Dr. David Feifel, M.D., Ph.D., discusses his transition from studying quantum physics to pioneering ketamine and TMS treatments in psychiatry. He shares insights on combining therapies, overcoming institutional barriers, and expanding access to innovative mental health treatments globally. Learn how these approaches are changing outcomes for treatment-resistant patients and shaping the future of psychiatry.
In this captivating episode, we explore Dr. David Feifel's unconventional journey from quantum physics to pioneering psychiatrist. Dr. Feifel shares how his fascination with consciousness led him to psychiatry, hoping to witness a "golden era" of breakthrough treatments. However, his early career was marked by disillusionment as the field remained stagnant, prompting him to seek innovative solutions.
Dr. Feifel discusses his groundbreaking work with Transcranial Magnetic Stimulation (TMS) and ketamine therapy at UC San Diego. He details the challenges of implementing these treatments in academic settings, including the crucial role of set and setting in ketamine therapy. His persistence led to the creation of the Center for Advanced Treatment of Mood and Anxiety Disorders (CATMAD), where he combined TMS and ketamine treatments with remarkable results.
The conversation then turns to Dr. Feifel's decision to leave academia and establish the Kadima Neuropsychiatry Institute, allowing him greater freedom to innovate. He also shares insights on his work expanding ketamine therapy to Rwanda, highlighting the challenges and rewards of adapting treatments to different cultural contexts. The episode concludes with a discussion on the future of psychiatry, including the complex interplay between innovation, regulation, and economics in bringing new treatments to patients.
Throughout the episode, Dr. Feifel emphasizes the importance of thinking beyond traditional pharmacological approaches in psychiatry, advocating for a more holistic and innovative approach to mental health treatment. His journey offers valuable lessons for clinicians and researchers looking to push the boundaries of psychiatric care and improve outcomes for patients with treatment-resistant conditions.
00:00:00] Things started to change. I saw things I'd never seen before. People with chronic depression, severe suicidality after, you know, sometimes after one infusion, just feeling like for the first time in their lives, they didn't have depression. And I was like, wow, there really is something to this.
Welcome to the Psychiatry Tomorrow podcast. I'm Dr. Carly MacMillan, and in each episode, we interview thought leaders in the deep end of psychiatry's next frontier. Dive into the latest research, innovative treatments, technology, and policy developments shaping the future of psychiatry. Join us on this journey to discover what's next in mental health care so you can stay ahead of the curve.
Hello. Today we're chatting with Dr. David Feifel, a visionary in the realm of psychiatry. From leaving a tenured position at UC San Diego to start Kadima Neuropsychiatry Institute, [00:01:00] to his groundbreaking research on novel treatment targets like oxytocin, to launching TMS and ketamine programs, he's been at the forefront of mental health innovations.
That's right. For those unfamiliar, Dr. Feifel has always had an eye on the horizon, but it wasn't always rosy. He recalls a time when pharmaceutical companies were backing away from drug discovery in psychiatry, given our lack of understanding of the biological basis of psychiatric disorders and the high cost of drug development.
He felt stuck with treatments from the 60s. Maybe, maybe you can relate. Absolutely. Absolutely. But much like I think both of us, uh, he hoped psychiatry's golden arrow was coming and he didn't just sit with that frustration. He took Truly bold steps, like investing very early on in the TMS machine, starting a ketamine program in the PACU at his institution at the time.
But what's truly compelling is how he navigated the challenges, especially when the initial results weren't as promising as he had hoped. And the unexpected reasons why an [00:02:00] outpatient cancer treatment center proved to be the perfect testing ground for ketamine for mental health. Yes, he took lessons learned from the PACU days about set and setting, um, to establish the nation's first ketamine infusion therapy clinic in 2008.
After breaking free of the constraints of academia, he started his own private practice and expanded his impact globally, taking this expertise to help establish ketamine therapy in Rwanda. Yeah. It's a beautiful melding of science and compassion. Yes, and we'll also delve into his intriguing research, exploring the future of psychiatric treatments.
