FEATURE: Stable Feelings

By on August 16, 2017

A psychedelic club drug has found its way into depression treatment. But for at least one woman, ketamine is better left on the dance floor.

 

“Tough Break” by Taryn Boals | tarynboalsart.com


JACKSON HOLE, WY – When we arrived at the University of Utah Neuropsychiatric Institute on an early September afternoon in 2016, the sturdy, modern brick structure seemed palliative in itself. For nine months I’d been in a severe depression; no amount of antidepressants, antipsychotics, talk therapy, dietary changes, exercise, or meditation had made a dent. Now my husband had driven me four and a half hours from our home in Jackson Hole to my first ever treatment facility in Salt Lake City.

Living in the rural West means being at a distance from state-of-the-art psychiatric care. In Jackson Hole, patients can receive top-level orthopedic treatment because surgeons are eager to live in a world-renowned ski town where a fresh crop of torn ACLs is guaranteed each season. However, psychiatrists, who are not nearly as well-paid and who are in short supply nationwide, find little draw to Jackson, where they would still have to piece together a client list without the support of a larger treatment facility.

For patients like me, whose mental health issues are not as in vogue as sports-related ailments, living in a small Western town often means seeking adequate care further afield—at your own inconvenience and expense. Like other people I know with severe depression or bipolar disorder, I had exhausted my options for treatment in Jackson and had no choice but to travel hundreds of miles to get well.

The University Neuropsychiatric Institute, or UNI (pronounced “You-Nee”) resides in an unfussy professional building on the university campus. With carefully manicured lawns and flowerbeds, it has an air of self-confidence. Large panels of windows line the front entry, and the lobby is lit in part by a skylight. There is a friendly receptionist at a sprawling desk, and a gift shop (neuropsych memorabilia for the whole family!). Graduate students bustle around with notebooks under their arms. This was clearly a place where sanity and balance would be restored, efficiently and sensibly.

Our destination was not, however, this main bastion of academic pulse and mental civility. I had an appointment at the Treatment Resistant Mood Disorder Clinic. As its name implies, the clinic is where doctors send patients when they can’t fix them with standard meds.

My husband Mark and I were directed to follow a labyrinthine route to the back of the building. We knew we had arrived when we passed through a metal hospital door and the comforting speckled carpets and photos of Arches National Park gave way to an off-white linoleum and bare walls. Let’s call the look “warm sterile.” Gone were the cozy offices and bright-eyed grad students. This was where the serious shit happened. Electro-convulsive shock therapy. Transcranial magnetic stimulation. Ketamine infusions.

I was there for the latter. I remember first hearing about ketamine in 2012. Researchers had released a report about ketamine’s ability to relieve major depression in a matter of hours. Scientists from Yale University and the National Institute of Mental Health had determined that ketamine caused new connections to form between nerve cells in parts of the brain associated with mood and emotion. I had been jonesing to try it ever since. But it’s expensive, and until recently was only performed at facilities on the East Coast. The use of “jonesing” makes it sound like I’m some kind of street-drug-knowledgeable person. I am not. The only recreational drug I’ve ever used is marijuana when I was 17. It didn’t go well—I ended up a ball of paranoia in the corner of a room. However, learning about ketamine’s magic for depressives made me think, “Bring on the K hole!”

Veterinarians know ketamine as a horse tranquilizer. Ravers know it as Special K, or simply “K,” a powerful dissociative that can cause near death experiences. First introduced for clinical use in 1970, ketamine is a standard medication used for anesthesia and pain management. Its antidepressant effects are a new discovery. Facilities like UNI have begun offering intravenous ketamine treatments to depression patients who can pay. Two sessions a week at $700 a pop, not covered by insurance.

Maintaining sanity when you’re mentally ill is indeed not cheap. Insurance may cover some medications and maybe 10 therapy sessions a year. For me, being financially stable has not protected me from becoming depressed, but it has certainly helped me pay for treatment. I fear for people living in poverty, who, according to a 2012 Gallup poll, are twice as likely to suffer from depression (31 percent, as opposed to 15.8 percent of people not living in poverty). A breakthrough therapy like ketamine is entirely out of reach for a demographic of people who may need it most.

Freaks welcome

At the reception desk, we were greeted by Chelsie (not her real name) with whom I had been corresponding to register for the treatment. I immediately knew Chelsie because, as promised, she was the one with the purple hair.

This is a good a time to reiterate that I was there for a reason. My head hurt all the time, my limbs felt leaden, I wanted to cry and/or collapse and be put out of my misery. Joy was a feeling-state completely out of my grasp.

