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Walk into Kalypso Wellness Centers in San Antonio, Texas, and you might be treated with one of five “proprietary blends” of ketamine. They’re not cheap — $495 per infusion — and not covered by insurance, but the company offers a “monthly” membership program to cut costs and advertises discounts for members of the military and first responders.

Kalypso promotes ketamine, long used as an anesthetic during surgery and more recently as a club drug, as a treatment for more than two dozen conditions, including depression, chronic pain, and migraines. “Congratulations on resetting your life!!!” it cheerily tells patients on a form they’re handed after an infusion.

Starting with just one office 19 months ago, Kalypso has expanded rapidly to meet surging patient demand for ketamine and now oversees two other Texas clinics and offices in North Carolina and New York. It recruits customers through online ads and radio spots, and even by visiting support groups for pain patients, people with depression, first responders, and grieving parents who have lost children.

“You name it, we’ve done it,” said clinic co-founder and anesthesiologist Dr. Bryan Clifton.

An investigation by STAT shows that Kalypso’s sweeping claims are hardly uncommon in the booming ketamine treatment business. Dozens of free-standing clinics have opened across the U.S. in recent years to provide the drug to patients who are desperate for an effective therapy and hopeful ketamine can help. But the investigation found wide-ranging inconsistencies among clinics, from the screening of patients to the dose and frequency of infusions to the coordination with patients’ mental health providers. A number of clinics stray from recommendations issued last year by the American Psychiatric Association.

STAT interviewed ketamine clinic owners, psychiatrists, and patients and reviewed online staff pages and screening protocols for dozens of ketamine clinics to gauge how patients are selected and treated. Among the findings:

• Some clinics don’t thoroughly screen patients, and experts worry they’re offering the drug to anyone who can afford it. Clinics can charge anywhere from $350 to close to $1,000 per infusion and many patients get at least six rounds of the treatment.
• In many cases, clinics don’t have a psychiatrist or other mental health professional on staff, though they are working with challenging patients who haven’t responded to other treatments and may have suicidal thoughts. And not all clinics collaborate closely with a patient’s own mental health provider or even require patients to have one throughout treatment.
• Clinics sometimes overhype the efficacy of ketamine, offer it for uses that haven’t been well-studied, and tout special blends that experts say aren’t supported by published evidence.

Patients are “getting treatments they may not need or that don’t work, or they’re getting more than they needed,” said Dr. Jeffrey Lieberman, psychiatrist-in-chief of Columbia University Medical Center. One of the biggest risks from the explosion in ketamine use, he added, is “people getting fleeced.”

Clifton said Kalypso works closely with referring physicians or mental health providers and makes sure that anyone who seeks treatment for suicidal thoughts “has adequate mental health care.” Other clinics told STAT that they try to work with a patient’s mental health provider or another physician.

There’s a clear need for new treatments for major depressive disorder, and experts agree that ketamine holds potential to rapidly treat depression and possibly other mental health conditions in some — though nowhere near all — patients. Drug companies are testing similar medications for depression, suicidality, and bipolar disorder, but it hasn’t yet been approved for these conditions.

That fact hasn’t diminished patients’ desire to try ketamine. Actify Neurotherapies, which oversees 10 clinics that provide the drug, said it has received nearly 28,000 inquiries through a call center or online request form — just since January.

“Ketamine has become this phenomenon,” said Lieberman. Continual media coverage has fueled the excitement, generating significant interest and optimism among patients and physicians alike.

Mental health specialists don’t begrudge providers for opening their doors and offering a potentially beneficial treatment to patients eager for relief before it’s approved by the Food and Drug Administration. But they say some clinics are going too far in their promises — and not caring appropriately for patients.

“This is not snake oil. It’s not something that has to be stamped out,” Lieberman said. “It’s something that has to be reined in.”

Seeing hope in an experimental therapy

Rory Basurto knows the date of his first ketamine treatment by heart: Oct. 17, 2017. For more than a decade, he had suffered from devastating depression and thick anxiety that felt “like walking around with a wet blanket on all the time.” The 36-year-old can rattle off a laundry list of treatments he’s tried: Paxil, Lexapro, Zoloft, Ritalin, klonopin, neurofeedback, psychotherapy.

“It helped until it didn’t. Until I completely broke down,” said Basurto, who lives in Encinitas, Calif. That was last fall, when he had to quit his job working with a family business and attempted suicide.

Basurto, like many patients contending with major depression, needed another option. Many don’t respond to conventional antidepressants, such as the SSRIs. And for others, the drugs just don’t work quickly enough, taking weeks to kick in.