From quantum physics insights to our excitement for the emerging golden era of psychiatry, it's a ride you won't want to miss. So gear up for a deep dive into the brilliant mind and work of Dr. David Feifel. We're ready to get started. Absolutely. And let's jump in.
Dr. Feifel, David. Take it from the beginning. How did you [00:03:00] choose psychiatry? Uh, well, it depends on how far back you want to go, but really the, I, I would say the orange, orange origins of it was a, um, a fascination I actually had with, um, uh, consciousness, the whole concept of consciousness back, which started in high school, which actually Uh, uh, uh, emanated from an interest in, um, quantum physics, believe it or not.
I don't, you don't want to ask me too many questions about that, but, um, I, uh, I picked up a book. I was, I was, I was just fascinated about the concept of time. Like, why are we able to go back to places in space that we've never been? visited, but not back in time. And I thought, I wonder if anyone's ever like, if we know anything about time, except the intuitive notion of time.
And, um, I, uh, found that there was actually a book, uh, by [00:04:00] physicists and there's a whole bunch of stuff from Einstein onwards, uh, about that we know about time. And it led me to, uh, uh, a field of physics called quantum physics and blew my mind, literally blew my mind because what, what quantum physics said, and this is not a, uh, kind of, uh, out there interpretation, like conservative, uh, physicists interpretation of experimental findings at the subatomic level was that, um, well, you know, the question about in the forest, if, um, If a tree falls and nobody's there to hear it, does it make a sound?
Well, according to quantum, uh, physics, quantum mechanics, the answer is no. That actually, uh, uh, matter requires a, um, requires a conscience observer. Uh, to bring it into reality, which is a really interesting thing because we think of, uh, we [00:05:00] don't, we, we think of matter as being out there, uh, solid and real.
And it may be, uh, I think the current prevailing, uh, belief in biology is that the, you know, matter creates the brain and brain creates consciousness. And here's the saying that actually cautious creates the things that make up the brain. So that's kind of a strange loop. Um, And so I wanted to become a quantum physicist, theoretical physicist.
But then I kind of thought, well, it sounds like consciousness is more important because consciousness makes physics. So I got interested in the brain and to fast forward, I decided that, uh, you know, um, great thing to do would be to get a PhD in neuroscience and, and go through the medical route. And, uh, uh, psychiatry seemed like it was the closest to studying the things was interested in.
Um, uh, you know, I first was interested in neurology, but it seemed like they were more interested in how things were wired together and, uh, and how, how they [00:06:00] moved body parts. And I was more interested in consciousness in the mind and long story short. So I, when it got into medical school, I did an empty PhD and I came to, uh, UCSD to do my, um, uh, my, um, residency in psychiatry.
And, um, it's very hard to study consciousness. I mean, it's not a lot of funding for it. And if you're a doctor, they want you to, they want you to study things that, uh, have practical applications. And I, and, and so I, uh, kind of, um, uh, got caught up in, um, trying to understand, uh, why. Our, uh, treatments, uh, are so limited and what are the, uh, I would, I would say Allison, one of the other, uh, things that really kind of confirmed, uh, the choice of psychiatry was that I wanted to be part of a field that was gonna really make [00:07:00] advances.
And I just felt that, uh, psychiatry was going to have a golden era during my residency, you know, just during my career, I meant to say, sorry. And, um, Uh, and so I, cause I was like, you know, this was, this was in the, uh, eighties and scans, you know, new, new technology, brain scans were opening up the brain and we were just able to, uh, you know, research and, and elucidate the, the workings of the brain in ways that.
unimaginable before I thought, wow, there's going to be a golden era, uh, in the, in, in the treatments that come out of this, in the field of psychiatry, just like years before there was a golden era, you know, in, uh, in car, in cardiac surgery where they, you know, Trent in the sixties, they were able to transplant hearts and all those surgeons became, you know, pioneers.
