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A controversial treatment for depression: Ketamine

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By Joey Peters/MinnPost

For more than two decades, Laura Clark has suffered from posttraumatic stress disorder. So three months ago, Dr. Gregory Simelgor hooked her to an IV in his Edina clinic for an unusual type of mental health treatment.

Over the course of two weeks, Simelgor injected Clark six times with ketamine, a drug used to anesthetize patients during surgery or other painful procedures. During infusions, Clark felt like she was floating. Sometimes, her lips and hands felt bigger than they actually were. Other times, she felt like she didn’t have hands at all. “It’s actually kind of pleasant,” she said.

For Simelgor, these sensations are a good sign: it means the ketamine is working.

In scientific terms, ketamine causes a disassociation between the brain’s frontal lobe and limbic system. But the point of the treatment isn’t what’s happening during infusion, it’s what happens later. “I want to know if it’s a good enough dose for the medication to reach your brain, reset your receptors and give you long-term benefits,” Simelgor said.

Simelgor is among a small but growing number of medical practitioners across the country who are treating mental illnesses with ketamine. In fact, the Ketamine Advocacy Network estimates that roughly 60 such clinics are currently operating in the U.S.

But the practice is controversial and divisive in the psychiatric community. While medical studies are pointing to ketamine’s potential as a reliever of depression, those studies remain preliminary and small-scale. What’s more, the U.S. Food and Drug Administration does not recognize ketamine as an antidepressant, but does as an anesthetic. Simelgor is not a mental health expert; he’s an anesthesiologist who trained in administering ketamine for anesthesia.

Simelgor acknowledges that concrete medical evidence for the type of treatment he offers is lacking. And because he’s not a psychiatrist, he can’t offer comprehensive mental health follow up on his patients. But he maintains that he’s seen considerable success in the more than 100 people he’s treated during the last year and half. “Eighty-five percent of the people we receive, we get them out of that rut or take them off the suicide watch,” Simelgor said.

He recalled with glee a recent young male patient who, before seeking out ketamine treatment, was caught by his mother staring at the barrel of a gun and had to be talked out of killing himself. “Now he’s talking to me about going back to school, starting to exercise,” Simelgor said. “It’s a totally different mindset. And that to me is extremely rewarding.”

From ‘K-hole’ to medical breakthrough?

Ketamine was first discovered and synthesized in the 1960s. The FDA approved it as an anesthetic in 1970, after which it became widely used on wounded soldiers during the Vietnam War.

But the drug also developed a reputation as a recreational drug, first among New Age circles. The most famous early ketamine proponent was St. Paul native John C. Lilly, who infused himself with the drug so often that — while under its influence — he came up with wild theories about aliens controlling human coincidences.

Such delusions illustrated ketamine’s hallucinatory effects when ingested in large doses, a state known as the k-hole among recreational users, who also know ketamine by its street name: Special K.

The rave and club scenes fueled ketamine’s popularity as a recreational drug in the ’90s and 2000s. But by the turn of the millenium, medical breakthroughs began to point to the drug’s potential as a treatment for depression. In one 2006 study by the National Institute of Mental Health, 18 patients were treated over the course of a year in a blind setting with both ketamine and a placebo. The study found “robust and rapid” antidepressant effects from ketamine, drawing attention across the medical community.

More studies have been done since, but skepticism remains. Michael Trangle, a psychiatrist based in St. Louis Park who is affiliated with Regions Hospital, says he himself is neutral on the issue of ketamine’s utility, but said he wouldn’t be comfortable referring his patients to the treatment. There is too little known about the long-term effects, including potentially harmful ones. “I do think it’s quite promising, but to set up shop and hand it out makes me worry about it,” he said. “Especially if you’re not a psychiatrist.”

Ketamine’s positive effects also wear off with time, a point that University of Minnesota Medical School professor Barry Rittberg, a psychiatrist, said he observed in a handful of his patients who had gone through the treatment.

Brian Johns, a psychiatrist at North Memorial Health in Robbinsdale who has conducted studies and prescribed ketamine for his patients, emphasized that all medical treatments for depression eventually wear off. That includes electroconvulsive therapy or ECT, the gold standard for treating severely depressed patients who are resistant to other treatments like antidepressants. “There’s nothing that we do that doesn’t require ongoing administration,” Johns said. “To me, it doesn’t make any sense to say it just doesn’t last.”

Johns added that while existing ketamine studies are small—conducted on a dozen patients, for example, instead of several hundred — their results have been “ubiquitously positive.”

