San Diego VA Offers Conflicting, Untrue Statements About Drug Treatment For Suicidal Vets
Friday, June 26, 2020
The San Diego VA has repeatedly lied about why it’s changing drug treatments for veterans at high risk of suicide, documents show.
An inewsource investigation published this month found the health care system is pulling depressed and suicidal veterans off ketamine, an effective drug, and putting them on a nasal spray called Spravato — which is not working and in some cases is increasing their suicidal thoughts. That story explained how the change in treatment sparked a veteran’s suicide and led to a congressional inquiry.
inewsource asked the San Diego VA why it made the decision. Its responses were conflicting and untrue.
The taxpayer-funded government agency is legally required to be transparent and accountable to the public. But during the past two years of inewsource’s coverage of the institution, its spokespeople have declined to respond to questions about dangerous and unethical human research at its facility, whistleblower retaliation, a COVID-19 outbreak at a counseling center and now the situation involving suicidal veterans. They will not address how VA records contradict their public statements.
Meanwhile, more veterans who have been removed from the ketamine treatments are coming forward out of anger and desperation.
“If anybody cared about us, the only time would be if 10 of us kill ourselves at one time,” said Tom Johan, a 73-year-old Air Force veteran in Ramona.
He’s one of eight veterans the VA pulled off ketamine treatments at the Kadima Neuropsychiatry Institute in La Jolla. There are 17 more patients who will be transitioned within the next few months.
Suicide prevention help
If you are having thoughts of suicide, you can call the National Suicide Prevention Lifeline at (800) 273-8255 or the San Diego Access and Crisis Line at (888) 724-7240.
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The VA is putting these vets on Spravato, which is administered at the VA Medical Center across the street from Kadima. Johan and three other veterans interviewed said Spravato did nothing for them.
Ketamine is an anesthetic that’s been around since the 1960s but was recently recognized as highly effective in treating depression and suicidal thoughts. A Yale psychiatrist in 2018 called it “arguably the greatest breakthrough in the field of depression in over 60 years.”
Spravato is a derivative of ketamine manufactured by Johnson & Johnson, and last year President Donald Trump promoted it as a game-changer in combating veteran suicides.
“It really takes that horrible anxiety, whatever causes somebody to be so desperate to commit suicide, you take it, it's an inhaler, and you take it and its results are incredible,” Trump told an AMVETS convention last August.
Spravato was fast-tracked through the FDA approval process and has become controversial among medical experts who question its safety, efficacy and cost. Forcing veterans to switch to the drug from ketamine, Johan said, is “absolutely the most dangerous malpractice I've ever seen.”
No veteran interviewed said they had received a straight answer from the VA about why it’s stopping treatments at Kadima. Neither has inewsource.
Johan and other veterans in his situation are considered “captured patients,” said Dwight Stirling, founder and CEO of the Center for Law and Military Policy, a nonprofit think tank in Huntington Beach. These vets are often labeled 100% disabled by the VA, unable to work and therefore reliant upon the VA healthcare system, he said. They can’t decide they’re unhappy with VA care and move to another hospital.
“Here we take the vets who are hurt the most as a result of their service and we put them into a system on the hospital side where they have no right to hold their doctors to account whatsoever,” said Stirling, a reserve judge advocate general in the California National Guard and a law professor at the University of Southern California.
“And so it's the population that we should be caring about the most. We have a system where we care about them the least.”
A veteran’s suicide and poor communication
The San Diego VA has sent at least 32 veterans to Kadima since 2017 but stopped authorizing their treatments last September.
In mid-October, a Navy and Marine pilot who’d been receiving ketamine at the clinic died by suicide. She wrote in her final email that the VA’s decision had pushed her over the edge. It was like losing a lifeline, she said.
Within days of the suicide, the VA rushed to authorize treatments for nearly all the vets under Kadima’s care. The San Diego VA director signed a Veterans Care Agreement with the clinic, which is used when the VA network can’t offer a needed service or treatment and must rely on an outside provider for care.
But nothing really changed. Kadima staff spent more than six months struggling with the VA to obtain further authorizations for the vets, to little success. Then on May 1, a VA psychiatrist began alerting patients they would be cut off from ketamine at Kadima and were expected to return to the medical center for Spravato.
Kiaya Bender, a Marine veteran from Vista who said he’s struggled with PTSD, depression and suicidal thoughts since he can remember, began treatments at Kadima last year. After a few sessions that didn’t do much, he woke up one day to find “things seemed brighter.”
“From there, I've been able to find a hobby and passion, like plants and gardening, and start going to school and setting goals and sticking to things longer than three to six months,” Bender said. Then the veteran choked up as he recalled being notified about the impending switch to Spravato.
“I'm a little emotional about it, because it scares me,” he said.
inewsource first asked the VA in May about why the treatment was changed. A spokesperson explained that before January the agency didn’t provide IV ketamine or Spravato but “has since established the capacity to provide both treatments on-site.”