So I said, this would be a great, [00:08:00] uh, uh, great field to go into. Be part of that, uh, golden era and help, and help kind of drive the field forward through that. And then I guess one of the things that happened was, uh, you know, a decade into my career, I started to question whether, uh, I was right about that because I found myself still prescribing things that, uh, you know, my, you know, mentors in medical school had been prescribing, you know, when they were, uh, residents.
And I thought, Hmm, I might've miscalculated, uh, the translation of all this exciting science into, um, into, uh, applicable, you know, real applicable, uh, treatments might not occur in my career. So I got very nervous. Uh, Uh, and started to really, and, and I, and I was doing research looking at new, new [00:09:00] targets, uh, new, new things that couldn't, and there was a lot of exciting things in the, uh, in, in the lab and in my animal lab.
But when we brought them to, to test in humans, they didn't pan out. So I was getting a little bit despondent that I might have miscalculated. And, uh, and the field wasn't really going to change much because it looked pretty, uh, pretty static. So it seems like the golden era hadn't materialized and you're kind of feeling stuck and frustrated.
So what happened? Well, you know, when, when you're, when, when you're feeling, uh, almost despondent and desperate, it, you, you're, I think, uh, the, the. more willing to take chances. And, uh, um, a couple of things happened. There was this technology that I was keeping my eye on called transcranial magnetic stimulation.
And I thought it was really interesting. It was the idea that we could non invasively stimulate areas of the brain and remediate [00:10:00] the abnormalities that underlie, um, these, you know, conditions like, uh, depression and anxiety and OCD, because we were learning a lot about them from, uh, like brain scan studies of, you know, what, what's the underlying, uh, neuroanatomical pathology.
And so we, we, we knew, We were getting a lot of traction, but we didn't know how to change that. So I thought, wow, TMS, that's really interesting. So I was, I was keeping my eye on that. And then it actually got approved, uh, for depression in 2008. And bam, I was right on it. And I went, I was right there. But at this time, I'm, you know, I'm, I'm a professor at UCSD and, uh, I might've been an associate professor.
I don't remember exactly, but it was 2008 and, uh, you know, I, I, I wanted to get, to get one to, and I went, I'm going to my chair at the time and saying, We got to get one of these machines. Uh, this is [00:11:00] this, I, I think this could be, you know, the future of psychiatry and it was, it didn't go over very well.
Sounds kooky. Yeah, this will never. And I was very adamant and I, I struck a deal. Um, where I kind of, uh, guaranteed, uh, uh, cause part of it was financial. We had to buy this, this, this device. And, um, so I, I, I basically guaranteed that, that we would cover the costs, um, you know, through using it and, um, and if God, um, you know, we would, uh, I had, uh, discretionary research from clinical trials.
So. So, uh, I convinced the department to purchase, uh, one of the first, uh, devices, certainly the first in San Diego and the first in the country. And I started doing it at the time. I mean, it wasn't covered by insurance. It was, uh, it was just very exciting. It was, it's dealt like, okay, psychiatry [00:12:00] is, uh, I mean, it's a procedure, you know, we're actually Yes.
Uh, we're not just, and, and it, it felt like maybe it's not a pill. Yeah, it's not a pill. And, uh, and, and actually, Alison, what's really interesting also is, uh, that it was one of the first things that were designed deliberately rather than, you know, uh, found by, uh, by serendipity as the medications were. So, I mean, there was a clear theory based on, you know, physics, um, and, and Faradays, uh, uh.
Uh, principles, uh, Michael Faraday from the, uh, uh, 19th century, uh, you could induce, you know, uh, uh, current in the neurons and exercise them, if you will. And then people kind of, you know, pursued that and developed it, uh, first as a research tool and then as a, as, as a treatment. So I thought this was really good.
This is the first time we're not just stumbling onto something. So, so that, uh, that was in its incipient, uh, um. And I jumped really on [00:13:00] that and got very involved with some of the seminal research that got it approved for OCD and, um, um, um, and some of the other studies. Um, and then around that same time, um, there were these two crazy studies, published papers that came out about this, using this, a low dose of this anesthetic ketamine, uh, to treat depression.
