Ketamine clinics shutting down

[randomdoc1]

I for one am relieved. It had gotten ridiculous.

Large network of clinics offering ketamine for depression shuts down

One of the largest operators of ketamine clinics in the country abruptly closed its facilities this week, leaving patients in the dark and out of treatment for depression and other chronic conditions.

www.statnews.com

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[WisNeuro]

Are people finally figuring out that the reality is nowhere close to the results promised by the hype?

 

[B52slinger]

Are people finally figuring out that the reality is nowhere close to the results promised by the hype?

There is still a lot of hype. When I speak with my non-medical family/friends back in CA there is a common sentiment that SSRIs are being pushed by Big Pharma and ketamine is the miracle "holistic" cure

 

[randomdoc1]

There is still a lot of hype. When I speak with my non-medical family/friends back in CA there is a common sentiment that SSRIs are being pushed by Big Pharma and ketamine is the miracle "holistic" cure

The irony…

These places have an anesthesiologist at best. No board certified psychiatrist. What could go wrong? lol

 

[Sushirolls]

My area, like, ketamine so yesterday, totes.

Psychedelics are in.

Getting to many more requests/inquiries about that.

 

[randomdoc1]

My area, like, ketamine so yesterday, totes.

Psychedelics are in.

Getting to many more requests/inquiries about that.

There’s another ketamine clinic chain closing many shops citing that these places are actually losing money. I think ketamine is still quite hip. And there’s a silent majority that doesn’t buy into these hypes. I researched the local places and their internet traffic is actually pretty low. So I’m hoping this is just the beauty of the market, bull can get you to the top but can’t keep you there. Be it cheesy telehealth start ups, incompetent midlevels, snake oil, etc. that and I think our economy may be starting to experience some recession?

 

[calvnandhobbs68]

My area, like, ketamine so yesterday, totes.

Psychedelics are in.

Getting to many more requests/inquiries about that.

With psilocybin I just say it’s actually illegal outside of a couple states and trials.

 

[allantois]

Online ketamine mills are next. It is outrageous what they charge as well as the lack of mental health experience their leadership has. Venture capitalists selling snake oil.. give me a break

 

[jbomba]

What are thoughts on ketamine assisted psychotherapy? Personally, I think there is a lot that can be done in this area.

This obviously much different than putting an IV in someone's arm, infusing them, and leaving them alone in a recliner in a room with a bunch of other people and telling them they're going to get better as a result.

 

[TexasPhysician]

Are people finally figuring out that the reality is nowhere close to the results promised by the hype?

I think the reality is every bit as amazing as hoped. The cost however is tough for many to sustain. Add in the venture capital/poorly provided care and its a difficult path to maintain a ketamine only center.

 

[Candidate2017]

I'm waiting for the APA to release a statement on the ketamine refugee crisis... "something, something, midlevels to increase access..."

It's as if a business model based on something that's inferior to current treatments (i.e., ECT) is doomed to fail. But really, we know the business model is based upon attracting a sufficient number of clientele for whom the current menu of controlled substances is not enough to whet their appetite.

What are thoughts on ketamine assisted psychotherapy? Personally, I think there is a lot that can be done in this area.

Propranolol has been shown to help with psychotherapy. Or buy a chaise longue for your office.

 

[wolfvgang22]

I for one am relieved. It had gotten ridiculous.

Large network of clinics offering ketamine for depression shuts down

One of the largest operators of ketamine clinics in the country abruptly closed its facilities this week, leaving patients in the dark and out of treatment for depression and other chronic conditions.

www.statnews.com

"The company’s CEO since January 2021 is Matt Stang, the former chief revenue officer of High Times magazine, which pushed for the legalization of cannabis."
I'm shocked, I tell you, shocked.

Anecdotally, the patient's I have had who have received I.V. ketamine come back and tell me that ketamine provided short term relief for depression and PTSD and anxiety, but after much expense they found they were right back where they started but poorer.
At which point I once again recommend evidence based psychotherapy, which the patient once again declines. Delta-8 is the hotness now around here.

 

[WisNeuro]

I think the reality is every bit as amazing as hoped. The cost however is tough for many to sustain. Add in the venture capital/poorly provided care and its a difficult path to maintain a ketamine only center.

While I think there is promise here as an alternative treatment, I've only seen modest effects for the most part locally. Also, I'd still say the hype train is crazy with ketamine. Unfortunately, most of the sites around these parts are run by the slimiest providers I can imagine hawking this as something that can completely cure your depression, save your marriage, manage your 401k, and beat Through the Fire and the Flames on Hard mode.