“Patients are getting more and more frustrated because the help that they’re getting failed them,” said Dr. Lori Calabrese, a psychiatrist who treats patients with ketamine at her clinic in South Windsor, Conn.

Ketamine has started to fill that breach. Since the early 2000s, small studies have suggested that it might have potential as a depression drug. Unlike traditional antidepressants that target the brain’s serotonin and noradrenaline systems, ketamine appears to block a receptor called NMDA, which is activated by the neurotransmitter glutamate.

The evidence is promising: A dose much smaller than what’s used for anesthesia — given through an IV — stems symptoms of severe depression in some patients with treatment-resistant depression, often within hours.

In Basurto’s case, he read about ketamine online after his suicide attempt. He reached out to South Coast TMS and Ketamine, an Encinitas clinic opened in 2016 by Dr. Drew Belnap, an anesthesiologist. Belnap consulted with Basurto’s therapist, who confirmed Basurto has anxiety and depression.

Since October, Basurto has undergone nearly two dozen ketamine infusions, paying between $450 and $500 per treatment. About once a month, he heads into the clinic, fills out a questionnaire about his symptoms, and settles into a zero-gravity chair. A staff member monitors Basurto as the ketamine drips into his bloodstream. He watches nature videos on a TV during the roughly 50-minute treatment.

He said the drug has changed how he grapples with the everyday challenges that used to knock the wind out of him, often leaving him sad or angry.

“Before, something happened and it was the end of the world. I still go through that, but it’s a lot quicker now,” he said.

Drug companies are racing to create a rapid-acting antidepressant that can produce effects similar to ketamine. Janssen, a division of Johnson & Johnson, is testing a nasal spray of esketamine, a ketamine-derived drug. When combined with an oral antidepressant, it has shown promise in quickly curbing symptoms of serious depression, and is also being tested in patients at risk of suicide. Allergan is developing its own experimental rapid-acting antidepressant, rapastinel. Like ketamine, it works on the NMDA receptor, which is involved in learning and memory.

But there are clear limitations to the data on ketamine. There aren’t data on long-term effects or potential risks down the road. There’s no clear consensus between the providers currently offering it on optimal dosing, how to go about maintaining the drug’s effects, or the best kind of care to complement ketamine treatment, such as cognitive behavioral therapy.

“The pace of ketamine treatment in real-world practices has outstripped what researchers are able to do and publish,” Calabrese said.

Seeing an “urgent need for some guidance,” an American Psychiatric Association task force issued a consensus statement in April 2017 that laid out the medical evidence on ketamine, the kind of training it thought physicians should have, and advice for thoroughly screening patients. Because ketamine can possibly affect heart rate or blood pressure in some patients, it recommended clinicians who provide treatment have advanced cardiac life support certification.

The panel said the screening process for every single patient should include a comprehensive diagnostic assessment, an in-depth look at a patient’s history of depression treatments, a careful review of medical and psychiatric records, and a clear informed consent process that walks a patient through the risks and limitations of ketamine treatment.

It’s clear that some clinics aren’t sticking to those suggestions.

Minimal screening and untrained providers

Screening practices and the extent of collaboration with mental health providers vary wildly from one ketamine clinic to the next. That means some patients might not get the support they need, particularly if they don’t respond to ketamine, experts said.

At Actify Neurotherapies, people first talk to a “patient care coordinator” who asks a few questions to make sure there aren’t any big red flags, like psychosis. “It’s intended to be a sieve with large holes,” said the CEO, Dr. Steven Levine. A patient then has a consultation with a psychiatrist on staff.

At Calabrese’s clinic, she requests records from each patient’s psychiatrist and primary care doctor, then does a lengthy intake. But at other clinics, the intake process is quicker and leans heavily on a screening tool such as the PHQ-9 questionnaire, which is commonly used to diagnose symptoms of depression. That’s fueled concern that any patient who can fork over hundreds of dollars for each infusion might be offered ketamine treatment, whether or not it’s the right course of action.

“Where is the bar where they determine a patient is not appropriate for ketamine treatment if they can pay?” said Dr. Cristina Cusin, co-director of a ketamine clinic at Massachusetts General Hospital. Cusin, who is also a psychiatry professor at Harvard Medical School, has run several studies on ketamine for treatment-resistant mood disorders.

One patient, a 28-year-old graduate student in California who didn’t want to be named out of concern being identified could affect her job hunt, told STAT said that since the start of this year, she has seen four different ketamine providers. All agreed to treat her with the drug for her severe depression, anxiety, and panic attacks, even though her response to the treatment varied and it didn’t always help.

