Dangerous ketamine clinics

The clinics we need to worry about aren’t necessarily dirty back-room operations. They have nice-looking websites, use all the right buzzwords, and offer convenient services in comfortable offices at reasonable prices.

Consider the following quotes from a website advertising a new clinic:

The (clinic name) offers exciting and cutting-edge IV infusions for the treatment of Depression, Bipolar Disorder…. administered by .…a highly experienced ….anesthesia provider that holds a national board certification in anesthesia by the NBCRNA.

Currently we do not require a referral for most cases of unipolar or non-rapid cycling bipolar depression…..We are Now Accepting Appointments. We welcome same day appointments, call us today to schedule…. Introducing our NEW Membership pricing option. Buy a membership for $(price) per month and receive discounted infusions…. If you are currently suffering from suicidal thoughts, please contact your local crisis center or call 911.

When the provider from this clinic advertised their services on a ketamine-related message board, I replied with the following question:

Please explain how a clinic can claim to ‘treat’ psychiatric disorders without requiring that their patients be properly diagnosed and monitored by a qualified mental health professional. I mean, if your patients are self-medicating a condition they self-diagnosed, how is that different from recreational drug use? And if your patients really have serious psychiatric disorders, wouldn’t they actually need mental health services, and not just whatever you’re offering?

I’m not saying this just to be obnoxious — I would really like to understand the logic behind a clinic like this. And I’d also like you to understand my serious reservations about it as a patient who is doing well receiving ketamine for severe, treatment-resistant depression.

I want the treatment that saved my life, and the lives of so many others, to be given safely and taken seriously. I don’t want psychiatrists to continue to refuse to work with patients who are benefiting from this treatment. I want the treatment to someday be covered by insurance, and I want people to stop acting as if patients like us are just taking stupid risks to get high. For these reasons I am concerned that clinics like yours are hurting people like us.

The provider quickly answered:

We understand your concern….Here, we do not diagnose mental illnesses and we make that very clear to all of our patients. We require that every mental health patient is diagnosed by and remains under the care of a mental health professional. In fact, we mandate that they provide us with the name, address and phone number of their mental health provider.

…we aim to offer an ancillary ketamine infusion service that most mental health providers support but are not willing to provide themselves. We are able to confidently administer a GENERAL ANESTHETIC in any setting and we are trained to manage any and all possible serious life threatening complications including acute tachycardia, severe hypertension, cardiac dysrhythmias and loss of patient airway… 

I answered:

I completely understand that mental health professionals rarely administer ketamine themselves (for good reasons) and think it is great that specialists are stepping up to provide ketamine to psychiatric patients on a consultant basis.

But given that this treatment is for patients at high risk for suicide, psychosis, mania, and other dangerous/severe symptoms, I do have an issue with advertising same-day service with no referrals required, even if you do ask for an address/phone number. There is a difference:

– A referral indicates that a mental health professional who has thoroughly evaluated the patient agrees that ketamine is appropriate for their diagnosis and treatment history, knows the patient will be receiving ketamine, and is on board to monitor the patient’s mental health and coordinate their care throughout this process.

– An address and phone number indicates that the patient has a mental health professional’s address and phone number.

The provider replied:

Thank you for your response. I would like to respond to your comments above which are based on assumptions and not on our current policies or procedures. Let me clarify, at (clinic name) we only treat uncomplicated unipolar and depressive phase of bipolar disorders without referral. We do NOT treat patients that are actively suicidal nor do we treat any patients without referral if we feel we may be putting them at risk of further mental health complications. We perform mania, psychosis and suicidal ideation screenings on all patients prior to Ketamine therapy. These type of screenings do not require mental health certifications or degrees to conduct. Patient safety is our priority and we are extremely confident that our current policies and procedures that are in place ensure the safety and continuity of care for all of our patients.

I was speechless. But here’s what goes unsaid:

No, I’ve thoroughly read your website and what you’ve said right here about your policies and procedures.  My concerns aren’t just “based on assumptions.”

 You said: “Currently we do not require a referral for most cases of unipolar or non-rapid cycling bipolar depression,” which implies that you consider “most cases” of unipolar or bipolar depression to be “uncomplicated.” But patients with these disorders ARE at high risk for mental health complications by definition. Just because someone denies manic, psychotic and suicidal symptoms before their infusion doesn’t mean they won’t encounter these or other serious mental health symptoms before or after they leave your office. And why would someone with truly “uncomplicated” depression require an experimental treatment like ketamine infusions anyway?