 

[PikminOC]

While I think there is promise here as an alternative treatment, I've only seen modest effects for the most part locally. Also, I'd still say the hype train is crazy with ketamine. Unfortunately, most of the sites around these parts are run by the slimiest providers I can imagine hawking this as something that can completely cure your depression, save your marriage, manage your 401k, and beat Through the Fire and the Flames on Hard mode.

Speaking of hard mode, will ketamine get me thru super Mario brothers 2? This is super hard.

And I hope other ketamine places close too but I don't think they will.

 

[PikminOC]

Are people finally figuring out that the reality is nowhere close to the results promised by the hype?

These clinics are expert marketing.

 

[PikminOC]

"The company’s CEO since January 2021 is Matt Stang, the former chief revenue officer of High Times magazine, which pushed for the legalization of cannabis."
I'm shocked, I tell you, shocked.

Anecdotally, the patient's I have had who have received I.V. ketamine come back and tell me that ketamine provided short term relief for depression and PTSD and anxiety, but after much expense they found they were right back where they started but poorer.
At which point I once again recommend evidence based psychotherapy, which the patient once again declines. Delta-8 is the hotness now around here.

"But therapy doesn't work for me"

 

[PikminOC]

There's huge profit in these cash ketamine clinics. It doesn't cost much to do this. Not sure why they are having financial problems.

 

[littlefred]

There's huge profit in these cash ketamine clinics. It doesn't cost much to do this. Not sure why they are having financial problems.

These companies are all about growth. Once the growth stops or stagnates then so do they.

 

[smalltownpsych]

"But therapy doesn't work for me"

It would work better if you stopped using cannabis and etoh. Going way out on a limb here, but I may have heard that these drugs make mental health conditions worse. Naw. Just need to find the right mix of chemicals to fix it.
Seriously though, I have worked with patients who have benefitted from ketamine but myself and the psychiatrist I refer these patients to are pretty clear that without making behavioral and cognitive changes, the benefits will be minimal and short-lived.

 

[randomdoc1]

It would work better if you stopped using cannabis and etoh. Going way out on a limb here, but I may have heard that these drugs make mental health conditions worse. Naw. Just need to find the right mix of chemicals to fix it.
Seriously though, I have worked with patients who have benefitted from ketamine but myself and the psychiatrist I refer these patients to are pretty clear that without making behavioral and cognitive changes, the benefits will be minimal and short-lived.

But THC and etoh are the ONLY things that help my sleep and pain. Are you saying I actually have to break away from what makes me comfortable? Practice distress tolerance? Delayed gratification? Are you saying there's no quick fixes? How dare you. You're supposed to be a compassionate mental health provider. pffft! lol. Evidence based practice clearly does not work.

 

[nexus73]

Good. When capitalism takes over it changes from providing appropriate care to the right patients to maximizing the volume of service whether people really need it or not.

Ketamine IV is not a growth industry, because IMO it's just too expensive. Who is the target market? People who can pay $3000 for a course of six infusions at minimum. This cuts out a huge portion of patients. Then it either works or it doesn't. If it does most people will need ongoing maintenance. Most people can't afford 1-2 maintenance infusions for 500-1000/month. So you are targeting a relatively small portion of the population who have the means to pay and also have depression that responds to ketamine. Maybe some drug seekers, but it's probably easier to get ketamine or other drugs for much cheaper elsewhere.

They want it to be like a med spa giving vitamin C "energy boosts" or "immune flux" or whatever BS branding you want and charge $100. Which is a price more manageable for most people.

Ketamine on it's own can't support most clinics. You either need to have other infusion services and convert to hydration bar, med spa type business, or have a med management practice + TMS, and all of a sudden it's getting a lot more boring and just like a typical old psych clinic. Which the venture capitalists probably don't want because the margins for mental health care aren't great.

 

[randomdoc1]

Good. When capitalism takes over it changes from providing appropriate care to the right patients to maximizing the volume of service whether people really need it or not.

Ketamine IV is not a growth industry, because IMO it's just too expensive. Who is the target market? People who can pay $3000 for a course of six infusions at minimum. This cuts out a huge portion of patients. Then it either works or it doesn't. If it does most people will need ongoing maintenance. Most people can't afford 1-2 maintenance infusions for 500-1000/month. So you are targeting a relatively small portion of the population who have the means to pay and also have depression that responds to ketamine. Maybe some drug seekers, but it's probably easier to get ketamine or other drugs for much cheaper elsewhere.