And I remember reading the first one back in 2008, and I was like, I was looking for stuff. I would say, there's got to be something out there. And I was looking, I looked at, read this paper in 2008, uh, out of Yale by, um, Berman. And it was like, pick eight patients. And it was amazing, phenomenal, so good that I just.
I said, it's, it's probably nonsense because, you know, uh, we see a lot of, uh, small studies that are very exciting, but they never pan out, right? They get replicated. Right. So I said, okay, um, file that away. Uh, six years [00:14:00] later, uh, it was replicated. NIMH better, better controls. larger sample. And here's this, like this, uh, drug that's been under our nose for 50 years.
And it is, um, it is, has the, it's rates of, um, effectiveness in, in people with treatment resistant depression. It's just remarkable. And, uh, to speed. The speed is amazing. People are getting better, you know, with within hours feeling, you know, improvements. And that is certainly, as you both know, not something we brag about in psychiatry, how fast our treatments work.
Um, so after the 2006 paper came out, I was still very skeptical, but I said, you know what, again, I'm like, we need something. And if this is half as good, As these, these, uh, results in these papers, it's a, it's a game changer. So I, uh, somewhat naively, uh, [00:15:00] uh, approached the powers that be, uh, to, um, get this, uh, see if they would let me start treating patients.
Cause I had a lot, I had a, I had a. Uh, clinic with that people from psychiatrists, the community were referring treatments and uh, depressed patients and didn't have a whole lot I could do with them. Cause when you, you know, you get a patient and they've been on 24 different combinations of medications, uh, you know, it's hard to, it's hard to be really smart and come up with something new that you really believe in anyway.
So I thought this, I had to try this and it wasn't easy. Uh, it took. Uh, many, many months, cause they thought it was a harebrained idea at first. Like you want to give an anesthetic to people with depression and you're a psychiatrist, like, yeah, why does it shrink? Why not? But I persisted and, uh, and eventually, uh, it got approved with certain limitations and the limitations were that it would [00:16:00] be done in the PACU, which is sort of the, uh, intensive care environment to the point where people recover, uh, after, after procedures.
Uh, and then, and then anesthesiologists would do the procedure. I thought, okay, well, that's great. And, um, you know, we did our first three patients and got no benefit on any of them. And I thought, Oh, this is this, all these papers are nonsense. It's ridiculous. Cause they were, they were reporting 70 percent plus response rates.
So I figured what is the chances that that 70 percent response rate is true. And I'm zero for three. I mean, it could statistically happen, but it's pretty unlikely. And I was this close, you know, to giving up on it. And, um, I, I thought about it a little bit. I read into it and I read about sort of the emergence reaction, you know, which is what, uh, they describe when people are under surgery and they come out and they, and they [00:17:00] are hallucinating and learned a little bit about sort of a set and setting and psychedelics.
And I thought, I wonder if. This is the kind of drug that's not just getting it into somebody's body, but it's actually, you have to prepare them the right way, the right mental set has to be the context. This was a horrible context, Paki, it was noisy, stressful, and the anesthesiologists were grumpy. I mean, they're like, you know, they, they, they, Yeah.
Throw open the, the, the curtain, you know, patient would be at a gurney, talk about setting and it's like, okay, what are we doing here? Cause they're going from patient to patient, right? Doing these, uh, these, uh, pre anesthesia checks and it's like, well, we're, we're doing an infusion of ketamine for what procedure?
No, just. the infusion. It's like, what? It's like, this is ridiculous. I mean, what are you wasting our time for? I mean, you know, so, and the patients are all like absorbing all this, right? All this stress and negativity. And nobody's really enjoying the, the experience and nobody's getting better. And I thought, [00:18:00] well, maybe this has something to do with it.
I hate to give it up if there's something there. So I went back to the pharmacy and therapeutics committee and I said, look, can you let me do it in a more conducive? And maybe it was somebody who's kind of like assigned to this and, you know, not just the anesthesiology, anesthesiology resident of today because really doesn't have time, uh, for this.