That you are “extremely confident” making complex clinical decisions based on a few screening questions shows a profound lack of judgment. Mental health screening questions are just tools, and how much training is required to use them depends on what you’re using them for.  People don’t need specialized training to use a knife as a tool for spreading butter, but they sure better have that training if they want to use that tool to perform brain surgery! While you say you will not treat patients if you “feel” you may be putting them at risk, you are making this decision with neither the necessary patient assessment data nor the necessary expertise to able to use your feelings as a gauge of mental health risk.

A clinic like this is a tragedy waiting to happen.

Afraid that I may lose access to treatment

The psychiatrist who oversees my care, prescribes my medications, and referred me for ketamine treatment, is closing her practice. Finding a replacement, however, is proving to be extremely difficult.

Most clinics and doctors that I can get to from the rural area where I live have a waiting list of months to years, or have stopped taking new patients all together. Worse, even when a clinic or a doctor in private practice is willing to schedule an initial appointment, they refuse to work with me once they find out that I am going for monthly ketamine infusions. So far:

a) Many just said they won’t provide me services  — without offering me any explanations, alternatives, or resources in case my treatment needs were urgent. Both irresponsible and cruel, individuals responding this way to someone who is trying to access treatment by a psychiatrist should not be working in the mental health field.

b) Others have apologetically said that they don’t feel that they have enough knowledge/experience with ketamine treatment to effectively work with me. It really is time that these psychiatrists start learning about the treatment and rethinking whether refusal to work with ketamine patients is really in the best interest of these patients as they seem to assume. After all, what level of expertise with ketamine are they thinking they need to have? These doctors probably already have plenty of patients receiving chemotherapy and other specialized medical treatments — and though they aren’t experts in the specifics of those treatments, they monitor their patient’s mental status and consult with his/her other doctors as necessary to coordinate care. Why should ketamine patients be any different? Of course it would be advantageous if all my healthcare providers could have advanced training and experience with all my disorders and treatments, but I’m in no position to hold out for unrealistic ideals. Isn’t a psychiatrist who lacks expertise with ketamine still better for me than being left without a psychiatrist?!! Because seriously, living where I do, those may be my only realistic options.

c) One psychiatrist that I spoke with said that by receiving monthly ketamine treatments from a specialist while having my psychiatric care and medications overseen by someone else I am inappropriately splitting my treatment and seeking drugs from too many doctors at once. This doctor really needs some basic education about ketamine treatment. First, it is entirely standard for ketamine infusions to be provided by a specialist who is not the patient’s primary psychiatrist. Few psychiatrists administer ECT themselves either – they refer their patients to a team of specialists to provide the electric shocks and anesthetic drugs, but they don’t accuse their ECT patients of inappropriately splitting their treatment by pursuing this arrangement. Second, ketamine treatments for depression are not illegal, they are simply off-label. If a psychiatrist is comfortable prescribing other treatments off-label, they really ought to ask themselves why they are so unusually judgmental about this one, and keep that personal bias in check when talking to patients.

Finally, I wish all of these individuals could understand that I have provided informed consent to receive this off-label treatment. If any psychiatrist is afraid to work with me because they think I might sue them for letting me exercise my right to receive a potentially life-saving experimental treatment, I’d say: Let me sign a waiver. I’m not asking you to give me ketamine infusions, just to allow me to receive them under my own volition. The risks are mine, and the decision to take those risks should be mine. For me and other patients like me, the risks of not having this effective treatment are worse.

I need to have a psychiatrist. And unfortunately, both my difficulty finding one and my fears that this will soon prevent me from continuing ketamine treatment are really starting to take a toll on me.

—————-

Update: I finally found a psychiatrist willing to see me — several hours away from where I live and with a limited schedule that will require me to miss work for appointments. But I’m very relieved to have found one!

Two years: I don’t take this for granted

It has been two years since I started ketamine treatment, and it is still working.  I’m currently dealing with pretty extreme job pressure/stress, and managing it better than I managed most ordinary, day-to-day tasks before ketamine. I don’t take this for granted.

I travel for an infusion every 30 days. To make the treatment last for the time in between, without dealing with the cost of off-label nuedexta or the hassle of finding a compound pharmacy to make a generic version of it, I’m currently taking dextromethorphan 30 mg (Robitussin Long-Acting CoughGels sold on Amazon) along with a little bit of Paxil (5 mg) twice each day. Paxil causes me terrible GI upset and does nothing for my depression, so the only reason I take any at all is to help extend the effects of the dextromethorphan, which in turn helps extend the effects of the ketamine.