They want it to be like a med spa giving vitamin C "energy boosts" or "immune flux" or whatever BS branding you want and charge $100. Which is a price more manageable for most people.

Ketamine on it's own can't support most clinics. You either need to have other infusion services and convert to hydration bar, med spa type business, or have a med management practice + TMS, and all of a sudden it's getting a lot more boring and just like a typical old psych clinic. Which the venture capitalists probably don't want because the margins for mental health care aren't great.

May go really well with the beauty market. Med spa, facials, microneedling, laser therapies, botox. People will pay an arm and a leg for beauty. Throw in overpriced questionable therapy for a mind, body, wellness model.

 

[annoyedpsychiatrist]

Lets be honest, what percent of the patients who go on to ketamine treatment does not have the following:

1. a significant personality disorder
2. poor insight into their mental health
3. questionable medication compliance
4. substance use issues
5. significant life stressors causing the depression

I would guess the percent of people who dont have at least one of those issues, is one percent or less.

 

[clozareal]

Anecdotally, the patient's I have had who have received I.V. ketamine come back and tell me that ketamine provided short term relief for depression and PTSD and anxiety, but after much expense they found they were right back where they started but poorer.
At which point I once again recommend evidence based psychotherapy, which the patient once again declines. Delta-8 is the hotness now around here.

I had a patient tell me that because they knew what they were missing while not depressed after ketamine, but not being able to afford further treatment, that made him much more depressed than he was prior to starting ketamine. I thought it would make him more hopeful that there was an experience of feeling not depressed.

 

[dl2dp2]

I think the reality is every bit as amazing as hoped. The cost however is tough for many to sustain. Add in the venture capital/poorly provided care and its a difficult path to maintain a ketamine only center.

This part I also find this interesting. I do think the treatment works if applied in the right way, but I'm fascinated by the fact that it's largely (or with high probability) a money-losing proposition, even at the self-pay level.

Lets be honest, what percent of the patients who go on to ketamine treatment does not have the following:

1. a significant personality disorder
2. poor insight into their mental health
3. questionable medication compliance
4. substance use issues
5. significant life stressors causing the depression

I would guess the percent of people who dont have at least one of those issues, is one percent or less.

I have patients who have all of the above and yet respond to ketamine. This IMO is not an issue.
One big big issue I've found is that people respond quickly, but then don't respond as well at relapse.

 

[wolfvgang22]

But THC and etoh are the ONLY things that help my sleep and pain. Are you saying I actually have to break away from what makes me comfortable? Practice distress tolerance? Delayed gratification? Are you saying there's no quick fixes? How dare you. You're supposed to be a compassionate mental health provider. pffft! lol. Evidence based practice clearly does not work.

Who are you and how did you get this transcript of my patients...lol. Seriously, though, it's nice to know I'm not the only one that hears these things daily.

 

[annoyedpsychiatrist]

I have patients who have all of the above and yet respond to ketamine. This IMO is not an issue.
One big big issue I've found is that people respond quickly, but then don't respond as well at relapse.

I mean objectively, do their lives become significant better, or is it a subjective response of what they endorse is better? Even if it is objective improvement, for how long is it sustained? Are you taking about maintenance therapy via spravato? Ive never seen a patient objectively do better in the long run tbh, but that is just from personal experience really. Also getting it covered was a pain, when I worked with an induction clinic as part of residency years ago. Dunno if that improved. People would also have weird effects from it during induction

 

[dl2dp2]

I mean objectively, do their lives become significant better, or is it a subjective response of what they endorse is better? Even if it is objective improvement, for how long is it sustained? Are you taking about maintenance therapy via spravato? Ive never seen a patient objectively do better in the long run tbh, but that is just from personal experience really.

In the long run, we are all dead. I'm talking about people who have "refractory depression" who don't respond to antidepressants. They report symptomatic remission on initial treatment with ketamine. In fact, in my experience very often people with personality disorders report MORE response due to often more significant placebo effect in this group.

Whether this correlates to long-run improvement of functional outcomes relates to other factors outside of ketamine (followup therapy, psychosocial management etc). Nevertheless, severe depression makes it difficult to do therapy. So the apparent short-term response itself is therapeutically useful. However, it is interesting that generating short-term responses per se is not financially viable.