I suppose I was fortunate in that I could still walk and even manage to smile, though not with authenticity. I could still go through the motions of much of daily life, including eating, showering, dressing, and taking my medication that wasn’t working. The fact that an evil presence had wrapped itself around my mind and heart and was slowly strangling the life out of me was not apparent from the outside. Probably to Chelsie I looked a little worn down or subdued.

Chelsie’s purple hair did offer me a glimmer of delight, beckoning like a human-head-shaped banner, “Freaks Welcome Here.” I was verifiably a freak. I had treatment-resistant depression. Like 30 percent of people who suffer from depression, I had only a partial response to the medication I’d been taking for more than a decade. The medication helped. But it didn’t prevent me from falling into two major depressions in my 40s.

Still, I thought of myself as one of the lucky ones. Another 30 percent of people with depression don’t respond at all to the available treatments. You can think of us depressives in a pie: one-third get remission from medications, one-third get partial results, one-third get no lasting relief. “That’s a dismal failure rate for a class of drugs designed to improve a person’s basic ability to function,” a recent article in TIME magazine noted.

Chelsie and the other nursing staff were jovial and welcoming, unfazed by my, or any other patient’s, inner turmoil. Chelsie seemed a part of the treatment, a form of transference not new to me. I can’t tell you how many receptionists and pharmacists I’ve had disproportionate feelings of attachment to, the secondary characters in the drama of mental health care who cheerily, efficiently play their parts. I want to kiss them for not reacting to me like the deranged beast I have perceived myself to be.

“It’s why I do what I do”

Ketamine treatment for depression is not yet FDA approved, so any treatment a patient receives is essentially experimental. The medical community is only beginning to explore ketamine’s effect on people with depression. In April 2017, a task force of the American Psychiatric Association issued a report based on a mere seven clinical studies involving 147 patients.

As the task force noted in JAMA Psychiatry, “The existing data surrounding the benefits of repeated infusions of ketamine remain limited … The lack of clinical trials in this area makes it difficult to provide suggestions on the frequency and duration of treatment with even minimal levels of confidence. Most studies and case reports published to date on this topic have examined the effects of less than one month of treatment.”

Can you imagine going in for treatment for cancer and trying a drug the doctors say that has only been clinically tested on 150 people, and only for efficacy of one month?

My doctor at UNI, Dr. Kendrick, explained during my intake interview that their clinic had seen encouraging results thus far. Mirroring numbers found in the literature on ketamine for depression, UNI has a 52 percent success rate among patients.

“These folks get better at a disproportionally higher rate than with traditional antidepressants,” Kendrick told me in a recent interview. “Seeing those numbers bear out is the part of this that keeps me engaged. It’s why I do what I do.”

As excited as he is about experimental depression treatments like ketamine, Kendrick is also a realist and he makes sure his patients are too.

“Ketamine is not a cure,” he said. “It’s a medicine like any other. If you stop taking it, your symptoms will recur.” What that means for long-term remission is that a patient would need to keep shelling out the big bucks to receive maintenance infusions. Kendrick said they do have a few patients at UNI who are able to do this financially and come in once a month for an infusion. So far, for that handful of patients, the treatment has kept their depression at bay.

Many people, like me, want to see if ketamine will work for them, Kendrick explained, and worry about the long-term plan later. “Patients tell me, ‘At least it would give me hope,’” he said. “They are aware that FDA approval might be forthcoming and they want to find out if it does work.”

It may be difficult for non-depression-sufferers to grasp just how appealing any kind of relief for any duration can be. For me, the possibility that my depression could be erased by one infusion was too tantalizing to pass up. I don’t think I even thought about the long-term efficacy. I was exhausted and I needed a break, any kind of break, to remember that I did have the capacity to feel good. After nine months of unrelenting depression, I’d nearly forgotten that I’d ever been un-miserable in my life.

A nurse ushered me to a hospital bed sticking out like a pale tongue in the middle of a dim room. She hooked me up to an IV and various wires. I was covered in blankets because the lab room was freezing and I wore a summer dress appropriate for the 85 degree heat outside. I’d wanted to seem sane, presentable, but now I wished I had on my rattiest sweatpants. Mark sat next to me in a drab, plastic chair. Fifteen feet away and behind a curtain, another ketamine patient from Jackson Hole rested on his bed. Piped-in classical music filled the room, which was otherwise about as welcoming as a large broom closet. Cabinets and sinks lined the far wall, which boasted one window. The nurse told me that one of her patients liked to watch the trees swaying outside the window during his treatment. He must have had a vivid imagination.

Kendrick arrived and gave the OK to start the infusion. If I had feelings of fondness for Chelsie, the good doctor warranted adoration. Trained as a child psychologist, Kendrick devotes part of his time to ketamine treatment in adults. He said he appreciates the balance this provides him as a clinician between working long-term with patients as well as helping people see quick results.

