Ketamine

We applaud last week’s front-page article high-

lighting a newer treatment for depression. It

stated that ketamine could treat depression, and

touched on cost, access, side-effect and data issues. We

have been in academics as well as practicing psychiatry

in Jackson for more than 30 years and wish to add useful

context to this article.

1. Jackson Hole has more therapists/clinicians and

money than most places. Thus, ketamine treatment

is somewhat easier to obtain here and the cost (about

$2,000-$4,000 for the initial half-dozen treatments) is

more easily absorbed. However, nationally there many

tens of thousands of prescribing practitioners,

and costs are coming down, particularly as in-

surers are increasing coverage. The following

comments are from a countrywide (as opposed

to countywide) lens. Over half of people in the

United States with a depression diagnosis are

untreated. And of those who are treated, more

than 95% is done using traditional psycho-

therapy and/or antidepressants.

2. The treatment of depression has been an evolving

fi eld for the last 130 years. Psychotherapy (often referred

to as “counseling”) started around 1900 and continues

to evolve. Some of the other earlier treatments, such as

insulin shock treatment and lobotomies, were abandoned

within decades of their appearance about 100 years ago.

Psychopharmacology (antidepressants, mood stabilizers)

and electro-convulsive treatment entered the scene at

a similar time, both continuing to evolve. ECT is much

better than in Jack Nicholson’s “One Flew Over the

Cuckoo’s Nest” time. Trans-magnetic stimulation (TMS)

became FDA approved in 2008. Psychedelics (including

LSD, psilocybin, DMT), empathogens (MDMA, known

as ecstasy) and dissociative anesthetics (ketamine) were

used recreationally since mid-last century, but within

the psychiatric quiver this century. However, most use is

either off-label/non-FDA-approved (the majority of ket-

amine treatments) or only investigational (psychedelics

and empathogens).

3. Current accepted psychiatric treatment is evidence

based. The longer a modality is around, the more data

evolves delineating the benefi ts and problems. However,

clinical enthusiasm often overapplies newer treatments

until such data has been developed. In the 1950s, psycho-

analysis was considered a treatment for almost every-

thing. In the 1980s, Prozac emerged and was considered

effective for almost anything that ailed you. But, patient

selection matters. Being able to say, for example, “With

your history and your previous response to treatment,

you are a good candidate for ketamine,” is where we want

to go. Randomized control trials are slow and costly, as

there are so many variables. In the end, one would like

to answer the questions: Which treatments? Combinedwith which other treatments? At what intensity? For which patient?

With which problem? For how long? By a

clinician with what training/experience? Leading to what

result and for how long?

4. Current protocols for treating depression include

psychotherapy or antidepressants for mild to moderate

depression. The gold standard — if one of these doesn’t

work — has been a combination of both of them, along

with encouraging self-help (including depression hygiene,

focusing on exercise, good sleep, good eating, structure). If

the depression is so severe that it is “treatment resistant”

to these approaches, then TMS or ketamine or ECT treat-

ment is added. There are some people (and practitioners)

who suggest that they somehow would prefer

to initiate fi rst treatment with ketamine (or

psychedelics). Decade(s) from now, there will

be different algorithms, but psychiatry has

“best practice” protocols, as of 2025.

5. There is no free lunch: Every interven-

tion has benefi ts and problems. The only rea-

son to use a given treatment is if the benefi ts

outweigh the costs. Sometimes there aren’t many (seri-

ous) problems, such as with exercise or as was thought

with Prozac when it fi rst came out and became widely

used by primary care providers to treat depression. Over

time, side effects get more sorted and quantifi ed. With

ketamine, the side effects currently seem overall mild.

However, we have a young family member who sustained

serious urological complications from overuse of ket-

amine. Time will tell.

6. Enthusiasm for these new interventions (ketamine

and psychedelics) is high. There are at least a dozen con-

ditions in addition to depression, with some data for ef-

fectiveness. MDMA (ecstasy) almost got FDA approval for

PTSD last year. There are anecdotal reports of ketamine

and psychedelics (micro-dosing, “psychedelic psychother-

apy”) used — it seems — for almost everything. Again,

time will sort out what works and what doesn’t.

In sum, ketamine is one arrow in an exciting and evolv-

ing quiver of methodologies for enhancing human well-

being. We continue to develop better arrows. But we also

need to be mindful of the target. The psychologist Abra-

ham Maslow conceptualized “defi ciency needs” and “being

needs,” the former including depression, anxiety and sub-

stance abuse, and the latter including self-actualization,

personal growth and living life to the fullest. Whether we

are aiming at being or defi ciency targets, utilizing psycho-

therapy, psychopharmacology, meditation, psychedelics,

and/or just living well in Jackson Hole, we have a mantra

in our practice. Move ahead one step at a time, making

tomorrow’s version of yourself better than today’s version.