But patient authorization forms contradict that. They show in April the VA was still sending veterans to Kadima because the agency couldn’t provide ketamine in-house. “No Network Provider Available” is cited in multiple forms that month as the “Reason for the use of the Veterans Care Agreement.”
The VA also said it had “communicated to patients and Kadima leaders” the reasons behind the transition. That is a lie:
- Every vet inewsource interviewed said they were given little to no warning or explanation for the change.
- Kadima psychiatrist and founder Dr. David Feifel and his chief operating officer, Renee St.Clair, produced emails showing the clinic was caught completely off guard by the VA’s move. Feifel and St.Clair also told inewsource the VA has made no effort to discuss continuity of care or collaborate on a transition plan for the veterans.
- Included in Kadima’s documents was an April 17 email from Dr. David Printz, the VA psychiatrist for many of the veterans interviewed. It shows Printz reassuring one of his patients being treated at Kadima that “the VA has no intention of discontinuing ketamine treatment in the community for you and other veterans.” Two weeks later, Printz let Kadima know the VA would be discontinuing the ketamine treatments.
inewsource also learned this month that the San Diego VA had sent a very different explanation of its actions to a reporter at another publication. We asked VA spokespeople to provide that email, but they have not.
Then they asked multiple times for inewsource to explain more about the story being worked on before they would provide answers. In one instance, they asked to be walked through the story “from start to finish.” inewsource refused because it deviates from standard journalism reporting practices and is not required under the federal Freedom of Information Act in seeking public records.
“It’s clear to me that the VA has been caught in a lie,” said Stirling, the USC professor and think tank CEO. “And they are doing exactly what they always do in such a situation, which is to try to get the reporter who has them caught off their backs.”
Last week, the VA spokespeople provided a new explanation for stopping the treatment:
They said Kadima had “repeatedly deviated from industry standards of care and from what VA had authorized by administering intramuscular ketamine.”
‘Desperate attempt to deflect blame’
The San Diego VA wasn’t taking issue with ketamine but rather how it was often administered at Kadima — with an injection rather than an intravenous drip. A VA spokesperson said the injection route “is not FDA approved and is not supported by any peer-reviewed research to support its long-term use for Treatment Resistant Depression.”
Several parts of the VA explanation are either misleading or untrue.
The VA’s authorization forms, which contain notes and messages between VA doctors, show the agency’s psychiatrists and administrators had authorized and known about intramuscular injections at Kadima since 2018.
VA psychiatrist Printz and chief of psychiatry Dr. Brian Martis authorized 20 “IM (intramuscular) Ketamine injections” at Kadima for a depressed vet in September 2018. They authorized another 24 for a different vet in June 2019.
In March, a different VA psychiatrist made note that his patient at Kadima, “has now been on IM ketamine treatments for the past 9 months” and “though he still struggles with chronic depression, his suicidal ideation and ability to function is much improved.”
On April 2, a note shows Dr. Susan Trompeter, the medical director for San Diego VA Community Care, recapping one patient’s care at Kadima with the VA’s head of psychiatry: "The patient has had repeated problems with IV ketamine infusions. … Because of this, he was switched back to IM ketamine.”
VA spokespeople would not reconcile these facts despite multiple inewsource requests.
They did, however, insist the authorizations were for Spravato or IV ketamine only, “as designated in the Veterans Care Agreement.” That is false, according to the agreement, which Kadima provided. It shows a boilerplate contract that makes no mention of Spravato, IV ketamine, intramuscular ketamine or even ketamine at all.
Feifel, Kadima’s founder, is a UC San Diego professor emeritus of psychiatry. He was responsible for bringing ketamine treatment to the university and founding the psychiatry department’s advanced treatment program. Feifel’s colleagues at the San Diego VA noticed his success with ketamine and began sending over high-risk veterans for treatment.
Asked to respond to the VA’s latest explanation for stopping veterans from being treated at Kadima, Feifel wrote to inewsource: “It is mind blowing that administrators who decided to suddenly cancel a successful treatment program that had been keeping veterans from suicide without giving the vets any warning, without consulting their treating VA psychiatrists or me, their outside psychiatrist, have the gall to make defamatory claims of substandard treatment of veterans.
“In my opinion, the VA administrators who made the decision to pull the plug on these veterans’ treatments in such an unprofessional and dangerous manner should spend less time trying to deflect blame by libeling my team and me, and spend more time acknowledging and correcting their own sub-standard of care decisions.”
The VA statement also labels intramuscular injection as inferior to IV by saying it is not FDA approved nor is the safety of its long-term use supported by research. That’s a problem because the same criticisms apply to IV ketamine, which the VA has used to treat vets and plans to use again for every patient failed by Spravato, a spokesperson said.
“The VA’s desperate attempt to deflect blame is transparent and utterly absurd,” Feifel said. “I can only shake my head and wonder what depths they will sink to next week to make us look like the culprits.”