“I love what I do,” he told me when I spoke to him recently. “I spend my time working with a population in which there are severe mental illnesses. Mental health is such a struggle for so many people. I enjoy sitting with people in that struggle.”

To a depressive’s ears, those words are more than music, they are a lifeline. Not many people want to enter your illness with you. “There’s nothing more intimate than sitting down and having people talk about things they might not tell anyone else in their life. It’s a vulnerable place to be and I take it seriously,” he said.

Down the K hole

Once the ketamine infusion started, 10 minutes passed before I noticed anything odd. Then, increasingly, objects in my field of vision would leave tracers as I shifted my gaze. It felt like a cross between being drunk and being at the eye doctor when they put dilating drops in your eyes and you lose your ability to read up close and everything becomes shiny and too bright. When I blinked, I couldn’t tell how long my lids were closed. A normal blink amount? Ten seconds? My pulse became very loud in my head like when my sinuses are stuffed with allergies. I tried to smile at Mark but my face was suddenly that of a stroke victim. “Do I look funny?” I asked. He patted my hand reassuringly and said no. “I feel like Gumby,” I said, trying to enunciate.

This ended up being the fun part of the trip, which is saying something. I wish I had talked to someone who had done ketamine recreationally so I knew what to expect. A good friend of mine who has used the drug many times was surprised to learn that it was being administered to people with depression. “It’s a fucking crazy drug,” she said. In her rave days, she encountered ketamine users seeking different experiences. “There were the introverted folks who preferred slumping into a corner over joining their saucer eyed friends of the dance floor,” my friend recalled. Other users enjoyed the ecstasy-like euphoria with K, that, according to my friend, ensued if they snorted just the right amount—i.e. not enough to fall into a K hole.

Maybe it was a mistake to have done my homework about ketamine’s large animal tranquilizing capabilities. I grew up around horses; I started riding when I was five years old. I feel a kinship with them. Their big, solid bodies and deep, curious eyes are a source of comfort. I love their dusty, horsey smell, their gentle and sometimes feisty spirits. Few feelings compare to that of a horse muzzle against my palm. As an adult I haven’t spent nearly as much time around horses as I would like, but they are still very much in my psyche and in my blood.

Perhaps it’s only natural that once the ketamine infusion began, I turned to horses in my imagination to soothe myself. I closed my eyes and imagined a horse lying on the ground, tranquilized. Holding the gaze of the horse’s big placid eye, I told her we were going to be OK, even though it was entirely unclear to me that we would be. The horse was trapped in herself, only able to blink her eye. We floated there in what I imagined Tibetan Buddhists might call bardo, a state of existence between death and rebirth. Then I began to panic that I was doing something wrong, that I had somehow caused the drug to have an ill effect on me. Why was I not joking around with the nurse like the patient next to me? I could barely speak. Tears began streaming down my face and all I could see was the horse lying immobilized, which was the saddest sight in the world to me. Instead of being reborn, I imagined us dying.

Kendrick had warned me the effects of ketamine would become more intense right at the end of the infusion when they flushed the last remaining portion of the dose into my system. This was what I was experiencing as I began to panic about dying. I closed my eyes and waves rushed in my ears. The horse and I were drowning. The tears continued to flow. Mark held my hand, but I couldn’t feel him. I was in a dark well separated from the world, it going on without me. I had somehow failed. Kendrick and the nurse came up to reassure me, but I could see from their worried faces that mine was not the typical patient response. “I’m so sorry,” I told Kendrick through my sobs. He told me it would be OK, that maybe the final flush of ketamine was too intense and they’d do it slower next time. “I’m really sorry,” I said, as if I’d let him down.

Readers who have taken ketamine recreationally may recognize that I was falling into a K hole. According to Kendrick, 10 percent of patients in a clinical setting have a negative incident like mine. A lucky 20 percent find it euphoric, while 70 percent report simply feeling “weird.” But according to my ketamine-expert friend, the K hole is a common experience. Out of body sensations and teetering on the edge of death are part of the deal. “The thrill, then, became digging oneself out of the hole and returning to reality unscathed,” she said.

Recreational users return to K again and again for what my friend described as the inimitable euphoria that precedes the K hole. “It’s a feeling that compels users to do more and more in one sitting until they seemingly lose control,” she said.

Had someone informed me that feelings of “teetering on the edge of death” and “losing control” were potentially in store for me, I might have thought twice about trying ketamine. Those were not feelings I would suggest inducing in a depressed person, even for 45 minutes. However, the healing properties of ketamine do not correlate with its out of body experiences. According to Kendrick, ketamine’s antidepressant power has nothing to do with the kind of “trip” a patient experiences. He did say, however, that most depression patients who have a negative first episode do not return because they don’t want to go anywhere near that K hole again. I was one of the rare ones, by his account, who came back for another infusion.

