Ketamine for mental health is ‘a little bit of the Wild West,’ says Utah doctor researching best practices

Many ketamine treatments are ‘off-label,’ without established dosages, yet they’ve become widely available at clinics in Utah and across the country.

(Francisco Kjolseth | The Salt Lake Tribune) Christie Goodwin goes through a ketamine treatment as her fiancé Luis Zerr offers comfort at the Promise Medical Family Practice and Ketamine Clinic in Orem.

From “the outside looking in,” Christie Goodwin recognizes, “I have a very good life.”

So as she has tried treatments over many years for her depression, she said, “there’s always that cognitive dissonance … you have a good life, act like it, there’s nothing to be depressed about.

“Unfortunately, depression doesn’t work like that. It doesn’t really care what you have, how much money you have, what your circumstances are.”

She’s been trying ketamine — an anesthetic becoming increasingly available as mental health care, in Utah and nationwide — for three years, most recently at Promise Medical Family Practice and Ketamine Clinic in Orem. While it hasn’t been a “magic” cure, she said, it’s helped.

”I used to feel like there was a me, a more authentic me, that was kind of trapped,” she said. After effective ketamine treatments, she said, her dad has commented, “’You sound so good.’

“And I said, ‘I am doing good.’ This is who I’ve always been … underneath it all. And I knew that I just couldn’t access her because of the depression.”

Using ketamine infusions for treatment-resistant depression “has a really well established evidence base at this point,” said Dr. Benjamin Lewis, medical director of a new Ketamine Assisted Psychotherapy program at the Park City Behavioral Health Clinic.

But only one form — the nasal spray Spravato (or esketamine), paired with an oral antidepressant — has been approved by the federal Food and Drug Administration for treatment-resistant depression.

That means other treatments, such as injections or oral doses or IV therapy, for other illnesses, such as anxiety or post-traumatic stress disorder, are “off-label,” without established dosages or standards for how to use them most effectively. And health insurers may refuse to cover them.

Yet they’ve become widely available, thanks to a surge in the number of ketamine clinics in Utah and across the country — creating “a little bit of the Wild West, in terms of what this looks like in a lot of outpatient settings,” Lewis said.

(Rick Egan | The Salt Lake Tribune) A syringe for treatment at the Ketamine Wellness Center in Taylorsville.

One reason for the growth, he said, “is we have a huge burden of mental health issues, and perhaps amplified or accelerated to some extent” by the pandemic.

And “while we do have good treatments for a number of mental health conditions, many people don’t achieve remission with those,” he added, leaving “clear gaps.”

” … We’re also in this period of time that has been referred to as the renaissance in psychedelic-assisted therapy and psychedelic research,” Lewis said. “And I think that has caught popular imagination as well, in terms of this sense of new promising tools.”

Although medical research is underway, psychedelics currently are considered Schedule I drugs — with no currently accepted medical use and a high potential for abuse. That leaves ketamine as “really the only legal, non-Schedule I medicine with psychedelic properties that can be used in this fashion,” he said.

”On the one hand, [it’s] very, very exciting to have a potential new set of interventions that might be helpful for otherwise difficult to treat conditions,” Lewis said, “but I think … that also comes along with a lot of hype and potentially overpromising as well, on the available science.”

‘Just about a million questions’

Initially used to sedate animals, ketamine was first approved by the FDA for human use as an anesthetic in the 1970s. It also gained notoriety as a recreational drug, though research shows its street use remains fairly limited.

The Huntsman Mental Health Institute in Salt Lake City, part of the University of Utah Health network, has a ketamine infusion clinic for treatment resistant mood disorders and serves people with treatment-resistant anxiety or depression.

Many people feel quick relief with ketamine, but “that tends to fade, even within about a week or so,” Lewis said. Patients may become depressed or anxious again, once they stop taking it.

Along with its “dissociative” side effects, Lewis said, ketamine produces a period in which the brain’s ability to learn and change is enhanced.

“Striking while the iron is hot,” Lewis explained, the new Park City clinic provides psychotherapy that helps a patient lean into that altered state and see their issues in a new light.

”So we’re using ketamine as a catalyst for that process,” he said, “as opposed to just delivering the medicine.”

The Park City clinic, which is also affiliated with the Huntsman Mental Health Institute, treats a wider range of patients with ketamine, such as people in palliative care who are dealing with distress about dying.

The clinic can bill a patient’s insurance for every part of the treatment but the ketamine itself. Those infusions cost about $500.

Lewis’s patients are paired with a therapist they retain throughout their treatment, who sits with them during dosing sessions. They’re given the drug in a comfortable environment, as they listen to curated playlists and wear eyeshades to block out light.

The therapist works with them in talk therapy afterwards. And throughout the following week, patients complete exercises, such as guided meditations, through a digital platform. They also answer questionnaires that document their mood, thought processes and other experiences with the drug.

The clinic is working to figure out how to best combine the medication with psychotherapy, Lewis said, from effective dosing to which music to offer. One major question is, “how do you sustain benefits?” Lewis said.

“My hope is that it really helps just inform how to do this,” Lewis said, “because it’s a new field, and there’s not a lot of evidence, and there’s just about a million questions about how to do this in an optimal way.”

Inside Utah’s ketamine clinics

Ketamine Wellness Centers began with one location in Phoenix, Ariz., in 2015, was acquired by Delic Holdings in 2021 and now has 13 clinics in nine states — including one that opened in February in Taylorsville.

