Every day, Marisa Russello was overwhelmed by suicidal thoughts.
Even one negative thought might cause her to spiral. A writer working on her book manuscript, she’d be unable to change a word without questioning the entire project’s value altogether. Her depression made it hard to fall and stay asleep. She developed insomnia and took to sleeping during the day. She knew not to listen to intrusive feelings, but her brain kept telling her otherwise. A darkness took hold of her consciousness and wouldn’t let go.
Russello, now 37, has struggled with suicidal ideation since age 12 and was diagnosed with bipolar disorder as a teenager. Following a serious suicide attempt in 2016 and after several hospitalizations, she started looking for more ways to keep herself among the world of the living.
She belonged to a Facebook group for people who, like her, had bipolar disorder. Some people posted about starting IV ketamine, saying that it had helped significantly with suicidal ideation — in some cases eliminating these thoughts altogether. So in 2019, at the age of 33, she decided to try IV ketamine herself.
“I was at the point where I was willing to try anything,” Russello explained.
Her insurance company, however, wasn’t so willing.
Ketamine has been in use since the 1960s as a local anesthetic, for which it was approved by the Food and Drug Administration in the 1970s. Over the past couple of decades, the drug has also gained popularity as a treatment for depression and suicidal ideation. But all mental illness treatment that uses IV ketamine is currently off-label, which means — as Russello would soon discover — that it’s often hard to get insurance to cover the treatments, which can cost anywhere from $400 to $1,000 per session.
IV ketamine can be difficult to access in other ways, too. Patients in need of treatment may live far from infusion centers and have trouble locating a practitioner who is willing to prescribe it.
Ultimately, Russello has been able to get the care she needs. But the challenges she’s navigated offer a window into the larger issues faced by the millions of Americans looking for ways to manage mental illnesses. For people without sufficient support systems and financial resources, a life-altering option may remain out of reach.
If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711, then 988.
The cost of ketamine
Russello has a careful way of speaking, thoughtful and measured. She’s autistic, she explains, which means she may present with a flatter affect — though of course her subject matter is serious, too.
By day, Russello is a part-time peer specialist for a local mental health nonprofit and a part-time consultant for the Mount Sinai Suicide Research Lab. She’s also a writer working on a memoir. Prior to that, she taught English as a second language to elementary school students.
Together with her husband Justin, a middle school teacher, she lives in upstate New York with their two dogs — Terry, a dachshund Chihuahua mix, and Lucy, a dachshund-lab mix. In her free time, she swims at the YMCA, participates in a monthly book group, plays board games, and spends time outside on walks.
Russello sees her psychiatrist and therapist regularly, and maintains a Microsoft Word document detailing which medications — including antidepressants, mood stabilizers, and antipsychotics — have worked to treat her condition and which haven’t.
Sometimes a drug works for a while and then stops, which means she has to find something new. The list of drugs Russello has had to stop taking stretches onto two single-spaced pages so far.
It’s easy to see, then, why Russello wanted to try something different. She began figuring out how to access IV ketamine by exploring a map of ketamine clinics all over the country, posted to her Facebook group. She found the one closest to her home at the time, about 40 miles away in Albany, and made her first appointment — but not before running into her first roadblock.
In order to try the new regime, she’d need $2,400. Her initial course of treatment ran $400 a session for six sessions: One every three days over the course of three weeks, followed by maintenance appointments that range from monthly to every three months.
A veteran of mental health treatment, Russello had become an expert in obtaining reimbursement and dealing with her insurance company. She had coverage through her husband’s work. At least some of the money she spent might be reimbursed, she hoped, even if the treatment cost was far beyond what they could afford on a regular basis.
She called her insurance company, which she asked STAT not to identify in this story over concerns about potential retaliation. The patient representative told her they’d reimburse the treatment up to a certain amount, which ended up being somewhere in the neighborhood of less than $50 per session.
This kind of decision, in which people like Russello must choose between their health and financial uncertainty, is familiar to many living with a chronic illness in the U.S. and at the mercy of a complex system of payers. Esketamine (Spravato), a nasal spray, is currently the only ketamine drug approved for depression, if taken in conjunction with an oral antidepressant. Though many insurances will cover this, including Medicaid, the out-of-pocket cost for the nasal spray runs $784 a month for two inhalers.
