must save another person, Nadia learns the importance of empathy and breaks free from her time loop.
Though the show is a fascinating look at how someone can utilize pseudo-psychedelic experiences to work through her trauma, it is still a work of fiction and not an example to be followed. However, Nadia’s experience of breaking out of her depressive loop is something others can achieve.
By following your doctor’s recommendations and working with ISHA’s certified medical professionals, you don’t have to get stuck in a time loop or die a thousand deaths before reaching a better headspace. Our doctors will walk you through the process of using ketamine safely from the comfort of your home to help you break out of your loop.
Lumanauw DD, Youn S, Horeczko T, Yadav K, Tanen DA. Subdissociative-dose Ketamine Is Effective for Treating Acute Exacerbations of Chronic Pain. Acad Emerg Med. 2019 Sep;26(9):1044-1051. doi: 10.1111/acem.13755. Epub 2019 Apr 29. PMID: 30901130.