It’s worth noting that the FDA approved ketamine for use as an anesthetic but hasn’t approved the drug in any form for use in depression. Feifel explained that ketamine is old and off-patent, and no pharmaceutical company wants to shell out the millions of dollars necessary to bring the drug through FDA approval because there’s no financial incentive. With no patent, the company can’t own the rights to the drug and recoup those costs.
Spravato, however, was manufactured to be just different enough from ketamine that it could be patented for depression, but because it's administered as a nasal spray, far less of the drug reaches the blood and brain.
There are 17 veterans at Kadima who have a limited number of ketamine injections left from prior VA authorizations. A San Diego VA spokesperson told inewsource in a June 15 email that by the end of September the agency will transition those vets back to the medical center for Spravato. inewsource then asked why, if the VA was concerned veterans were receiving unsafe treatment at Kadima, it was allowing them to stay there for another three months. The spokesperson did not answer.
“The fact is,” Feifel wrote, “the ketamine treatments Kadima provides the veterans does deviate from industry standards, but not in the way the VA is suddenly alleging, rather these treatments are advanced well beyond the standard of care for depression, and that is precisely why they sent scores of vets to us year after year.”
Outrage among vets building
Johan, the Air Force veteran, told inewsource he’s lived with a burden for decades — a rage that has cost him marriages and relationships with his children. He described it as an “anger and dark cloud that is above you that nobody should ever have to experience in their entire lives.”
Like others interviewed, Johan tried everything under VA care: drugs, electroconvulsive therapy and transcranial magnetic stimulation. But his initial ketamine treatment in 2011 “was like a rebirth,” he said.
“My mind was refreshed. I could think. I had compassion. I could see colors. I wasn't afraid to be around people.”
Then Johan was pulled from Kadima — “dumbfounded” and “frustrated” was how he described the news — and put on Spravato. It didn’t work, so the VA administered IV ketamine, which also didn’t help him. He said the VA doctors are not ketamine experts like Feifel, “who's got his own private practice, who has bent over backwards, who knows and has studied this for 30-some odd years.”
“You would think that the VA would say … ‘Let us work with you and find out what's working so we can coordinate this,’” Johan said.
But they have not, which he called “asinine.”
His anger is also back.
“I'm going to be the biggest thorn in the VA’s side,” Johan said. “I'm going to find the justice for all vets out there so that this crap doesn't happen.”
Quiet and subdued, 58-year-old Marine veteran Hector Mejia sat on the couch across from Johan during the interview with inewsource. The two met years ago as they both navigated the depression treatment circuit at the VA. Mejia said he’s undergone about 100 electroconvulsive treatments, dozens of rounds of transcranial magnetic stimulation and has been prescribed as many as 20 medications a day for his depression. The only thing that worked was ketamine injections.
“It helped me get through the week,” Mejia said.
But he too was pulled from Kadima and went downhill fast. Recognizing this, Johan paid the $400 for an emergency ketamine injection for his friend at Kadima in June. Mejia says he’ll never forget the gesture.
“I appreciate him so much for doing that for me,” Mejia said.
Joel Andrews, a 45-year-old Army veteran who like Johan struggles with depression, anger and suicidal thoughts, has not been taking the transition well. He tried and failed with Spravato, and last week received IV ketamine at the San Diego VA. It didn’t work.
“I was just in a super bad mood afterwards, and it just trickled down. And you get that storm in your head and you can't get your thoughts to slow down,” Andrews told inewsource. He fired off an irate email to his VA psychiatrists that said, “I am back on that path of not wanting to be here anymore.”
The email continued, “I have hated myself since about the age of 9. Kadima was the first time in my life that I didn’t feel that way. Then you people came along and RUINED THAT! It's not like I can get my healthcare anywhere else.”
Luckily, Andrews included Feifel in the email. The doctor rushed the Escondido veteran in for an emergency ketamine injection. By Sunday, Andrews wasn’t perfect but much improved.
“It would’ve gotten a whole lot worse if they hadn't helped me out,” Andrews said.
Elected officials are now aware of what is happening at the La Jolla healthcare system.
Congressman Mike Levin, a Democrat whose district covers most of northern coastal San Diego County, told inewsource in a statement, “Any decision to change the health care treatment of our veterans should be based on the best medical practices, and the VA must have strong communication with their patients throughout that process.”
Local veterans, some of whom were succumbing to their depression after learning about the end of their treatment, are now going public to push for change. Two vets profiled in inewsource’s original story have been interviewed by staff members of Congressman Scott Peters, D-San Diego.
The House Committee on Veterans’ Affairs inquiry into ketamine also continues. Stirling, from USC, said he expects the vets will get no relief unless Congress threatens to cut the San Diego VA’s budget.
If that doesn’t happen, Stirling said, “the VA simply will not change.”
The San Diego VA has not responded to inewsource’s requests for comment about the inquiry. It also continues to not answer questions challenging the accuracy of its previous statements to inewsource.
inewsource photo and video journalist Zoë Meyers contributed to this report.
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