I’m sharing these details because too many disbelieve that ketamine is a real, long-term option for living with depression. It can be. For me it is.

Starting over

I’m starting 2017 with a new doctor, not because changing doctors was something I wanted or planned to do, but oddly enough, because of politics. Sure, when looking at ongoing treatment for a chronic illness you have to expect the unexpected — but not usually things like this!

I’ve known for a while that my (former) doctor and I didn’t have the same political opinions — but why should that matter when receiving medical treatment from a caring professional? He had an annoying tendency to talk about Trump before/after my infusions as if this was ordinary small talk, and though that bothered me, I put up with it. Then at our last appointment he started complaining (gloating?) about how many of his liberal patients had been calling him in a crisis soon after the U.S. presidential  election. I can’t swear if he actually used the word “crybaby,” since I was still feeling effects of ketamine, but I am certain that was what he meant.

I knew I couldn’t feel comfortable calling him for help after that, whether or not my depression/anxiety was directly related to election results. If I’m going to be depending on someone to help me with this illness by sticking me with needles and giving me incapacitating drugs, I need to be able to trust that they’ll behave like a caring professional.

So I started looking for another ketamine provider, and I’m lucky that new options have become available since I started this treatment nearly 2 years ago. My new doctor is still very far away from where I live, and the routine is pretty much the same.  I don’t know what this doctor thinks about Trump or liberals and hope they never tell me.

No comment

A month ago I stopped participating in discussion forums about ketamine because I was finding them too stressful.  It was disturbing to me to see desperate people asking for and receiving medical advice from random strangers on the internet — because apparently they don’t have a doctor to ask (and sometimes don’t even think they should have to have one). But I also got really tired of having to defend my treatment and how I feel about it to random strangers. The worst are the ones who know just enough about ketamine research to express their opinions using scientific jargon, and then talk down to me when I don’t accept that kind of ‘splaining as a substitute for real empirical evidence.

My recent post “Going for depression treatment, not for tripping balls” was written largely in exasperation with posts by fans of intranasal/oral ketamine, who are for some reason personally invested in hyping up alleged dangers and problems with IV ketamine. (It seems inordinately important to them to believe that their treatment is better than IV ketamine, and to distinguish themselves from IV ketamine patients by characterizing us as stupid, risk-taking drug abusers.) Even after I left the discussion forums to avoid this shit, I’m still frustrated by people trying to post comments of this nature on my blog!

Comments are welcome here, but ultimately, this is my personal blog about my own experiences, not an open discussion forum. I don’t need to give equal time on my blog to whatever concerns you may have about the treatment that is saving my life. Since I don’t work for a health insurance company, I have no interest in using my blog to promote the obviously profit-driven (rather than science-driven or patient care-driven) views these companies have about ketamine treatments. Finally, I will not post comments that make broadly scientific-sounding claims without providing any actual references to published research. Moderating open discussions responsibly is hard, too hard for me to be willing to take that on now. But I’m also not willing to let my blog become a vehicle for spreading stigma and misinformation.

Going for depression treatment, not for tripping balls

I’m traveling nearly all day today to visit my doctor for a ketamine infusion, as I’ve been doing approximately every 3-5 weeks. I don’t look forward to doing this, so I tend to procrastinate on making the appointment and feel a bit anxious the night before, just as I would with an appointment for dental work or a mammogram. But I continue doing it because it has helped keep my feet on the ground (rather than in a depression hole) for most of a year, something no other previous treatments were able to accomplish. When weighed against the risk of falling back in that hole, the risks associated with this peculiar and poorly understood treatment are a reasonable trade-off in my case. If I had a less serious depression that could be reasonably managed any other way, the cost-benefit ratio would be much different and I wouldn’t be doing this.

I certainly don’t do this because I want to. The treatment sessions were interesting at first because they feel so different from anything I’ve experienced in waking life and I’m a generally curious person, but I have no desire to keep repeating them. If there were a way to get the benefits of this treatment without the hour of dissociation I would absolutely choose that. It would be so awesome if a ketamine metabolite (or something similar) could be developed as an antidepressant with the same benefits and lack of daily-life side effects as monthly IV ketamine – but with no trippy infusion, no needles, fewer risks, no traveling, lower expense, and no drug-abuse stigma. But at this point in time, empirically supported alternatives like this are not available.

