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.
My teenage daughter and I sat grieving together tonight over this tragic loss. As she wrote online, “I am beyond heartbroken about Robin Williams’ passing. It goes to show how depression is a potentially fatal medical issue that deserves the same kind of treatment and care as other physical illnesses. Anyone, even a bright, talented, hilarious and joy-spreading person can suffer from it. He was universally loved and created so much brilliance on and off the screen. The world lost a gem of a human being today. ”
So it has. When will people understand? When will doctors, hospitals, policy makers, and all people UNDERSTAND that depression hurts a vital organ and thus can be life-threatening?
Yet what we see all around us are budget cuts leading to closures of mental health facilities, reductions in available services, health care “coverage” that covers less and less, insurance policies that discriminate against those suffering with mental health problems, and a pharmaceutical industry that appears to be dictating the shape and direction of treatment for psychiatric illness.
When will people understand what a sixteen-year-old girl understands so well?
For other responses please see the article Robin Williams’s death: a reminder that suicide and depression are not selfish, this video response from someone who has experienced deep depression, and the following very important post by Tom Clempson, entitled ROBIN WILLIAMS DID NOT DIE FROM SUICIDE:
Robin Williams didn’t die from suicide…
When people die from cancer, their cause of death can be various horrible things – seizure, stroke, pneumonia – and when someone dies after battling cancer, and people ask “How did they die?”, you never hear anyone say “pulmonary embolism”, the answer is always “cancer”. A pulmonary embolism can be the final cause of death with some cancers, but when a friend of mine died from cancer, he died from cancer. That was it. And when I asked my wife what Robin Williams died from, she, very wisely, replied “Depression.”
The word “suicide” gives many people the impression that “it was his own decision,” or “he chose to die, whereas most people with cancer fight to live.” And, because depression is still such a misunderstood condition, you can hardly blame people for not really understanding. Just a quick search on Twitter will show how many people have little sympathy for those who commit suicide…
But, just as a pulmonary embolism is a fatal symptom of cancer, suicide is a fatal symptom of depression. Depression is an illness, not a choice of lifestyle. You can’t just “cheer up” with depression, just as you can’t choose not to have cancer. When someone commits suicide as a result of depression, they die from depression – an illness that kills millions each year. It is hard to know exactly how many people actually die from depression each year because the figures and statistics only seem to show how many people die from “suicide” each year (and you don’t necessarily have to suffer depression to commit suicide, it’s usually just implied). But considering that one person commits suicide every 14 minutes in the US alone, we clearly need to do more to battle this illness, and the stigmas that continue to surround it. Perhaps depression might lose some its “it was his own fault” stigma, if we start focusing on the illness, rather than the symptom. Robin Williams didn’t die from suicide. He died from depression. It wasn’t his choice to suffer that.
A new study in the Australian & New Zealand Journal of Psychiatry has found that adolescent girls worldwide are experiencing increasing rates of depression and anxiety. The review, led by Dr. William Bor of the Mater Children’s Hospital in South Brisbane, Australia, examined 19 studies from 12 countries. Teenage girls in the U.K., Northern Europe, and China seemed especially hard-hit.
The review cited cultural issues, body image pressures, early sexualization, and growing economic inequality as contributing factors but highlighted school stress as a common source of growing mental health problems: “The school factor is the common denominator and the most likely factor across the multiple countries.”
These data point to an understanding of depression that we at Boston MindCare have long believed makes the most sense: that it is an illness arising from stress-induced brain damage, which may then lead to the neurotransmitter imbalance that pharmaceutical companies have been targeting for years with mixed success, perhaps because the target is an effect of the illness rather than a cause. The newest treatments for depression – transcranial magnetic stimulation, brain implants, and ketamine infusion therapy – target broken brain circuits rather than brain transmitters, finally recognizing that the problem may be rooted in the damaged connections that might then be leading to deficient neurotransmitter activity.
If this understanding of depression-as-brain-circuit-damage were more widespread, perhaps some of the misunderstanding and stigma associated with the illness could be dispelled. “I have stress-induced brain injury” paints a much more precise picture of what is going on than “I have depression;” perhaps a day will come when an understanding of depression as brain injury – a medical condition – will compel more medical centers, insurance carriers, policy makers, and others to stop discriminating against its sufferers.
…ceased is the lightning’s flash:
His rage dies down like a fierce south-wind.
But now, grown sane, new misery is his;
For on woes self-wrought he gazes aghast,
Wherein no hand but his own had share;
And with anguish his soul is afflicted.
Yonder man, while his spirit was diseased,
Himself had joy in his own evil plight,
Though to us, who were sane, he brought distress.
But now, since he has respite from his plague,
He with sore grief is utterly cast down,
And we likewise, no less than heretofore.
Are there not here two woes instead of one?
