On the phone, Amanda Leech is measured, yet emphatic.
“I’ve been dealing with depression since I was a kid,” she tells me. Amanda is 46.
“In 2015, I had what you would call a complete and utter breakdown and I was hospitalized for six months. I was suicidal. I had a plan to end my life.”
Amanda speaks with the unmistakable tone of someone who is used to repeatedly telling a story to people who seem to only listen out of politeness or obligation.
“Nothing that happened in hospital helped me,” she says, adding that the treatment failures include a long list of antidepressants and 17 sessions of electroconvulsive therapy, or ECT, which passes electric current through the brain in order to trigger a seizure that changes the brain chemistry.
“I was, you know, living like a zombie,” Amanda says. “Not even living,” she corrects herself. “Just existing.”
Her illness wrecked her career as a veterinary technician. It robbed her of the ability to effectively parent her daughter who was just six when Amanda went into the hospital.
After she was discharged, she moved from Surrey to Sechelt. She was still suicidal, she tells me.
Then two years ago, her life changed. On one of the days Amanda was able to get out of bed, she saw psychiatrist Dr. Anthony Barale at the Sechelt Hospital. Barale had begun prescribing ketamine to help people with treatment-resistant depression.
“He interviewed me, and he said, ‘You know, out of all of the people that I have interviewed, you are the person that needs this program the most,’” Amanda said.
The program was simple. Patients sat in a comfortable chair in the hospital’s outpatient clinic. They were hooked up to an IV bag. Amanda says after checking her vital signs, Barale would call for a millilitre of ketamine to be added to the infusion.
“I can’t even tell you how incredible it was,” Amanda tells me, her voice brightening.
“I hadn’t felt this good possibly ever in my entire life… it was just heaven, really. It was such a relief from how my brain had been just plaguing me with all these horrible dark thoughts. I remember one day just kind of going oh, you know, I haven’t thought about killing myself today. That’s huge for me.”
It sounds miraculous, but what Barale was doing wasn’t new. Ketamine was created in 1962 as an anesthetic that proved invaluable to American troops in Vietnam. More than 20 years ago, the first scientifically rigorous studies began confirming that in doses too small for anesthesia, ketamine is a potent and rapid antidepressant. The effects take just minutes, with mood improvements that last for days or weeks.
I know. I was treated with ketamine myself several years ago after being diagnosed with PTSD. In my case it wasn’t an IV infusion, but an intramuscular shot. I wrote about ketamine therapy last fall for The Tyee. Amanda saw that story and reached out to me.
I had become interested in the subject after learning that in March last year, the College of Physicians and Surgeons of B.C. quietly and without warning effectively told doctors to stop using ketamine to treat mood disorders. It released its order publicly in July.
The order said ketamine — even in oral doses as small as a few drops — could only be administered by an anesthetist in an “accredited non-hospital medical/surgical facility.”
Kelowna psychiatrist and clinical assistant professor at the University of British Columbia Neil Hanon told The Tyee in October that ending doctors’ ability to use ketamine in their private practice, or also in his case, at a street clinic where he works, denied patients a successful treatment that had been available for years.
Among the college’s concerns were that it was a novel treatment, and the efficacy and safety of the drug was in question, even though the World Health Organization lists ketamine as one of the safest drugs there are even at full anesthetic doses.
The college edict wasn’t a suggestion. Any doctor who defies the college, no matter how noble or principled the reason, risks losing their licence.
Up until then, the hospital in Sechelt had been treating about 40 severely depressed patients with ketamine infusion therapy. After the college statement, it shut the program down.
It did restart treatment nine months later. Inexplicably, however, the program was limited to just eight people who were only permitted a monthly maintenance dose. Vancouver Coastal Health did not respond to questions about the reasons for the program’s shutdown and scaled-back restart.
Amanda was not one of those admitted back into the program. By the time we spoke on the phone in late January, she had spent most of a year trying to understand why.
“Oh god, like how hard is it to get something that I know will help me?”
After talking for half an hour, Amanda says something I will never unhear.
“I’ve just been thinking,” she says with a nervous half laugh. “If I went to the Downtown Eastside, would I actually get ketamine if I bought it off someone or would it be, you know, fentanyl or something else?”
Amanda doesn’t pause long enough for me to answer.