 

[randomdoc1]

In the long run, we are all dead. I'm talking about people who have "refractory depression" who don't respond to antidepressants. They report symptomatic remission on initial treatment with ketamine. In fact, in my experience very often people with personality disorders report MORE response due to often more significant placebo effect in this group.

Whether this correlates to long-run improvement of functional outcomes relates to other factors outside of ketamine (followup therapy, psychosocial management etc). Nevertheless, severe depression makes it difficult to do therapy. So the apparent short-term response itself is therapeutically useful. However, it is interesting that generating short-term responses per se is not financially viable.

Interesting points people are making. It is nice that some people subjectively experience vast improvement and may even demonstrate better functioning in day to day life. Even if it was sustainable financially, it leaves me with a question. The physician in me wonders how to go about weighing longterm benefits over risks? Does it really make sense to chronically give patients ketamine where in a decent chunk of these patients the effect may be able to be achieved less invasively? What are the long term draw backs? The idea of chronic use of an anesthetic and controlled substance makes me apprehensive. In some ways, it feels similar to patients who swear up and down that chronic opiates and/or benzos are medically necessary. I guess not enough data at this point to make that judgment on ketamine.

 

[Merovinge]

In the long run, we are all dead. I'm talking about people who have "refractory depression" who don't respond to antidepressants. They report symptomatic remission on initial treatment with ketamine. In fact, in my experience very often people with personality disorders report MORE response due to often more significant placebo effect in this group.

Whether this correlates to long-run improvement of functional outcomes relates to other factors outside of ketamine (followup therapy, psychosocial management etc). Nevertheless, severe depression makes it difficult to do therapy. So the apparent short-term response itself is therapeutically useful. However, it is interesting that generating short-term responses per se is not financially viable.

I really think ketamine needs to be paired with intensive treatment at the residential or PHP level where it can unlock some motivation/ability to engage with intensive work and really address what needs to be addressed such that when the inevitable crash comes from withdrawing ketamine you have actually built a foundation to stand upon.

Going somewhere to sit in a dark room getting ketamine from an anesthesiologist strikes me as another long line of hope for a magical medication that will fix everything without any work. Spoiler alert is that it never does.

 

[whopper]

I've had so much success with Auvelity (or generic DXM mixed with generic Bupropion) I speculated this is going to majorly cut into Ketamine. I've already had patients that were able to stop Ketamine telling me the Auvelity works much better for them and they don't have to pay for it out of pocket.

Ketamine does work very well for some people but like any antidepressant treatment, there's a lot of room for not working or only partially helping. Anytime an option is taken off the table there's going to be a segment of our population that can no longer get the treatment they need but the realistic market forces might not be enough to keep it available.

Some people can't absorb Selenium to a degree where if they don't take it in IV form they're dead. Guess what? The only company that made IV Selenium years ago decided to stop making it. WTF are those people going to do? The company did say they'd make a several year supply of it to be stored in a refrigerated unit, but their responsibility to the patients was zero and once they were out they were out. Thankfully another company later on decided to make it, but this was market forces doing their thing. The new company charged much more than the prior company for the same product. There is randomness to market forces that is outside our control.

 

[comp1]

If the rat will push the lever for the drug delivered to their brain, we should be very wary of rapidly rolling it out and have a higher bar for using it.

 

[PikminOC]

Good. When capitalism takes over it changes from providing appropriate care to the right patients to maximizing the volume of service whether people really need it or not.

Ketamine IV is not a growth industry, because IMO it's just too expensive. Who is the target market? People who can pay $3000 for a course of six infusions at minimum. This cuts out a huge portion of patients. Then it either works or it doesn't. If it does most people will need ongoing maintenance. Most people can't afford 1-2 maintenance infusions for 500-1000/month. So you are targeting a relatively small portion of the population who have the means to pay and also have depression that responds to ketamine. Maybe some drug seekers, but it's probably easier to get ketamine or other drugs for much cheaper elsewhere.

They want it to be like a med spa giving vitamin C "energy boosts" or "immune flux" or whatever BS branding you want and charge $100. Which is a price more manageable for most people.

Ketamine on it's own can't support most clinics. You either need to have other infusion services and convert to hydration bar, med spa type business, or have a med management practice + TMS, and all of a sudden it's getting a lot more boring and just like a typical old psych clinic. Which the venture capitalists probably don't want because the margins for mental health care aren't great.