Experts also express concern about the coordination of care between clinics and a patient’s usual providers. Some clinics say they’ll work with a patient’s mental health provider if he or she wants them to do so. Levine said each of Actify’s clinics “engages the person’s outside primary team” throughout the course of treatment. At Kalypso, co-founder Clifton said staff follow up with a referring provider if there is one or will work with a patient’s primary care provider unless the patient specifically requests that they don’t.

At Ketamine Clinics of Los Angeles, co-founder and anesthesiologist Dr. Steven Mandel said contact with a mental health provider “ranges from no contact to two or three times” a week. Sam Mandel, an entrepreneur who opened the clinic with his father, Steven, and now serves as chief operating officer, said the only reasons the clinic wouldn’t stay in contact with patients’ mental health provider is if they don’t make themselves available or if a patient doesn’t have one, in which case the staff works with the primary care provider.

Many clinics don’t require patients to continue seeing a mental health provider, which means that ketamine becomes the sole source of mental health care for patients who can be among the most complicated to treat. “When there’s no sort of collaborative involvement, that’s worrisome,” Lieberman said.

Dr. Nora Janeway, a primary care doctor in New Hampshire, recently found out that a young patient had just received a series of infusions at a ketamine clinic run by two nurse practitioners.

Her heart sank: This was a particularly complex patient who first came to Janeway’s office a few months ago on a slew of psychiatric prescription drugs, including two benzodiazepines, an antipsychotic, a mood-stabilizing medication, and a stimulant. Janeway wanted the patient to connect to a psychiatrist to manage those medications, but that hadn’t happened yet when the patient started receiving ketamine. Janeway said she was never contacted for records or notified of her patient’s treatment.

“There’s no sense of obligation [in regards to] continuity or follow-up of the patient,” she said.

Basurto, the patient who has received nearly two dozen ketamine infusions since last October, hasn’t seen a mental health provider in six months, he said. Belnap, the anesthesiologist who oversees Basurto’s treatment, said he strongly encourages patients to see an outside mental health care provider, but he can’t force them to do so. He noted that many patients taking traditional SSRI antidepressants for long periods aren’t undergoing psychotherapy either.

In many cases, ketamine providers aren’t qualified to provide mental health care on their own. They’re often anesthesiologists or pain physicians, and in some cases, nurse practitioners. STAT’s review of staffing found that many clinics have no mental health providers on staff. Clifton and his three co-founders are each in the San Antonio office one day a week — and on Tuesdays, a physician assistant staffs the office. Two of Kalypso’s affiliated clinics are run by physician assistants, another is run by a primary care doctor, and the last by a pain physician. Clifton and his co-founders train those providers for a few days and then oversee the care at those clinics through a management service agreement, he said.

The APA says that whoever is providing ketamine treatment needs to be trained in how to address behavioral health problems, because ketamine can cause dissociative effects such as hallucinations. The organization also says it’s critical that clinics have caregivers qualified to make sure patients aren’t at risk for behavioral problems — including experiencing suicidal thoughts — before they’re sent home.

Anesthesiologists, in turn, argue that psychiatrists aren’t qualified to provide ketamine treatment on their own. They’re not prepared the same way anesthesiologists are to deal with problems that could crop up during an infusion, such as an irregular heart rhythm or more serious cardiac issues.

Belnap noted that the safety information included in every box of ketamine says that the physician administering ketamine should be trained in using anesthetics and managing problems with a patient’s airway.

“I’m not saying psychiatrists can’t [administer ketamine], but they need to have someone in the room or in the clinic who knows ketamine — because they don’t,” Belnap said.

One thing is clear: Collaboration is critical.

“You don’t treat an advanced disease with just an infusion and a ‘see you next time,’” Cusin said. “If [doctors] replace your knee but don’t do physical therapy, you don’t walk again.”

But in some clinics, that appears to be the case, experts said.

Even in her clinic at Mass. General, staffed with experts used to dealing with complicated mental health issues, Cusin won’t allow a patient to receive ketamine if that person doesn’t have a primary mental health provider. She and her colleagues can’t provide both ketamine treatment and comprehensive psychiatric care themselves.

“It’s hard. It’s unrelenting. There’s always someone relapsing,” she said.