-from Ajax by Sophocles, c. 440 B.C.E., trans. R.C. Trevelyan
Every week 800 Iraq & Afghanistan veterans are diagnosed with depression and 1000 with PTSD, according to estimates by the VA. Some West-Coast veterans have found help for their struggles through the Mosaic Multicultural Foundation, a nonprofit organization that fosters healing from trauma through creative mentoring. Their program entitled ”Voices of the Veterans, Voices of War” is a series of four-day retreats in which “The deeply moving and revelatory personal stories of veterans are converted into poetry and narratives that help make sense of otherwise bewildering and tragic experiences. The public ceremonies that occur after the retreats allow fellow citizens to become compassionate witnesses to the stories of war and the necessity of creating a conscious and genuine return for veterans.” Mythologist Michael Meade runs the retreats, using mythic stories from ancient Greece, India, Ireland, and other cultures to encourage veterans to explore their own experiences and create their own narratives or poetic works about them.
In another effort to use the arts as healing energy, the Pentagon has funded Theater of War, directed by founder Bryan Doerries, which produces readings of Sophocles’ Ajax and Philoctetes for veterans, service members, and their families. Ajax describes the events leading up to the suicide of the famous Greek warrior, who has returned from war afflicted with grief, violent outbursts, and a despair that affects those close to him. Philoctetes tells the tale of a warrior whose own men abandon him on an island after he begins to exhibit bizarre behavior. There he suffers years of isolation, unable to get the help he needs for a major wound, and when he tries to rejoin his comrades, he is plagued by flashbacks and other PTSD symptoms. From the Theater of War website:
“It has been suggested that ancient Greek drama was a form of storytelling, communal therapy, and ritual reintegration for combat veterans by combat veterans. Sophocles himself was a general. At the time Aeschylus wrote and produced his famous Oresteia, Athens was at war on six fronts. The audiences for whom these plays were performed were undoubtedly comprised of citizen-soldiers. Also, the performers themselves were most likely veterans or cadets. Seen through this lens, ancient Greek drama appears to have been an elaborate ritual aimed at helping combat veterans return to civilian life after deployments during a century that saw 80 years of war.”
Depression, PTSD, and other mental illnesses have been part of people’s life struggles from the very beginning of human civilization. Our human stories connect us even across millennia. This Memorial Day weekend we are thinking of the pain of veterans, the suffering of those who feel isolated and alientated by depression and PTSD, and the frustration of all who have dealt with or have to deal with a broken mental health system. There is so much trauma, so much woundedness, in the world; may we be part of its healing, wholeness, and increased health.
UPDATE: Click here to listen to a May 29, 2014 article on NPR featuring Aquila Theatre’s production of Philoctetes, in which the title role is reimagined as a female combat soldier.
“The hardest part of depression is finding a way to tell people. It is like you are hiding a terrible secret. I think I felt ashamed of myself for getting depression, like somehow I had failed. That’s what depression does to you: it makes you feel like a terrible failure…it feels as if you are not you anymore, you’re just a hollow shell. You can’t be bothered with yourself anymore so why should other people? How can you possibly tell someone that you feel like you want to die? How can you describe the arctic winter wipe out blizzard that has become your headspace?” -David at Time to Change
Have you ever said this to or about someone with depression, even just in your own mind?
Chances are, most people who live in the presence of depression have wrestled at one time or another with thoughts and feelings like these. Many of these phrases or similar ones can be found on internet lists entitled “worst things to say/what not to say to someone with depression.” Arguably one of the hardest aspects of the disease, for both patients and their loved ones, is its incomprehensibility. People who have not suffered with depression cannot know fully the experience of those who do suffer or have suffered with it and cannot understand why it has the power to do what it does. This can be terribly isolating for both sides, exacerbating the insidious effects of an already taxing illness.
For people who haven’t been through it, learning about depression and trying to develop empathy are important and can be difficult, but writers like William Styron, through their attentive and vivid descriptions of deep depression based on true life experience, can increase understanding of this “storm of murk.” From his book Darkness Visible:
I was feeling in my mind a sensation close to, but indescribably different from, actual pain…[others'] incomprehension has usually been due not to a failure of sympathy but to the basic inability of healthy people to imagine a form of torment so alien to everyday experience. For myself, the pain is most closely connected to drowning or suffocation—but even these images are off the mark…
…with their minds turned agonizingly inward, people with depression are usually only dangerous to themselves. The madness of depression is, generally speaking, the antithesis of violence. It is a storm indeed, but a storm of murk. Soon evident are the slowed-down responses, near paralysis, psychic energy throttled back close to zero. Ultimately, the body is affected and feels sapped, drained.
That fall, as the disorder gradually took full possession of my system, I began to conceive that my mind itself was like one of those out-moded small-town telephone exchanges, being gradually inundated by floodwaters: one by one, the normal circuits began to drown, causing some of the functions of the body and nearly all those of the instinct and intellect to slowly disconnect.
…What I had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain., like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze sites this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.