Med spa iv is more like 400 a pop

 

[allantois]

For one, I would like to see more treatment accessibility for average American. There’s zero reason why ketamine that is decades old should be expensive to patients

 

[annoyedpsychiatrist]

to me it makes me think of the dystopian film equilibrium from years ago, where sometimes instead of normalizing appropriate emotional responses and developing coping skills, our goal instead becomes eliminating all emotion. Sometimes feels like the future is headed that way in psychiatry/the way its pushed. I have to explain to patients sometimes that depression can be a normal response

 

[smalltownpsych]

I really think ketamine needs to be paired with intensive treatment at the residential or PHP level where it can unlock some motivation/ability to engage with intensive work and really address what needs to be addressed such that when the inevitable crash comes from withdrawing ketamine you have actually built a foundation to stand upon.

Going somewhere to sit in a dark room getting ketamine from an anesthesiologist strikes me as another long line of hope for a magical medication that will fix everything without any work. Spoiler alert is that it never does.

Completely agree. These are the types of patients that I have worked with who received ketamine treatment and some had dramatic and sustainable improvement. If patient is going in the right direction it can help, if they are passively looking for a magic fix, then it just reinforces their hopelessness as the positive boost to mood wears off and nothing changed.

 

[Merovinge]

For one, I would like to see more treatment accessibility for average American. There’s zero reason why ketamine that is decades old should be expensive to patients

IV ketamine is tougher but my organization is able to get esketamine nasal treatment covered for patient's with regular ole insurance. Not sure it's as good, but we went that route in an effort to keep costs as low as possible/maximize accessibility.

 

[randomdoc1]

to me it makes me think of the dystopian film equilibrium from years ago, where sometimes instead of normalizing appropriate emotional responses and developing coping skills, our goal instead becomes eliminating all emotion. Sometimes feels like the future is headed that way in psychiatry/the way its pushed. I have to explain to patients sometimes that depression can be a normal response

I often describe to patients that proportionate emotions serve a biological purpose. Just like how our BP and temperature have a normal range, so does emotion. Did you get a bodily injury and experience some inflammation? It's supposed to happen! That's called your immune response. And that medications are designed to treat pathology---bonafide disorders. BP meds treat hypertension. Antibiotics treat things like sepsis. You don't take stuff like that just because you don't like it when your HR goes up when you exercise....

Plus, if we had stuff that was so wonderful with minimal risk, we'd give it. But we don't. No point in trying to shove a square peg into a round hole. Try as you might.

I actually make an interesting analogy with plants. For a plant to thrive, they all have their individual needs. But definitely a degree of sunlight, water, nutrients from the soil, even wind. If you don't provide those, they don't thrive. You don't medicate the plant first unless there is identifiable pathology. Interesting thing, most plants need wind. The wind creates micro-traumas which stimulates strengthening of their stem. I've tried growing certain plants indoors, not realizing this. And eventually they cannot hold up their weight, they snap and die. We too have a natural habitat we thrive best in, and it's not a habitat with zero distress. My understanding is we are at our best in a physically active state, a diet high in variety, almost in a fasting like diet as that is what years upon years of evolution has favored? Meh. Just my thoughts.

 

[Stagg737]

I had a patient tell me that because they knew what they were missing while not depressed after ketamine, but not being able to afford further treatment, that made him much more depressed than he was prior to starting ketamine. I thought it would make him more hopeful that there was an experience of feeling not depressed.

Sounds like the perfect time to have a discussion about why they have that perspective and how therapy can be so beneficial...

to me it makes me think of the dystopian film equilibrium from years ago, where sometimes instead of normalizing appropriate emotional responses and developing coping skills, our goal instead becomes eliminating all emotion. Sometimes feels like the future is headed that way in psychiatry/the way its pushed. I have to explain to patients sometimes that depression can be a normal response

Yep, and to piggyback off of this and Randomdoc, I tell my patients that my goal is NOT to make them devoid of emotions, it's to help them experience emotions more appropriately in ways that don't impair their function. I don't want them to feel numb, that's anesthesia's job.

 

[Merovinge]

I often describe to patients that proportionate emotions serve a biological purpose. Just like how our BP and temperature have a normal range, so does emotion. Did you get a bodily injury and experience some inflammation? It's supposed to happen! That's called your immune response. And that medications are designed to treat pathology---bonafide disorders. BP meds treat hypertension. Antibiotics treat things like sepsis. You don't take stuff like that just because you don't like it when your HR goes up when you exercise....