Now, just in case you are one of those people who is going to try to tell me that taking much smaller doses of oral or intranasal ketamine at home on a frequent basis is a good alternative to monthly IV ketamine in a doctor’s office, I’m not going to consider that until I see some research evidence on the effectiveness and safety of this approach for treating seriously depressed human patients. At this point in time there is NOT EVEN ONE published study evaluating taking ketamine at home, and my disorder is too severe for me to voluntarily take a chance on a remedy without empirical support. Yes, there is one study to support doctor-administered intranasal ketamine, so I do have the option of traveling all day to dissociate on that every month in a different doctor’s office. But why? The IV treatment is working, and I have no good reason to switch. I’m certainly not going to switch just to avoid having random strangers label me as a self-destructive drug abuser.

The drug abuse stigma many people seem to attach to my depression treatment is hurtful and to the best of my knowledge, unsubstantiated. Yes, there will be irresponsible clinics administering IV ketamine more readily than they should and some patients will end up abusing it — but that risk also occurs with many other medications (including anxiolytics, stimulants, sleeping pills, and the currently available forms of oral/intranasal ketamine). If you are one of those people who is going to feel compelled to tell me that IV ketamine poses a uniquely unacceptable and stupid addiction/abuse risk, I’m going to need you to cite empirical sources to explain how this risk (a) is worse than with the many addictive medications patients can use unsupervised at home, and (b) outweighs the benefits of the treatment.

Some of the scary claims being made about the addiction risk of  IV ketamine treatment — in unmoderated discussion forums and in obnoxious comments that people have unsuccessfully tried to get posted on my blog — could easily be the basis for an updated ketamine-centered version of the 1936 movie Reefer Madness, with subplots that sound like paranoid conspiracy theories. Even when the people making these claims are doing it out of a desire to protect the public from harm, their Ketamine Madness story overlooks how harmful depression can be without effective treatment. It also overlooks how harmful it can be to stigmatize others for their health conditions and healthcare needs.

Stigmatizing IV ketamine is likely to prevent depressed and suicidal patients who have run out of other treatment options from getting potentially life-saving help. And if mental health professionals share these stigmatizing attitudes, they’ll be pushing some of their most desperate patients to take the underground route of seeking the medication from a sleazy clinic with inadequate psychiatric care and frightening consequences. For many of us with severe, treatment-resistant depression, IV ketamine may be the last or best available option we have while waiting for research to develop better solutions. We need doctors who are open to working with us and to helping us make safe, reasonable decisions about ketamine. We need the support of our families, friends, and other communities when we pursue treatment. Stigma is probably the last thing that we need.

Ketamine for depression: Tough talk and a warning

Ketamine infusions aren’t anything like going to a spa or meditative retreat for rejuvenation, deep insights, or personal growth. They are a medical procedure for a serious illness, with many similarities to going for ECT.  I feel the need to say this because as someone who really believes in the future of this treatment I think a lot of the public hype about it is becoming dangerous.

People seem to be expecting ketamine treatment to be the definitive answer for their suffering when nothing in life really works that way.  They are waiting to experience some kind of sign during or right after their infusions, rather than understanding that all recoveries require time, effort, adjustments, and so on. But more frightening is the related tendency for people to downplay the need for psychiatric supervision while receiving this treatment. Depressed people are being tempted to seek help from anyone who can administer ketamine without seeming to realize how risky this is. Too many are relying on internet forums for crucial information and support because they lack sufficient professional care. And some of the patients doing improvisational ketamine treatments with inappropriate providers don’t seem to have exhausted other proven options, such as psychotherapy (or TMS, ECT, and so on). Taken together, these trends are very alarming.

Doctors need specific expertise to be able to provide ketamine treatment effectively and safely. They also need to be closely monitoring your mental health, overseeing all your various medications, and addressing your questions/concerns (or communicating with a mental health professional who has responsibility for these aspects of the treatment).

If your depression is severe and treatment-resistant enough to require an experimental treatment like ketamine, it is definitely serious enough that you need psychotherapy and/or another form of careful monitoring by a mental health professional. Please, the possibility of hospitalization ought to be kept in mind, at least as a back-up plan, if you are thinking you need to start this treatment. That people’s first impulse is instead to find some doctor willing to play around with giving them ketamine as part of an uncharted and incredibly expensive do-it-yourself project suggests that the hype about ketamine being a quick and easy miracle cure has gone way too far.

I understand all too well that people suffering from depression feel very desperate. And I know that some of the doctors hanging up their shingles as ketamine providers genuinely believe they are going to help these people (and not just cash in on their desperation). I am just afraid that people are going to end up getting really hurt.