And, and they agreed and he moved it actually to the outpatient cancer center, which doesn't sound like it's, uh, but it actually was a little bit, you know, it was a little bit more conducive and a little, a little bit more privacy and, you know, had a dedicated infusion nurse. And things started to change and people, I saw things I had never seen before.
And, uh, people with chronic depression, severe suicidality after, you know, sometimes after one infusion, just feeling like they've. For the first time in their lives, they didn't have depression and I was like, [00:19:00] wow, there really is something to this. So I realized that this was very different, that this was something that wasn't your classic Western medicine paradigm where you just got to get the drug into the patient and the drug is the, is the, carries the therapeutic aspects in it because it interacts with a body.
tissue and fixes something in a patient is sort of an afterthought. This is something where, you know, the conditions have to be right. And it's like, this is really interesting. Enjoying the Psychiatry Tomorrow podcast and hungry for even more insights into the future of mental health care? Then you won't want to miss out on the Psychiatry Tomorrow newsletter from AusMind.
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Just head to ausmind. org slash tomorrow and we'll see you inside. So it turns out that that was Uh, the first ketamine infusion program anywhere. Uh, this is again, 2008, it's going to be 15 years. And, um, uh, so that I had these two really, I felt like I was like practicing a completely different type of psychiatry than every other psychiatrist world.
I had these two different, uh, uh, treatments. I was zapping people's brain noninvasively. I really liked the term zap, but, uh, uh, but, uh, we were stimulating people's brains, targeting guests. targeting certain areas, trying to induce a change in the firing over time. And I had this drug that was repurposed, but that produced this incredible experience.
It seemed to be, uh, part of a, uh, a very, very robust, uh, uh, therapeutic effect for depression and [00:21:00] suicidality. And were you ever giving them together? Uh, I started to, yeah, I started to give them together. So, uh, it made sense, right? You have patients who are, and I, and they, and, and I do that currently a lot because they have very complimentary, um, care.
Um, features, you know, one is, um, sort of not fast, but more durable to late effects. One is very fast, not as durable as we'd like. Well, anyway, so around 2008, 2009, I thought, Oh, I think, Psychiatry might, after all maybe be at, at that, that golden age is coming. , that golden age that I was waiting for just took a little longer.
Uh, and I might, I, I, I, I might be able to ride that wave after all. And I actually became very convinced. I just felt that this was the beginning, uh, of the end of a very long, long dry spell. Mm-Hmm, . It's taking a step back not too [00:22:00] long before that. It was really the, I would say the nadir of, of psychiatry there, every conference I went to was talking about how pharmaceutical companies were actually pulling out of CNS R& D.
I don't know if you remember this, no new ideas, they tried new novel mechanism drugs and they were failing. It was just too expensive. They were backing out if they could make more money in sort of diabetes or whatever. And, um, and, uh, there, there was a, there was an, uh, an op ed piece in the New York Times by Richard Friedman, a psychiatrist who writes in the New York Times.
And it was about the, the, the, the, uh, pipeline crisis in psychiatry, how there's no new drugs, how the drugs we're using are 50 years old. And I think if I recall, this was around 2011, 2012. Uh, so I was already starting to use these things. So I was feeling we were pulling out, but for most people who didn't know TMS, they were still in those doldrums.
And that's what it felt like, [00:23:00] doldrums. Like we were, psychiatry was this big ship on the Atlantic and there's no wind and we not going, there's no land in sight and we're, you know, we're stuck. Yeah. And, um, I just felt, okay, I think, This is the beginning of a revolution. And I got very excited and I, uh, I thought, you know, what do we need?
We need a center that can, uh, specialize in these things. I had the, the term sort of interventional psychiatry was, this is way before that. This is a, uh, we need a center where, where people can come who aren't responding to the conventional things and they can get these, um, these, uh, advanced treatments.
Uh, that are given by, uh, you know, providers that, you know, you know, specialize just in those and they know how to combine them and optimize them and I propose this to, um, to [00:24:00] UCSD, to, to my department and to the, to the, uh, health services and they really like the idea. They were really supportive of it.