Leap of faith

Simelgor first came across ketamine’s potential as treatment for depression and anxiety in 2015 while reading a medical journal for anesthesiologists. “One of the things that they mentioned in the article was that [anesthesiologists] should probably take a lead on it,” he said. “We’re familiar with how it works, the side effects, how to monitor patients.”

Simelgor, who still works at Hennepin Healthcare (formerly known as HCMC) in addition to running his Minnesota Ketamine Clinic, started looking around the Twin Cities to see if the treatment was available to patients.

He didn’t find much. Johns once helped administer 15 ketamine infusions a day at North Memorial, but that was several years ago. The clinic has since stopped because of costs, Johns said, and many of his patients have switched to a cheaper intranasal spray.

Because the handful of psychiatrists who do provide it don’t advertise it and often don’t take new patients, access for patients around the Twin Cities can be tough. “It’s been around; it’s just kind of underground,” Johns said.

Simelgor wanted to create something different. Though his day job at Hennepin Healthcare already demanded 55 to 60 hours of his time during the week, he wanted to explore something new and see where it would take him. “Call it a mid-life crisis, I don’t know,” he said.

He accepted his first patient in October 2016, and his first few treatments were just as big a revelation to him as they were to his patients, he says:  “I started thinking to myself, ‘Holy shit, this thing works!’”

Simelgor follows a dose that’s been established as the de facto standard for the use of ketamine for mental health treatments: 0.5 milligrams per kilogram for 40 minutes — a much lower dose than the 2-3 milligrams per kilo dose usually used in anesthesia.

At that level his patients don’t have full-on hallucinations, but do experience different perceptions of existing objects. Pictures on the wall may change shapes. Isolated noises may sound amplified. Lights may look brighter.

During infusion, Simelgor monitors his patients’ vital signs to be on the lookout for potential complications like arrhythmia and high blood pressure. The slow infusion of ketamine through an IV means he can stop the dose at any point if a patient feels uncomfortable.

While he hasn’t gotten institutional backlash, Simelgor has gotten pushback from some people in the medical community. One wrote on LinkedIn asking him what made him a psychiatrist and gave him the authority to use dangerous medicine. “I wrote back, ‘Yes, it is a dangerous medication if you don’t know how to use it,’” he said. “I am familiar with it. I am not pretending to be a psychiatrist. I’m just doing a service.”

Ketamine treatment is also expensive. Patients pay $600 per infusion, which, if they follow the recommended procedure of six over two weeks, will cost them $3,600. Because no health insurance plans recognize ketamine treatment, patients have to pay the full cost out of pocket.

Most of his patients are high-functioning people with full-time jobs and must share their medical history over the phone before getting accepted for treatment. Sometimes, if they have medical conditions like epilepsy or personality disorder that may not mix well with ketamine treatment, Simelgor will turn them down.

But he doesn’t judge whether a person’s depression is not severe enough for ketamine treatment — Simelgor said he can’t do this because he’s not a psychiatrist. Ideally, he would have a psychiatrist working side-by-side with him for matters like these.  “I just need to find somebody who is going to be open-minded about joining forces,” he said.

Treatment, not cure

Laura Clark, for her part, said she is sure of one thing — that ketamine treatment is working for her. She traces her PTSD back to abuse she experienced while living for seven years with a “cult-like” group early in her life.

In 1994, eight years after she left the group, she was diagnosed with PTSD. She tried several treatments since then, including therapy and antidepressants. They’ve helped, she said, but didn’t end her nightmares and daily anxieties.

But since her ketamine treatment, Clark said her anxiety triggers no longer overwhelm her. She sleeps better. She’s calmer, but “not in a doped-up way.” She uses her energy toward newfound hobbies instead of toward trying to hold her life together.

She still takes antidepressants, and she also returned to Simelgor’s clinic for one infusion after his standard treatment, something that Simelgor said 10 percent of his patients do. It was three-and-a-half weeks after her last infusion, and she felt like the effects were wearing off.

She isn’t sure if she’ll have to keep going back to the clinic continuously for infusions.

Simelgor emphasized that ketamine infusion is a treatment for depression, not a cure. “It’s a chronic disease, so chronic diseases need chronic treatment,” he said.

Top photo: Dr. Gregory Simelgor is among a small but growing number of medical practitioners across the country who are treating mental illnesses with ketamine. (Credit: Mike Dvorak)

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