Utah had been on its expansion list before the acquisition, said CEO Kevin Nicholson, as he and his partner looked for areas that were struggling with mental health. For example, a nonprofit ranked Utah 48th for its access to care, considering its prevalence of mental health issues.

(Rick Egan | The Salt Lake Tribune) Chloe Hagl talks about one of the treatment rooms at the Ketamine Wellness Center in Taylorsville.

Along with the increase in Ketamine Wellness Centers clinics, their target patients have changed, he said.

”We used to focus purely on treatment resistant depression” — patients would either have a previous diagnosis or be diagnosed in a screening with an on-staff clinical psychologist, Nicholson said.

That industry focus was, in part, driven by “fear of litigation,” in Nicholson’s view. But Ketamine Wellness Centers have since changed their model, serving a broader array of patients, Nicholson said, and they aren’t the only provider to do so.

The clinic can treat mental illnesses such as post-traumatic stress disorder, obsessive compulsive disorder, anxiety and depression, usually in six sessions of intravenous ketamine over several weeks, said Belinda Brokke, clinical administrator at KWC’s Taylorsville location.

The center provides an average of about 50 to 60 treatments a month, Nicholson said. Each session costs $449. Historically, health insurers haven’t covered ketamine for most mental illnesses, though more are starting to provide that coverage, Brokke said.

“I’ve had a couple of patients actually get completely off all of their medications” after ketamine therapy, Brokke said.

Side effects are generally minor — dissociation, high blood pressure, nausea and headaches — but KWC patients are monitored, she said. About half of people getting ketamine treatment for mental health get nauseous three or four treatments in, as the provider tries higher doses, Brokke said.

There are risks associated with ketamine use, especially for someone with an underlying condition, such as a history of psychosis, bipolar or personality disorders or substance misuse, so providers must appropriately screen potential patients, Lewis said. There’s also a risk for heart or airway malfunctions when doses are too high.

A standard dose is .5mg per kilogram of a person’s body weight, Lewis said, adding that formula was derived from earlier research on ketamine infusions for depression. The issue for all methods of ketamine treatment is that different people metabolize it differently, which is a “good theoretical reason to have a little bit more flexibility on dosing,” he said.

Starting a ketamine clinic requires specific approvals from the Drug Enforcement Agency and Utah’s Division of Occupational and Professional Licensing. And emergency response systems must be in place, Lewis said, though “this terrain is not very regulated at present,” meaning the quality, level of training and experience of providers can be inconsistent.

Clinics need someone authorized to prescribe the drug and to administer it, Nicholson said. For example, in Utah, a physician, psychiatrist or a nurse practitioner could prescribe ketamine to a patient, and a registered nurse or paramedic could administer it, he said. KWC clinics follow requirements set by the American Society of Anesthesiologists for monitoring, documenting care and assessments, Nicholson added.

Under current laws, patients given ketamine can be left alone, with some level of monitoring of their vital signs. And under the federal public health emergency declaration about the coronavirus pandemic, some people are acquiring ketamine via telemedicine.

‘That feels completely different’

Antidepressants helped Dane McFarland when he was teenager.

He stopped taking them as an adult. But after completing a bachelor’s degree and starting to work in sales, he felt his mood deteriorating again. He tried what he calls “a litany” of conventional treatments without finding relief.

Now in his early 30s, McFarland began ketamine treatments at Affordable Ketamine Clinic in Kaysville in 2021. He schedules therapy sessions to prepare before treatments, which he has been getting about every six weeks.

“Sometimes you get the nice experiences of self actualization and unpacking things,” he said. “And sometimes it’s a really hard look at yourself through a microscope, and it’s weird, both of those are useful.”

He offered this description of how he feels ketamine has helped him: Imagine “kind of a pleasant day,” with blue skies and few clouds, as “normal” for most people. “For a person with depression … there are clouds over, it’s probably drizzling. And that’s normal for us.”

”After the ketamine treatments, it feels like my normal is now closer to like what today is,” he said, on a clear day. “And that feels completely different for me.”

He still has depression, he said. “But I feel like, hey, I don’t have like 20-pound weights [on me] trying to go through the day. That feels great.”

Goodwin, who lives in Saratoga Springs, dealt with depression as a teenager, and then with postpartum depression after having children in her late 20s. She has struggled with major depression through her 30s and now into her early 40s.

(Francisco Kjolseth | The Salt Lake Tribune) Christie Goodwin gets a first dose of a ketamine treatment from nurse practitioner Anne Vincent, owner of the Promise Medical Family Practice and Ketamine Clinic in Orem.

When she began ketamine therapy three years ago, she filled out surveys about her mood each time, and she estimates it took about two months for her self assessments to improve. She began with sessions twice weekly and has tapered down to roughly every three weeks, though she would go closer to every 10 days if she could afford to, she said.

She first used Spravato, the nasal spray, which her insurance covered. She switched to getting intramuscular ketamine injections, at $199 a session at Promise Ketamine, and tried intravenous ketamine in December.

Ketamine doesn’t help everyone, she said, but she’s “all about dismantling stigma” around trying it.

“Even when I get depressed now, it’s never quite as bad as it was then,” Goodwin said. “So to me, that’s a gift I’m very grateful for.”

Editor’s note • Paul Huntsman, who is chair of The Salt Lake Tribune, is a member of the Huntsman family, which provided funding to found the Huntsman Mental Health Institute.

Leto Sapunar is a Report for America corps member covering business accountability and sustainability for The Salt Lake Tribune. Your donation to match our RFA grant helps keep him writing stories like this one; please consider making a tax-deductible gift of any amount today by clicking here.