And we actually, uh, for a couple of years, I, uh, I, I created and ran a center called the Center for, uh, Center for Advanced Treatment of Mood and Anxiety Disorders, CATMAD, uh, was the acronym. Tried to tell you something a little bit more, uh, maybe, uh, appealing, but that's the best I could do. Um, and it was great cause we had people literally coming from all over the country or internationally to get these treatments.
And I just felt this is what I want to do. This is exactly what I went into psychiatry for, um, to, to do these, um, kinds of things, but, um, you know, um, uh, to continue the story, um, I just felt that, um, I can, uh, sadly, uh, um, uh, academic medical centers [00:25:00] are. Contrary to what you might think, not a great place to be extremely innovative.
Yep. We hear that a lot now. We see that we hear that. It's very, it's very sad, but it's very true. And, and you'll hear it from a lot of people like me who've left academia because they want to be able to really kind of, uh, innovate and, I think there's been a tremendous change in that, um, um, academia, academic medicine has become very, very risk averse and it's more, more so than in the past, more so because what's, what's, what's changed and everyone.
Uh, says this, uh, quite consistently, uh, who's been through it and who understands what's going on. It's, it's, it's gone from physician led, uh, or, [00:26:00] or, um, you know, scientist led, Um, to administrator led places. Um, the, the number of administrators has just ballooned and you really start feeling like you're working for the administrators.
They call the shots and it's like, and you really are, you really are. You really are. I did not like that. I did not go into medicine to. Yeah, I don't want to be pejorative, but I mean, some of these people had no clue, uh, you know, and their, and their, and their agenda was completely different than mine.
They were just like, nothing bad should happen. You know, we, you know, we, it wasn't, it really wasn't the same. So it's sad. Uh, and, uh, I can tell you that these two treatments, TMS and ketamine and things that I'm involved with now, psychedelic research, um, except for a few places like Johns Hopkins. Um, Um, for the psychedelics, but you know, I don't think that they're, they've really embraced these things or they embrace, embrace them much later, [00:27:00] much later than a lot of docs out in private practice.
The psychedelics are a little different cause they're, they're, they're, they're, they're hard to research and hard to, so they're not available, but ketamine and TMS. Uh, definitely, uh, uh, you know, sort of grew, uh, out, out in the community rather than out of, uh, uh, academic centers. So, uh, so I left, I left in 2017.
I gave out my tenured, uh, position, which was really hard 'cause I'm really an academic, uh, uh, at heart to my DNA. Uh, research and, um, but I just felt that, uh, this was so exciting and, and I would have much more freedom, um, if I wasn't under the constraints of, um, uh, you know, a university. And so fortunately I was able to maintain an appointment at UCSD, Professor Emeritus and, um, and I started a clinic called Kadima, [00:28:00] Kadima Neuropsychiatry Institute.
And, uh, Yeah, the rest, uh, we've been having a lot of fun since then. Well, tell us about, you know, uh, about your project in Rwanda with Ketamine. Oh, yeah, that is really cool. Um, and very gratifying. So, uh, Rwanda is this lovely country, um, uh, uh, in, uh, northeast, uh, Africa near, uh, Uganda, the Congo, uh, Republic of Congo.
And, um, It, um, has, um, uh, a very, very dark history. There was a, uh, uh, intra tribal genocide in 1994, um, and, um, they, the, the population suffers from probably a disproportionate amount of mental illness because of that. Not only in the, uh, generation that went through it, but. You know, in the subsequent generations, it was very complex.
Um, [00:29:00] uh, through, through a connection in Rwanda, um, uh, a psychologist named Cindy Cassidy, who is an American who Um, lives in Rwanda and works there. Um, we were contacted, Kadim was contacted to, um, possibly bring some of these advanced treatments to Rwanda. Um, and, um, long story short, um, it, it, uh, it, it translated into an invitation to go, for me to go speak about Ketamine to the, uh, to a, uh, an, uh, All Africa Anesthesiology Conference, um, and to give a presentation about these treatments to the Ministry of Health.