Regular IV ketamine, by contrast, is cheap due to its lack of patent protections, costing around $73 for 50 milliliters. The expenses associated with ketamine treatment are the result of the costs of administration, rather than the drugs themselves.
What’s more, Russello then lived an hour from the clinic — a significant hurdle given the frequency of her treatments. She made the appointment anyway.
What ketamine treatment is like for patients
Why IV ketamine works for some people struggling with depression and suicidal ideation remains a bit of a mystery. Nor is it clear why others who try the treatment fail to respond. Research suggests the drug may help rewire the brain by affecting its production of the amino acid glutamate, which acts as a neurotransmitter. Clinicians who champion its use say that it’s most likely to be effective in combination with other treatments such as medication and therapy.
Some people have negative experiences on ketamine. But when it does work, it can be transformative. In a 2022 study of 156 patients in French teaching hospitals, ketamine infusion for acutely suicidal patients resulted in an elimination of suicidal ideation for 63% of patients within three days of administration. Those kinds of results are unheard of with typical psychiatric medications, including both third-generation antipsychotics or the newest atypical antipsychotics and old standby drugs like lithium carbonate — the latter of which can typically rate an absolute risk reduction of 25% over the course of a year.
Another recent study of 365 patients, published in the New England Journal of Medicine, found that ketamine’s effectiveness was comparable to electroconvulsive therapy for people with treatment-resistant major depression.
Russello first started IV ketamine treatments at Albany Ketamine Infusions in September 2019. She’s now settled into a routine during treatments. She requests a room without windows and asks for all the lights to be turned off. In her pitch-black room, nursing staff at the center set the infusion for 56 minutes, adjusting her dose based on her recent symptoms and feedback from the previous session, following a brief consultation with her anesthesiologist.
Following her treatment, she gets 10 minutes to “return to Earth,” as she says, before the nurse returns to the treatment room to discontinue her IV. But when asked about what it’s really like to participate in ketamine treatment, she stays vague about what she sees during treatment — stars and thoughts.
“That’s not uncommon for moderate high and high dose ketamine sessions, to have a pretty total loss of memory from the event,” said Ian Pocock, a licensed clinical social worker based in Seattle, Washington, who engages patients in ketamine-assisted therapy in their private practice.
“It’s mostly stars,” agreed Anna Gazmarian, the author of “Devout: A Memoir of Doubt,” and an editor for The Sun, a literary magazine. Gazmarian has been prescribed IV ketamine as frequently as once a week. She started taking ketamine in 2018 following a diagnosis of treatment-resistant depression, stopped during her pregnancy, then restarted following the birth of her child in 2021 as a way to better manage her postpartum depression and anxiety.
In addition to ketamine IV, Russello also takes ketamine troches or lozenges every few days throughout the month. She’s tried both mint and root beer flavorings. The mint is far better, she said; with the root beer, she couldn’t even finish the pack. An added bonus is that the troches help with her chronic migraines.
It took until the second treatment for Russello to start feeling its effects. “A few days after my second treatment, I went from having daily suicidal thoughts to none,” she said. “I was shocked. It was like [they were] siphoned out of my brain. Ketamine was a miracle.”
The insurance hustle
Russello’s first attempt at making a claim resulted in a small reimbursement of the infusion costs — just $53.62. In subsequent claims, her insurance company returned just a few dollars here and there, and then began denying claims altogether, citing the treatment as experimental.
She next tried submitting “superbills” — a term used in medical billing to refer to a list of the services rendered and pricing associated with treatment, typically associated with out-of-network costs. But all her clinic bills from 2021 and 2020 still remain “in processing” when she logs into her insurance company’s portal in the present.
Despite growing evidence of ketamine’s efficacy for cases like hers, the insurance company wouldn’t budge. Russello’s therapist has written a letter to her insurance company in support of her use of ketamine, as has her psychiatrist. Both mention her five prior hospitalizations and the long list of discontinued medications, vitamins, diet changes, and light therapies that she’s tried and failed. Since 2021, Russello has stopped making claims, though her treatment persists.
