The New York Times featured an article on ketamine treatment last week on the front page of the Metro section. This is Boston MindCare’s response to that article:
The very first sentence in Andrew Pollack’s recent article on ketamine calls into question the integrity of physicians who dispense the anesthetic to treat depression. While Pollack did offer some perspectives from patients who have benefited from ketamine and physicians who administer it, he also pandered to those who would be inclined to view the medication fearfully, using sensationalistic (and headline-grabbing) terms like “club drug.” A description of the history of ketamine treatment centers in the U.S. and the successes these practices have seen would have been more informative. Years of published clinical research have shown positive results in the majority of depressed patients given ketamine, yet the only link provided to any journal is to a commentary stating that treating patients with ketamine for depression is “ethically and clinically inappropriate,” adding to the veiled suggestion that physicians who dispense it are like snake-oil salesmen exploiting vulnerable and desperate people.
What is unethical is to withhold treatment known to be life-saving from patients who have exhausted other options, especially when the safety record of that treatment, which is on the WHO list of essential medicines, has been well established for decades in millions of people. No one would think twice about halting a study and making a drug widely available that has been shown to be life-saving for a majority of cancer patients. Depression, as usual, however, is treated as a second-class citizen.
Anesthesiologists, with their years of hands-on daily experience with ketamine and other anesthetics, rigorous training in resuscitation and titration of medications to the desired effect in individual patients, institutional obsession with patient safety, and culture of treating patients with moment-to-moment judgment rather than reliance on pharmaceutical protocols, are ideally suited to be leaders in the use of ketamine for novel applications, and in fact already have been. Ketamine infusions have been successfully administered off-label for a condition known as CRPS since the 1990’s in both inpatient and outpatient settings, a highly relevant fact unfortunately left out of Pollack’s article. Off-label use of medications is often necessary, not just desirable, largely because patient needs often outpace the costly and ponderous process of FDA approval, especially when there is no champion for new applications of a generic drug. Doctors who are willing to think outside the box and apply their skills and training to make sound medical judgments about medications, including new ways to apply them, should be met with support and respectful discourse rather than suspicion.
Meanwhile, no one has questioned the ethics of a culture in which treatments are only made accessible to patients if manufacturers stand to make a profit from them. Few seem to want to challenge the established drug-prescribing regimens in psychiatry, where only now is the focus shifting from neurotransmitters to neural circuits. Perhaps what critics, including the psychiatrists cited in Pollack’s article, most fear or resent is that in the case of depression, ketamine already has a better track-record of favorable responses than the no-better-than-placebo products pharmaceutical companies have been peddling for decades. Unsurprisingly, millions are being spent to develop new drugs that mimic ketamine, when it would be simpler to accept and support an established drug used in a new way. Ketamine treatment centers around the country have their proof: they are bringing relief and transformation to many whose suffering seemed beyond hope. To accuse an entire cohort of practitioners of questionable ethics and clinical judgment, without a detailed examination of the time and care taken by these practitioners to make treatment decisions and ensure patient comfort and safety, is irresponsible, wrong, and patently unfair. A critical eye should instead be cast on the broken mental health system and its slog of revolving-door protocols, to see what is truly “clinically inappropriate.”
Last week a discussion on San Francisco Public Radio also explored the question, “Is it ethical to use ketamine to treat acute depression?” After Ketamine Advocacy Network founder Dennis Hartman’s powerful description of his personal experience with ketamine treatment, the following statement by Dr. David Feifel of UCSD hit home:
One needs to consider what are the risks of NOT treating somebody. You’ve heard from Dennis what the risks are. While we study this drug that’s already been approved and been used in humans at doses ten or more times the dose that we use for treating depression, typically – I mean, its dose as an anesthetic…it’s used every single day in our hospital, in hospitals around the country, at much much larger doses – while we sit around and study this drug for years and years to come that’s already been out and been given to humans for many many many many years, people like Dennis are dying.
Obviously at Boston MindCare we feel that ketamine therapy is NOT unethical; on the contrary, it is an option that should be more widely accessible to patients facing severe, debilitating, often life-threatening depression and other medical problems for which it has shown promise. Skepticism is healthy, but unfounded fear can be crippling and can obstruct healing. Our hope is to be instruments of greater accessibility and to allow more avenues for that healing to open.