Psychiatrist Uses Prescription Hallucinogen for Hard-to-Treat Depression
One in an ongoing series
Helping a patient sometimes means going to the ends the earth. For Sarah Noble, DO, it meant going to the edge of the future.
Dr. Noble, a psychiatrist at Einstein Medical Center Philadelphia – Jefferson Health, has added a prescription hallucinogenic drug – a version of the street drug ketamine – to the options she uses in treating patients with severe depression.
Einstein is at the forefront of employing this new form of therapy, and is the only site in Philadelphia that accepts insurance for what is an expensive treatment available for private pay at local clinics.
“I’m always looking for ways to try to help my patients, and I could see this kind of medicine and therapy is the wave of the future,” says Dr. Noble, Director of Outpatient Psychiatry.
Dr. Noble personally knows the emotional toll of depression; she experienced several bouts of severe depression when she was in college and medical school.
FDA Approval in 2019
The new drug she is prescribing, esketamine (Spravato), is a slightly altered form of ketamine, which is illegal when used recreationally as a street drug. But in 2019, in response to scientific research showing the therapeutic power of psychedelic drugs such as ketamine, as well as psilocybin (“magic mushrooms”), MDMA (Ecstasy) and others, the FDA approved Spravato for depression.
Patients who have had prolonged, unrelenting depression and have not responded to other therapies can begin feeling better in a day, Dr. Noble says.
And she says patients often remain in remission, “which is really powerful because with most of our patients, we struggle to get them into remission and to stay in remission.”
A study published in 2019 in the journal JAMA Psychiatry found that people treated with standard antidepressants plus Spravato were about 50% less likely to relapse after remission as people who received antidepressants plus placebo.
Spravato is administered as a nasal spray twice a week for a month, then once a week for a month and then every one to two weeks as symptoms require.
At the moment, Einstein patients receive the treatment in the infusion center, which doesn’t accommodate the presence of a therapist. Dr. Noble is applying for an Albert Einstein Society grant to create a space in the behavioral health offices for patients to be treated while a therapist is present to maximize the therapeutic impact of the experience.
There is a long waiting list of patients who would like Spravato treatment, she says, and her office receives many calls with inquiries every day.
Specialized Training and Certification
Dr. Noble recently completed a 10-month program through the Integrative Psychiatry Institute in Colorado and received certification as a Psychedelic Assisted Therapy Provider.
She was trained specifically to guide patients who take Spravato, psilocybin and MDMA. The FDA is considered likely to approve MDMA for PTSD treatment as early as this year.
As part of the certification, there was an optional experiential weekend, in which some participants were treated with ketamine.
“It was a special experience, with 20 mental health professionals basically taking turns being the patient, the therapist or the observer,” says Dr. Noble. She couldn’t take the drug because of medical reasons, but she was the therapist and the observer.
“We did a lot of group and individual work that weekend,” she says. “It was very powerful. People saw real growth.”
While Dr. Noble didn’t have the experience with the drug, she does have personal experience with the illness it treats.
Depression in College and Medical School
Dr. Noble experienced her first “massive depressive episode” when she was an undergraduate at Sarah Lawrence College, a prestigious liberal arts college, where the teaching philosophy “was to challenge everything you ever believed in,” she says.
Plus, “I grew up in a small town in the Midwest and I came east and it was the first time I saw such massive wealth inequality. I was like – I’m in the most privileged ivory tower. I have to do something that will make the world a better place.”
One day, she walked into a science building and saw a poster for medical school. Dr. Noble says, “I thought, ‘That’s it! I’ll go to medical school.’”
Medical school “turned out not to be what I thought it would be. I got very depressed and thought it was the worst mistake of my life.”
She received treatment for depression. And then she found the place she belonged.
“When I went to my psychiatry residency interview, I felt, ‘These are my people.’ I felt happy again,” Dr. Noble says.
“From residency on, I have felt joy. It is just amazing to be able to share all the intimacies of someone’s life with them all day long, and be with them in all of their joys, sorrow and pain. It’s amazing.”
It’s the reason she’d go to the ends of the earth to help her patients, and in this case, to the edge of the future.