This was last February. This is a wonderful trip and I met a lot of amazing people there. It's really beautiful people, beautiful country. And, um, they were very excited, uh, more so than I expected. They were really [00:30:00] open to it. You know, they're very progressive. Um, and they said, well, we need that here. And could you, could you and Kadima help us establish these clinics?
And I said, I'd love to, you know, it would be, it'll be, I can't think of anything more gratifying than to have these, exciting revolutionary treatments get spread to places that, that really need them, but don't have, uh, don't have them. Um, so, um, uh, there are two clinics now being, um, developed in Kigali, the, um, the, uh, capital of Rwanda.
There's two clinics under construction right now. And, um, In October, a delegation of, uh, psychiatrists and, um, uh, nurses and therapists are going to be visiting us at Kadima to sort of shadow and learn more about, um, ketamine. Uh, assisted [00:31:00] therapy and TMS. Um, and hopefully bringing that back and, and, and starting those clinics there.
There's a lot of also, um, anticipation of translating that into some of the other things that are coming down the road to like the, the. the psychedelic drugs that are under development here, like psilocybin and 5 MeO DMT and, uh, and LSD, uh, formulations. So I think it's the beginning of something very exciting, uh, on the continent.
And it's just, just a total pleasure. Yeah, it sounds really stimulating. I'm, are you going to do any group, uh, group ketamine therapy? You know, it's interesting. We'll have to see because there, uh, is a different cultural, um, situation, uh, in, uh, in Rwanda than, than there is here. And, um, uh, and there's a lot of, uh, and part of that is a relic [00:32:00] of the Rwanda.
Of, of this, uh, horrible genocide there. Um, and so there's, uh, honestly from what I understand, a lot of, uh, a lot of, uh, uh, people are very closed off and, and mm-hmm, to their fellow countrymen in many ways. And there's a lot of, um, of stigma. Yeah, there's lot of stigma and. uh, suspiciousness. So I don't, you know, one of the things that, that we are, we, when I say we, Mike, my associates at Kadeema are, are, are really interested in seeing how this will apply in that different cultural setting.
Um, and, and what we, what needs to be adjusted, um, uh, to make it as successful there as it's, I was kind of thinking about group integration as a way to help scale, because obviously you'll be great, have great demand. It makes sense. It's a, it's an intuitive, um, uh, [00:33:00] you know, uh, a path to do that, but yeah, but, um, uh, it may not be a good fit for, um, uh, for that country.
We'll have to see. Okay. I, I have a question actually about how mental health care and health care gets paid for in Rwanda. So, who will be paying for the ketamine treatments? Is that the government that's gonna be doing that or is it philanthropically funded? Well that's, the nice thing about a country that um, uh, is I think maybe, um, the, the power structure is a little bit simpler.
Let's put it that way. Um, is that, um, um, to this, for this meeting that I went to, you know, they just, you know, the minister of health just said, okay, all you insurance companies, you're going to be there. The FDA, they're a version of the FDA. You're going to be there, you know? And, um, there's, it's, it's, it's in some ways easier to, to, to make it happen.
So the short answer is yes, the, the, [00:34:00] the, um, government will be paying for it. The, the, the insurance companies, they have insurance companies that I don't totally understand the, the, um, structure and dynamics, but, but they're basically going to write, write it into their policies and the FDA is going to kind of, uh, you know, uh, review and.
We presume sign off on it. And, uh, cause it's, there's, there's a sort of a decision that we need to do this and it's, uh, it's been, uh, I'm amazed at how, how, uh, And in such an uncomplicated way, uh, compared to what you would, what, you know, what would happen here in the United States, uh, things have moved forward.
I mean, my gosh, it was February and there's already, you know, clinics being built and, and, and, uh, and representatives being sent to learn it. And that, that, that. That's, that's amazing. Again, and we're like, you know, thinking of when we were talking about the early ketamine stuff, like over 15 years later, and still major payers and government [00:35:00] payers do not pay for ketamine in the United States.
