La Jolla clinic laments loss of authorization for ketamine treatments for veterans with depression

The La Jolla campus of the San Diego Veterans Affairs Healthcare System is the main hospital for veterans in the county.

“It was like a bomb went off in our clinic,” Renee St. Clair, chief operating officer of La Jolla-based Kadima Neuropsychiatry Institute, says of getting a call from the Veterans Affairs San Diego Healthcare System indicating it would no longer authorize the clinic’s administration of the drug ketamine as an anti-depressant for veterans.

Kadima founder and medical director Dr. David Feifel has been using ketamine to treat veterans with depression for more than 10 years, many of them with referrals from the VA.

“These are not run-of-the-mill, ‘I had a bad childhood so I need therapy’ patients; these are people with severe PTSD that have tried everything,” St. Clair said. “These are the worst of the worst that need something, anything.”

But in September, “we got a call from a claims staffer from the VA Community Care Center who told our receptionist to stop treatment and we needed to stop treating all vets,” St. Clair said. “We thought, ‘What is happening? You can’t just cut them off.’ But that’s what they told us to do.”

At the time, Kadima was treating about 30 veterans.

St. Clair immediately began communicating with the VA, saying there would be an increased suicide risk for those cut off from the drug.

Some patients got word that their treatments might no longer be authorized.

“It was a bad scenario,” St. Clair said. “It was just awful. One of the vets that Dr. Feifel had been treating for five years sent him an email basically saying it was her lifeline and she doesn’t have anything to live for, and killed herself four days later. The next day we got an email from the VA indicating we had received retroactive authorization for her treatment.”

“In April, we got authorization for six months of weekly treatments, but for some that will run out sooner because they get their treatment more than once a week,” St. Clair said. “Once those run out, I’m sure that’s the end of that. I don’t know what’s going to happen to these people.”

However, the San Diego VA said no patients will go without care.

“Patients will receive ketamine from VASDHS or the community provider as they are transitioned to VASDHS by Sept. 30,” according to spokesman Christopher Menzie.

Menzie added that the patients would receive “veteran-centric and comprehensive care for treatment-resistant depression, including intranasal and intravenous ketamine. These treatments are FDA- and VA-approved and are considered the standard of care for ketamine treatment for treatment-resistant depression.”

“By contrast,” Menzie said, “the intramuscular ketamine injections that have been administered by Kadima are not considered standard of care by the VA and the rest of the field.”

St. Clair acknowledged that Kadima uses ketamine “off label for depression” and that it is not a Food and Drug Administration-approved use of the drug.

At the time of St. Clair’s interview with the Light, she said 10 vets had been moved to the VA for care.

In March 2019, the FDA approved Spravato (esketamine) nasal spray, in conjunction with an oral anti-depressant, for the treatment of depression in adults. It is manufactured by Johnson & Johnson and is derived from ketamine.

As of January, Menzie said, VASDHS has been administering ketamine to patients with treatment-resistant depression first with Spravato, then, if patients don’t respond to Spravato, they have the option to receive ketamine intravenously.

However, St. Clair argues that the two drugs are “different species.”

“Ketamine has been around since the 1970s, maybe earlier, used during the Vietnam War,” St. Clair said. “It’s fast-acting and takes away pain.”

With Spravato, “the dosage is really low, you can’t adjust the dosage, it’s self-administered as a nasal spray — it’s just different,” St. Clair said. “It has a great place for someone early in their depression … which is fantastic. But for vets with severe conditions, it is not equivalent.”

An investigation by inewsource, a nonprofit journalism organization in San Diego, reported on veterans who said Spravato did nothing for them, and it said the VA gave “contradictory” or “untrue” explanations for the change in treatment.

“I don’t think we’re done losing our vets over this,” St. Clair said. “We have a few that I am personally terrified for.” ◆