Studies vary but have found response rates to ketamine as high as 70 percent among people with major depression who have failed a few other antidepressants, Cusin said. But the rate is lower for patients with extremely treatment-resistant depression, and how long any improvement lasts varies from one patient to the next. Cusin carefully explains what patients can expect during the informed consent process, and also talks with their therapist. Not all clinics lay such a thorough foundation.

The stakes couldn’t be higher for patients, Cusin said: “Imagine if you take out a loan for $5,000 or $6,000 for treatment, and it doesn’t work. That could be heartbreaking.”

‘They’re throwing bait in the water’

A number of clinics’ websites pump up the promise of ketamine with the same four-year-old quote from Dr. Thomas Insel, the former director of the National Institute of Mental Health: “Recent data suggest that ketamine, given intravenously, might be the most important breakthrough in antidepressant treatment in decades.”

They neglect to include another line that appears a few paragraphs down in Insel’s 2014 blog post about ketamine: “There are still a number of questions to resolve about the best dose, the mechanism, and the long-term efficacy and safety of ketamine.”

Asked recently by STAT whether he was concerned about the use of his truncated quote in the promotional material, Insel responded by noting many caveats when it comes to ketamine treatment for mental health conditions, but said he had “no regrets’’ about the post.

Insel, now president of Mindstrong Health, a medical technology company based in Palo Alto, Calif., said “optimal care for someone with a depressive disorder requires careful diagnosis and comprehensive treatment.”

“I suspect that does not happen in every ketamine clinic,” he added.

The use of Insel’s quote is a prime example of the way some clinics aggressively promote the potential of ketamine while underselling its risks and limitations. Victory Medical, a ketamine provider in Texas, for example, says on its site that “the path to happiness begins with the first session.” The website for Sierra Ketamine Clinics in Nevada proclaims that “patients who have lost hope and thought they would remain in the grips of chronic pain and mental illness for the rest of their lives have emerged across the country with renewed spirit and joy.”

Mental health specialists said they’re troubled by the way such glowing language might appeal to patients in need of help.

“They’re fishing. They’re throwing bait in the water and trying to lure people in,” Lieberman said.

Like Kalypso, some clinics offer special blends they say can curb side effects. But without published data, experts said there isn’t robust evidence to support those claims. Others make statements that similarly aren’t supported by strong, published evidence, including that their treatment plans work better than protocols published in scientific journals or that they can treat a slew of conditions with ketamine.

On its website, Kalypso says that it has a 91 percent success rate. Clifton told STAT the company offers ketamine for 32 conditions, including lupus and cancer-related pain. When asked whether there was evidence to support each of those uses, Clifton said “absolutely” and said the company is “compiling all of our data to be able to publish it all.”

At the top of its website, the company also prominently highlights its $199 genetic testing services to determine the “right formulation” of ketamine. But experts said genetic testing hasn’t been proven to offer any meaningful information about ketamine treatment at this point.

“We are currently still researching how to best use this test for patient therapy,” Clifton said.

Many clinics use social media to reach patients. To mark National Suicide Prevention Awareness Month, Rocky Mountain Mind & Body clinic in Colorado tweeted to its followers that it was offering a “special”: After patients finish an initial infusion series, they’ll get their first maintenance infusion free.

Some patients said they felt pressured to try ketamine, despite being unsure whether it was the right treatment for them. Alexia Taylor, a 41-year-old who has depression, called the New England Center for Healthy Minds in Acton, Mass., in February to ask about ketamine treatment.

She was floored to find out it would cost thousands and said she wasn’t interested.

“They didn’t want me to get off the phone,” she said. “They said, wouldn’t you like to feel better?”

The New England Center for Healthy Minds said that the screening and scheduling of patients is handled by an outside company called Neuragain, a network of ketamine providers. Julie Lassner, who works with patient and provider services at Neuragain, said the company’s receptionists only collect basic formation needed to secure an appointment, and then formal screening is conducted by the the Center for Health Minds.

All the providers STAT interviewed were quick to say they’re not prescribing ketamine to get rich. Clinics charge anywhere from $350 to upward of $1,000 for a single treatment — with a generic drug. Much of that money covers the significant overhead of running a clinic, providers said.

Most clinics offer a series of six infusions over two to three weeks, and many offer “boosters” as patients feel their symptoms creep back. It’s not clear whether all these infusions are necessary. According to the APA’s review of the research, the evidence is limited on the benefits and risks of longer-term treatment, such as monthly booster infusions.

Some patients scrimp and save for months to afford the treatments. Others ask friends and family to help them, put it on credit cards, or dip into their savings.