Plus, if we had stuff that was so wonderful with minimal risk, we'd give it. But we don't. No point in trying to shove a square peg into a round hole. Try as you might.

I actually make an interesting analogy with plants. For a plant to thrive, they all have their individual needs. But definitely a degree of sunlight, water, nutrients from the soil, even wind. If you don't provide those, they don't thrive. You don't medicate the plant first unless there is identifiable pathology. Interesting thing, most plants need wind. The wind creates micro-traumas which stimulates strengthening of their stem. I've tried growing certain plants indoors, not realizing this. And eventually they cannot hold up their weight, they snap and die. We too have a natural habitat we thrive best in, and it's not a habitat with zero distress. My understanding is we are at our best in a physically active state, a diet high in variety, almost in a fasting like diet as that is what years upon years of evolution has favored? Meh. Just my thoughts.

I really enjoyed this post (I love the plant analogy and am likely stealing it), but I would point out that modern dietary theory is much more centered around regular consistent food intake rather than the IF hype that came about a decade or so ago. Restricting food intake leads most people to periods of overeating, if not outright binge eating and more consistent blood sugar levels is associated with better physical and likely mental health. Recommending restricting food intake for extended periods of time can actually cause very real harm to people so certainly something I would be careful about if that's part of your clinical practice.

 

[randomdoc1]

I really enjoyed this post (I love the plant analogy and am likely stealing it), but I would point out that modern dietary theory is much more centered around regular consistent food intake rather than the IF hype that came about a decade or so ago. Restricting food intake leads most people to periods of overeating, if not outright binge eating and more consistent blood sugar levels is associated with better physical and likely mental health. Recommending restricting food intake for extended periods of time can actually cause very real harm to people so certainly something I would be careful about if that's part of your clinical practice.

Agreed! Maybe I should have elaborated. It's more of a eat what you need model. lol. We live in a culture of abundance. More is not always better.

 

[whopper]

I heard through the grapevine that a doctor in my area tried some patients on Auvelity and got better to the point where they didn't need to go to his Spravato treatments that the same doc provided. So guess what the doc did? He won't give out Auvelity ever until the insurance stops paying for the Spravato.
WTF.

 

[randomdoc1]

I heard through the grapevine that a doctor in my area tried some patients on Auvelity and got better to the point where they didn't need to go to his Spravato treatments that the same doc provided. So guess what the doc did? He won't give out Auvelity ever until the insurance stops paying for the Spravato.
WTF.

I've seen ketamine clinics with FNPs do their so called "med management" which was keep the patient on the same med that never worked indefinitely and keep giving ketamine. Talk about conflict of interest.

 

[Merovinge]

Agreed! Maybe I should have elaborated. It's more of a eat what you need model. lol. We live in a culture of abundance. More is not always better.

Oh absolutely, intuitive eating combined with avoidance of ultra processed foods is the best advice that can be shortened into one sentence regarding food intake.

 

[TexasPhysician]

I heard through the grapevine that a doctor in my area tried some patients on Auvelity and got better to the point where they didn't need to go to his Spravato treatments that the same doc provided. So guess what the doc did? He won't give out Auvelity ever until the insurance stops paying for the Spravato.
WTF.

Not a large sample size, but I am 0 for 2 on patients tolerating more than 2 days on Auvelity.

 

[whopper]

So far it's worked great on my own patients who are treatment resistant and works quickly. I've had a few where it caused insomnia, or a dissociative experience (and not in a good way).

Among my patients who hit a plateau of me really not being able to do much more (e.g. already tried 3 SSRIs, 2 SNRIs, Mirtazapine, Buspirone, 2 atypicals, a TCA, an MAO-I, TMS, blood tests to rule out a physical etiology, and still no or only partial improvement) more than 50% showed significant improvement to a degree not achievable on the other meds. It's not surprising given this is a new mechanism while with SSRIs, you tried 3 and failed don't even expect the next one to work.

The problem I'm experiencing is insurance coverage, and if not covered, and this is being debated in another thread, telling them to consider Bupropion mixed with OTC DXM.

 

[clausewitz2]

Oh absolutely, intuitive eating combined with avoidance of ultra processed foods is the best advice that can be shortened into one sentence regarding food intake.

The evidence base for intuitive eating is not very good. I would second an emphasis on less processed, less calorie dense, frankly less delicious foods.