Russello says she is lucky — her parents are able to pay for her ketamine treatment as well as some of her other psychiatric costs. If she and her husband had to pay out-of-pocket, they’d spend $450 per treatment. Without her parents’ support, she said, she wouldn’t be able to afford the treatment, even with her “good insurance.”
Her husband Justin feels the same way: “Without their support, I don’t think this would have been a possible avenue for us.”
The cost of ketamine treatments are an obstacle for many prospective patients. Pocock, the clinical social worker in Seattle, engages patients in ketamine-assisted therapy in their private practice. A single ketamine session runs $870 out-of-pocket — but the therapy portion may be covered by insurance. “Ketamine is a catalyst for a therapeutic process,” Pocock explained.
Their hope is that if more providers move toward offering ketamine-assisted therapy in group settings, or include peer counselors — patients who have undergone ketamine treatment in the past to act as a “sitter” for new patients — there might be an opportunity to lessen the cost burden among those who can best benefit from the therapy.
“There are people who are doing community health care,” Pocock explained, such as nonprofit ketamine centers like Alchemy in San Francisco, where patients may access ketamine for as little as $60. Unfortunately, there aren’t very many of them.
Why ketamine can be so hard to access
Nearly four years after beginning ketamine treatment, Russello goes for a treatment about once a month, with ketamine troches in between. She’s now just a half-hour away from her appointments, instead of an hour — the clinic moved closer, offering an added benefit.
Still, many patients have to travel significant distances to get to clinics like these, provided they can afford treatment.
Further complicating the issue of access is the current ketamine shortage, which can be chalked up to both increased demand as well as supply chain issues and other manufacturing delays. It’s occurring at the same time that national clinics like Ketamine Wellness Centers and Field Trip Health and Wellness are shuttering locations in the wake of business challenges, stranding some patients in the midst of treatment.
Gazmarian is among the patients impacted by ketamine shortages, having changed her appointment in Durham, North Carolina, due to shipping delays. “My clinic told me a certain date, then canceled, then rescheduled for a few days later,” she said.
On the bright side, Gazmarian is happy she no longer has to drive two hours for an infusion. When she first started ketamine in 2018, she had to make the journey from Durham to Charlotte every other day, paying $450 per dose. Now that her psychiatrist has opened a new clinic, she only has to drive 20 minutes to her appointments in Raleigh, once every three months.
For Russello, the reason she’s been able to access ketamine treatments comes down to family support — not just from her parents, but from her partner, too.
In June of this year, she will have been married nine years. Her husband takes her to all her ketamine appointments, since she can’t drive immediately following treatment. He also sits with her while she’s receiving her infusion in case she has a bad reaction. “Your reaction to ketamine depends on your mindset going in,” she said. If she’s not in a positive space when she’s starting treatment, Justin helps reorient her to where she is and will squeeze her hand to bring her back.
Patients who lack local support systems may be left without options. Some community health clinics, like Alchemy in San Francisco, are easily accessible by public transit, but patients cannot receive treatment without a friend or family member accompanying them.
Life after ketamine
Russello’s anesthesiologist told her the ketamine is more effective when she’s also taking an antidepressant, so she’s kept both of hers — Trintellix and Aplenzin. She still takes a small pharmacy of other medications, too: an antipsychotic, drugs for anxiety and insomnia, Adderall for ADHD.
She wonders what might happen after her parents are gone; if she’ll still be able to afford ketamine treatment. It’s stressful to consider this prospect.
Her husband Justin puts it succinctly: “We’re a one-and-a-half-person income family, and we’re not poor, and we’re not struggling by any means. But it’s still difficult for us to manage that amount of money. I can’t imagine people who don’t have the means and are still struggling with depression. It’s not fair.”
In the meantime, the ketamine continues to work for Russello. Suicidal thoughts still pop up here and there. But she refers to the thoughts she has now as fleeting, easy to dismiss. Instead of being consumed by them, she can keep living, for now.
This story is the second in a series on the U.S. mental health system, supported by a grant from the NIHCM Foundation. Our financial supporters are not involved in any decisions about our journalism.