Insurers don’t yet cover ketamine treatment for major depressive disorder, because it hasn’t been approved by the FDA for a psychiatric indication. Levine, the Actify Neurotherapies CEO, said an estimated 40 percent of people who contact the company don’t end up scheduling an appointment due to cost. That, critics say, points to another possible issue: the high price will exacerbate health care disparities.

“The problem is, the patients who most need the treatment are the patients who can’t afford it,” Cusin said.

‘Whose job is it to rein this in?’

So what will it take to rein in rogue practices?

Mental health experts called for professional societies to follow in the APA’s footsteps and issue recommendations outlining training requirements and screening protocols for providers who treat mood disorders with ketamine.

The APA also strongly recommended that every clinic come up with standard operating procedures based on the best evidence available. That plan should outline clear steps for screening and obtaining informed consent; assessment of a patient’s physical and mental status before, during, and after infusions; and a plan for managing problems that crop up during or after treatment.

Another idea: create a registry to collect data on every patient who receives ketamine treatment for mood disorders. That will help provide more evidence on outcomes, both in the short-term and the long run.

Experts have pinned some hope — but not too much — on the FDA approving one of the new treatments in the works. A drug approval would mean clear information on dosing, treatment protocol, and indications for which a treatment is approved. And it could clear the path for insurance coverage; if insurers are involved, screening might be more stringent and more people would be able to afford treatments.

None of those are surefire fixes. Ketamine can still be offered off-label to patients with a range of conditions. As clinics continue to crop up, experts are skeptical that use of ketamine will become standardized any time soon.

“Whose job is it to rein this in?” Lieberman said. “Nobody’s gonna come down on them unless something happens.”

[Read the Original Post Here]

Aug. 21, 2018 — Ketamine, a widely used anesthetic that’s also an illicit party drug, has taken on a new role in recent years: treating severe depression in people who have not responded to standard treatment. Researchers have called it the most exciting breakthrough in the field of depression research in the past half-century.

One form of the drug, being developed as a nasal spray called esketamine, is in the final stages of testing needed before it can go to the FDA for approval.

Average scores on the Children’s Depression Rating Scale dropped by 42.5% following low-dose IV ketamine infusions among 13 teenagers with treatment-resistant depression, findings published in Journal of Child and Adolescent Psychopharmacology showed.

“Adult [treatment-resistant depression] research has begun to explore repeated administrations of ketamine, which may have promise for greater effectiveness and longer remission periods than single doses,” Kathryn R. Cullen, MD, division of child and adolescent psychiatry, University of Minnesota Medical School, and colleagues wrote. “Although adolescence is a key time period for emergence of depression and represents an opportune and critical developmental window for intervention to prevent negative outcomes, no information is yet available on the efficacy or tolerability of ketamine as a treatment for [treatment-resistant depression] in adolescents.”

Researchers examined the efficacy and tolerability of IV ketamine among teenagers aged 12 to 18 years with treatment-resistant depression who received six open-label IV ketamine infusions (0.5 mg/kg) over the course of 2 weeks.

Ketamine was infused over 40 minutes, followed by a 2-hour monitoring period to assess depressive symptoms. To determine the extent and duration of clinical response, the investigators examined response and remission one day following the six infusions and measured duration of response in a 6-week follow-up period. In tolerability assessment, they also monitored vital signs and dissociative symptoms.

Thirteen teenagers completed the clinical trial. Average Children’s Depression Rating Scale-Revised percent change was 42.5% (P = .0004). The results showed that five participants met criteria for clinical response and three responders showed sustained remission at 6-week follow-up, with relapse occurring within 2 weeks for the other two responders.

Ketamine infusions were generally well-tolerated, with transient dissociative symptoms and hemodynamic symptoms. However, one participant who had a high level of suicidal thinking at baseline reported a high level of suicidality throughout the study. Importantly, the researchers found that participants who received higher doses due to their higher BMI had the best responses.

“The preliminary results reported here are promising; but large-scale, double-blind, randomized control designs are needed to determine if ketamine is a safe and effective treatment for adolescent [treatment-resistant depression],” Cullen and colleagues wrote.

“Important questions remain regarding optimal dose, response prediction (patient selection), and long-term safety following acute treatment,” they continued. “Before ketamine can be considered for broader clinical use, efficacy and safety data are needed on strategies to sustain ketamine-induced remission. Ultimately, safe and effective strategies to achieve sustained remission during adolescence could restore healthy neurodevelopment and improve outcomes over the lifespan.” – by Savannah Demko

Disclosure: The authors report no relevant financial disclosures.

[Read the Original Post Here]