…One does not abandon, even briefly, one’s bed of nails, but is attached to it wherever one goes, And this results in a striking experience—one which I have called, borrowing military terminology, the situation of the walking wounded. For in virtually any other serious sickness, a patient who felt similar devastation would be lying flat in bed, possibly sedated and hooked up to the tubes and wires of life-support systems, but at the very least in a posture of repose and in an isolated setting. His invalidism would be necessary, unquestioned and honorably attained. However, the sufferer from depression has no such option and therefore finds himself, like a walking casualty of war, thrust into the most intolerable social and family situations. There he must, despite the anguish devouring his brain, present a face approximating the one that is associated with ordinary events and companionship. He must try to utter small talk, and be responsive to questions, and knowingly nod and frown and, God help him, even smile. But it is a fierce trial attempting to speak a few simple words.
From these paragraphs any reader can understand that the phrases mentioned in the very beginning of this post are failures, albeit understandable ones. They are failures of empathy, of understanding that depression is NOT a choice or a bad habit or a moral failing but a disease that affects a vital organ. Because that organ is not the pancreas or the heart, and the manifestations aren’t elevated blood sugars or pulmonary edema but rather lie in behavior and cognition, which usually involve human will, there is wishful thinking that human will should be able to fix what’s wrong, and frustration when it alone is insufficient. It’s hard to know what to say, and even harder sometimes to know how to help. Very often, well-meaning platitudes are all we feel we have.
Recognizing the gap between our understanding of depression and the reality of it is an important step; a commitment not to give up on closing that gap is a step that has to be re-taken daily, and sometimes moment to moment.
Photo source: namiwalks.org
Today is National Children’s Mental Health Awareness Day, and we would like to highlight Chiara de Blasio, daughter of New York City mayor Bill de Blasio, who was honored in Washington for opening up about her struggles with depression and addiction. In a candid essay she published on xojane last Tuesday, May 6, she wrote,
I had an amazing, unconditionally loving, and unbroken family. I went to good schools. I lived in a beautiful neighborhood. So why, then, did I always feel empty? I was surrounded by love, but I always felt less-than, out-of-place, restless, irritable, and discontent. Perhaps you’re reading this and thinking that I was simply ungrateful. Yes, I was. But a lack of gratitude wasn’t my only problem. I was the problem. I was not born a happy person.
Some people believe that it is impossible for people who come from backgrounds like mine to suffer from the diseases of depression and addiction. They may believe that we don’t appreciate what we have, make bad decisions, and/or have some sort of moral deficiency. I am here to tell you that that is not true — 10 percent external conditions. Mental illness does not discriminate. However, that does not mean that there isn’t hope for each and every one of us.
May is Mental Health Month. This year’s theme is “Mind Your Health.” Please check out this calendar for suggestions on how to celebrate this month and its theme, or consider joining Chiara de Blasio in helping to end stigma around mental health issues by speaking out here about your own journey with mental health challenges.
One way to honor the month is this week’s Massachusetts NAMI (National Alliance on Mental Health) Walk for Mental Health Awareness. Boston MindCare will be there! Please join or support the walk this Saturday, May 10 or support a NAMI walk near you.
Ketamine has been used for decades as an anesthetic. It is also an analgesic and a potential hallucinogen. How does this strange drug work to alleviate symptoms of depression?
In an age of burgeoning developments in molecular medicine, the evidence points to some exciting answers. Ketamine seems to heal the damage done to the brain’s synapses by depression and severe stress, and to do so within a matter of hours.
The word synapse first appeared in Foster and Sherrington’s 1897 Textbook of Physiology. It was suggested by English classicist Arthur Woollgar Verrall and comes from the Greek synaptein meaning “to clasp, join together, tie or bind together, be connected with.” In the brain, synapses are the junctions between cells at which molecular signaling takes place.
Neurons are not unlike ourselves: if they can stay in healthy relationship with one another, connected, communicating, then their world, the brain, can thrive. Stress or depression, however, breaks those connections, damages individuals and the world they inhabit, disrupts communication. When depressive illnesses take hold, in more ways than one, the mind goes dark.
Researchers Ronald S. Duman and Nianxin Li wrote in the abstract for a 2012 paper, ”We have found that ketamine, an [NMDA] receptor antagonist, causes a rapid induction in synaptogenesis and spine formation in the [prefrontal cortex] via stimulation of the [mTOR] signaling pathway and increased synthesis of synaptic proteins.” In other words, what ketamine does is rebuild broken synapses. It increases the synthesis of synaptic proteins – the building materials needed for structurally sound synapses – and reverses the atrophy of neurons caused by stress and depression. As shown in the image from Duman’s laboratory that has become an instant classic in this field of research, and as described by N.I.H. researcher Carlos Zarate, ketamine can make neurons that once looked like dead trees in winter look like blooming trees in spring again (image source here):
It’s sometimes said that “the space between” is what matters most. It’s where things are set in motion, where fruitful exchanges can happen. Ketamine targets that space on a molecular level: it can be a powerful contributor to synaptic plasticity and synaptogenesis. Simply put, at the appropriate doses it has the potential to restore the structure and function of patients’ brain cells and offers, for many, the possibility of resetting and restoring their lives – and without the six-to-eight-week wait required by so many oral medications. Spring is no longer just around the corner. It’s here.