Stanford Medicine News Center - May 19th, 2017 - by Tracie White
Geuris “Jerry” Rivas, a native of New York, was diagnosed with severe obsessive-compulsive disorder when he was 15. Obsessions with organizing and reorganizing the belongings in his bedroom — posters, comic books, videos — took over most of his day.
Forced by germ obsessions to compulsively wash and rewash his hands, he started wearing gloves all day to both protect him from the germs and stop him from washing his hands raw. Now, at 36, OCD symptoms continue to cost him jobs and relationships. He’s managed to turn his organizational skills into a profession — he’s a home organizer and house cleaner — but still he struggles daily with his obsessions, missing work, risking relationships.
“It’s caused me a great deal of suffering,” Rivas said. “I’ve tried many, many medications. I’ve wasted so much of my life.”
In 2012, running out of answers, Rivas took part in a clinical trial to try ketamine as a treatment for OCD. The trial was run by Carolyn Rodriguez, MD, PhD, then a researcher at Columbia University and now an assistant professor of psychiatry and behavioral sciences at Stanford Medicine.
And with a single infusion of the drug, he experienced, for two weeks, what it was like to live without the compulsions and obsessions that had for years controlled his life.
“I felt like, for the first time, I was able to function like a regular person,” he said.
Beginning more than a decade ago with a study funded by the National Institutes of Health that showed ketamine infusions inducing dramatic improvements in treatment-resistant depression, ketamine research has burst into the field of psychiatry, spurring studies like Rodriguez’s that have shown success in treating OCD, bipolar disorder and post-traumatic stress disorder.
Researchers have a way to go, though, in determining exactly how ketamine works in the brain and whether another drug might be identified or developed that has the same benefit as ketamine without its addictive potential and hallucinogenic effects. Meanwhile, enticed by headlines about the drug’s efficacy, private ketamine clinics have begun popping up across the country, making costly new treatments available to patients who are searching for help to stop their suffering now. Ketamine is approved as an anesthetic by the Food and Drug Administration, but insurance companies don’t cover its off-label use for mental health disorders. So patients who have run out of treatment options are paying hundreds of dollars a dose for repeated ketamine infusions.
As scientists continue to search for answers about the drug, many patients are already taking the risk of trying it. Advocates say that the dose used for mental health disorders is smaller than that used for anesthesia or by abusers and can be administered safely. But there is evidence from people who abuse the drug routinely — in much higher doses — that chronic, high-frequency ketamine use may be associated with increased risk of cystitis, an inflammation of the bladder, and cognitive impairment, Rodriguez said.
“The fact that these clinics exist is due to the desperation of patients,” said Rodriguez, who is currently researching the drug’s safety as a long-term treatment for OCD. Still, she understands what motivates the clinicians to prescribe the drug now to patients in dire straits — those who are suicidal or who have tried every possible medication and therapeutic option and continue to suffer each day.
“I see it as a way to treat people whose OCD is very, very severe,” she said. “People who can’t come out of the house, who are suicidal, who have no other options.”
Janssen Pharmaceuticals is currently conducting a phase-3 clinical trial of ketamine in people with treatment-resistant depression. The company plans to ask the FDA to approve the drug for use in treating this condition. Alan Schatzberg, MD, a professor of psychiatry and behavioral sciences at Stanford, along with other Stanford faculty including Rodriguez, is investigating the mechanism of action for ketamine in treating depression.
A few academic research institutions have begun offering ketamine treatment to patients, including UC-San Diego and Yale University.
“I think it’s a game changer, and it’s here to stay,” said David Feifel, MD, PhD, professor emeritus of psychiatry at UC-San Diego, who studies the effect of ketamine on clinical depression. Feifel began prescribing the drug for patients with treatment-resistant depression in 2010.
“I’ve found it to be very safe,” Feifel said, adding that the American Psychiatric Association recently issued safety guidelines on how to use ketamine clinically.
“There’s a recognition that people like me and others are using the drug to treat patients now,” he said. “There’s an incredible need for something.”
The drug hasn’t worked for everyone he’s treated, Feifel said, but for many it’s been “life-changing.”
“I usually tell people to wait and see for 24 hours after treatment,” he said. “I had one patient who said she was eating cereal the next day and suddenly it felt like all the lights were popping on in different parts of her brain.”
When Rivas, the patient who received a single dose of ketamine during a clinical trial four years ago, heard that certain private ketamine clinics are now offering the drug as treatment for OCD, he said he understands why patients take the risks and pay the high prices. As more research has become available, he’s begun considering it himself.
“I’ve been suffering through my OCD for so long, I’ve gotten to the point where I’d try anything,” he said.