Exactly. So, it's, they should take a cue from these other countries that there's real value. Yeah, yeah, I think. What do you think about that? Um, David, do you think things are, are looking more optimistic for ketamine to be paid for? Ivy? Yeah, I do think so. Um, I'm part of the National Network of Depression Centers.
Uh, it's a, it's a, a sort of a group of academic, uh, centers, um, representatives who, who work on different problems, problems on depression. And I'm part of their ketamine task force. We just sent a, we just sent a letter to Uh, I think it's the Journal of Affective Disorders. Um, um, uh, kind of a consensus statement, uh, about, Uh, insurance, uh, we feel that it's really important that insurance, uh, you know, really strongly consider covering IV ketamine and we lay out all the argument for it.
Uh, so I, I, I, I do think it's going to happen. Um, it's so paradoxical, you know, um, we have, um, one of the [00:36:00] biggest breakthroughs in, uh, in psychiatry, um, and efficacious. And, um, because of these very dogmatic sort of structural things, well, it's not covered by the FDA for the indication of depression. So insurance companies will not cover it.
Uh, and it's not covered, uh, it's not covered, it's not covered by the FDA or not approved by the FDA because there's no economics in it because the, you know, no one's going to do those studies. Right. No, he's going to do it. Hundreds of millions of dollars to jump through the hoops, um, of, um, FDA approval.
And if you can't own the rights to it, it's just, there's no, there's no economics in it and your investors are not going to let you do that. So it just sits there as this, uh, blockbuster and, and with, with very little access because it's, it's, it's not covered by, not approved by the FDA and therefore not covered by the insurance.
Uh, and then comes something like Spravato, [00:37:00] which, um, is in all honesty, uh, uh, you know, I'm glad we have it. We utilize it, but certainly, certainly not more efficacious than, uh, intravenous or intramuscular ketamine. But because, um, it, uh, it's S ketamine and because it is a nasal, it, it, it sort of, um, it skirts that, uh, obviousness.
Uh, um, the restriction on getting a patent, it's different enough from the idea of using, right? Yeah. And so there's a patent there that allowed, uh, Janssen to kind of go and spend several hundred million dollars to get it approved, and it's approved now, and insurance companies are covering like Medicare covers it, and it is, uh, like without doubt, uh, more expensive to those insurance companies.
Mm-Hmm. than sort of what? or other places charge for, um, the, the original, [00:38:00] the original version, um, um, which is still the gold standard. So it's, it's a very, uh, counterintuitive and paradoxical system that is all based on, and a lot of things people think there's a lot of. Malevolence and so forth. And I talked to colleagues who, you know, I think, Oh, it's all big pharma.
But, you know, it's also the fact that we have an FDA, um, and, uh, and that's. Something we, we, we want to have to make sure that drugs, but it's also make it also really limits what kind of drugs can get approved because it's so expensive to get FDA approval. Therefore, yeah, there has to be really a high profitability to, to go down that road.
It just creates unintended consequences like. having this blockbuster drug that, um, that, that, uh, very few people can access because it's not covered by insurers. Yep. All right. Well, thank you so much [00:39:00] for taking us on this journey from academia to Africa and, um, uh, in between. So any last thoughts? No, I just think it's a really exciting time.
I'm sure you guys, uh, would, would concur. This is an exciting time to be in our field. Um, it is completely changing. Um, and I think it's going to be, um, unrecognizable from those of us who kind of, uh, Started when we had, you know, uh, monoamine, uh, drugs and that was it. And, and, uh, and, you know, talk therapies like CBT, um, it's going to be unrecognizable in a good way.
And we're going to have a lot more options, a lot more powerful treatments. And it's really privileged just to be, uh, you know, part of this. Uh, this revolution in the field. Absolutely. Thanks for being a revolutionary. Thank you so much. Thank you. That's it for [00:40:00] today's episode of the Psychiatry Tomorrow podcast.
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