Five days after my first infusion, I returned to the clinic armed with my own music. The logic in my head told me ravers understood something important about K and it had to do with your auditory input. If I’d really been on my game, I would have curated an entire playlist for myself. Instead, I picked one of the uplifting albums in my iTunes library, and let myself relax. Lucius’s “Wildewoman” is not what I would describe as particularly profound music. It’s kind of poppy and feminist, good for a road trip. But under the influence of ketamine, some lyrics took on a deeper meaning related to depression that I thought was being secretly revealed just to me:

She’s gonna find another way back home

It’s written in her blood, oh it’s written in her bones

Or

You gotta believe me when I say I know.

You aren’t riding on this wave alone.

My eyesight still went wonky, the blood still rushed through my ears. But I actually had fun during this infusion. My mom was by my bedside this time; she sat happily reading articles to improve her bridge game. During a moment of euphoria, I texted a friend who also struggles with depression: “Ketamine is amazing!” I gushed. “I love you so much! (Emoji, emoji.)”

The final flush of ketamine at the end still wasn’t great, but I managed not to sob. Then they sent me out wobbly into the world, and my mom and I went out to dinner. I tried to engage in some semblance of normal conversation even though my head seemed like it was inside a pillow, or in fact was a pillow. That night I slept fitfully.

The next day I did not arise feeling cleared or released or better in any way. Instead, a full day panic attack ensued. I was dizzy and confused and terrified. And my head still felt like a pillow. Getting a hold of Kendrick took hours (how dare he have a busy schedule taking care of kids with psychiatric problems?) When he did call back around 5 p.m., he had the mercy to tell me I did not need to come back for more treatments. This was the same doctor who, during my intake interview, had the blunt fortitude to tell me that modern psychiatry is about 100 years behind the rest of modern medicine. When I asked him about that comment in our recent interview, Kendrick said, “Psychiatry is desperately in need of the objectivity medicine has. I cannot do imaging of your brain and say, ‘Ah, I see where your anxiety is bad,’ or, ‘Here’s the center of your depression.’ Practicing psychiatry can be like trying to study the geography of Earth from space.”

Kendrick does not mean to disparage his field. Instead, he wants patients to have clear, honest information. “The fact of the matter is that there are no trials that indicate, say, that Zoloft is better than Prozac,” he said. “That’s where the art of practicing psychiatry comes in. I never want my patients to fault themselves for where we are at with psychiatry. Depression is a life-altering illness and I don’t want to over-promise results.”

Tender transformations

Several months later, after I finally found a more successful treatment for my depression, a friend showed me a charcoal drawing that so mirrored my ketamine hallucination it was uncanny. A horse hangs in a sling, as if it has a broken leg or other life-threatening condition that requires its weight to be lifted off its feet. The sling cradles the horse’s belly; it’s legs hang down limply. Where hooves should be, the horse has human hands and feet.

While this was not the exact image in my mind during my first ketamine infusion, the artist’s melding of human and horse conveys nearly identically the merging I experienced. The drawing is not an easy image. At first glance, a viewer might find it unsettling. The more I return to it, however, the more I see great tenderness there. The horse’s sad, resigned eye; her demeanor of surrender. She has no choice but to give herself over to the support, to hope and wait.

I met the artist who made this drawing, Taryn Boals, and she told me she drew it during a difficult time in her life when she herself was going through depression. Making the drawing helped release something, she told me. The drawing gave form to her inner ordeal, something no medicine can do.

Depression, like cancer, is an illness for which the treatment can be as toxic as the disease itself. Ketamine is just one of the various medications I’ve ingested that led me temporarily closer to darkness than light. But my story is not an anti-medication screed. I’ve had just as much trial and error utilizing other therapies: the Paleo diet caused an emotional breakdown, years wasted with ineffective therapists kept me more miserable than happy, and trying to look on the bright side only caused more internalized shame. While ketamine may not have budged my depression, it did give me a potent image for my experience: the horse in bardo, releasing her weight into the sling that undergirds transformation. PJH

Meg Daly is a freelance writer based in Jackson, Wyoming. Her work has appeared in Homestead, The Oregonian, Oregon Business, Women’s Review of Books, and other publications. She is the editor of the 1996 anthology, Surface Tension: Love, Sex, and Politics Between Lesbians and Straight Women. Daly is working on a memoir about her experiences with depression and treatment.

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About Meg Daly

Meg Daly is a freelance writer and arts instigator. She grew up in Jackson in the 1970s and 80s, when there were fewer fences, but less culture. Follow Meg on Twitter @MegDaly1

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