“I just, I’m at my wit’s end, and that’s the only place I can think about trying to get ketamine. Where else do you get it? I just don’t know.”
Before we say goodbye, I tell Amanda not to lose hope.
“Amanda, listen,” I say. “I’m going to continue pursuing this. I’ll commit to keeping in touch with you as I learn more details and continue to try to get some answers.”
But Amanda is way ahead of me. Over the next month and a half, she shares the details of emails, letters and phone calls she and her mother exchange with anyone they can think of who might be able to help.
In early March, Amanda’s psychiatrist Dr. Hendri Eksteen calls her on behalf of himself and Barale.
“Unfortunately, there will be no ketamine,” Eksteen says in a voicemail he leaves for her.
“All the questions you have regarding why you weren’t part of the group for maintenance and things, I wouldn’t be able to answer that… I don’t know.”
In the space of a minute, Eksteen mentions ECT three times as an alternative, adding that they can use some ketamine as part of the anesthetic before the procedure.
Later that day Amanda sends me an email to share the news.
“I don’t even know where to turn next,” she writes before signing off.
Nine days later Amanda is dead.
Before telling you what happened, I want to be transparent and honest by telling you that when I found out about Amanda’s unnecessary and tragic death, it changed my involvement in this story. That’s neither an apology nor an admission that I’ve been anything less than thorough. It’s just true. I also want to acknowledge that while most of what follows is based on facts and documents, a few details come from what Amanda told me. I can’t doublecheck them by asking her again.
But I’m certain the questions Amanda had about her treatment were simple and straightforward. She had asked people who should have been able to answer them. Yet some of the responses Amanda received were unhelpful, misleading or false. As I pore over them to figure out what happened to Amanda, they seem like a trail of moldy breadcrumbs which lead her down a dark path.
That trail seemed to begin last March when the Sechelt Hospital stopped the ketamine program. The hospital told Amanda it was because of COVID-19. However, it didn’t appear that the hospital halted other IV treatments such as chemo. Those patients sat in the same outpatient chairs, hooked up to the same IV bags as Amanda and other psychiatric patients. It is true that there were concerns about potential shortages of ketamine. It’s the anesthetic of choice for intubations, because of its safety record.
But Amanda told me that months before the coronavirus outbreak in China, the hospital was already cutting back appointments, according to the staffer who booked them.
“She just told me that there were too many people that needed it,” Amanda had told me.
After several months without any treatment, Amanda told me she called Eksteen “begging for an alternative.” That’s when he told her about ketamine lozenges. They are essentially small doses of ketamine added to a melt-in-your-mouth candy made to order by a pharmacist.
So, in June, prescription in hand, Amanda visited the drug store.
“And the pharmacist says, ‘You must have fallen through the cracks,’” she told me. “‘People have been on these since March.’”
Taking one at night before bed “did feel like they helped me a little bit,” she said. But the lozenges were like weak tea. That’s not surprising. It comes down to how much of the drug can be absorbed by the body, known as its bioavailability. With a lozenge, most of the dose never makes it to the brain.
More months passed, and still the IV ketamine program had not resumed. In October, Amanda got a response to several emails she’d sent to the Vancouver Coastal Health authority. But they told her the same thing the hospital said months earlier in March: the ketamine program was shut down due to COVID-19.
For the first time, however, the concerns of the College of Physicians and Surgeons were also mentioned. The college was prohibiting anyone but an anesthetist in a hospital or a hospital-type setting to administer ketamine, regardless of what form the drug was delivered in and regardless of dose. As far as the college was concerned, half a teaspoon held under the tongue was the same as a syringe in a muscle or a vein.
It was about this time I wrote my first story about the behind-the-scenes battle between doctors and the college over ketamine therapy.
The one Amanda had read. After it was published, the college appeared to blink. It issued a new statement that seemed to allow the use of oral ketamine.
But there’s no evidence the college did anything to clarify the rules for those it says it serves: patients.
Why do I say that? In November, Amanda’s pharmacist refused to fill her prescription for lozenges. He told her the college had forbidden them.
“The pharmacist said that ‘People are going to die, and the college will be sued,’” she told me afterward. It’s not clear where the pharmacist got his information, but it was wrong.
“I panicked. I stood outside of the pharmacy and bawled my head off,” she recounted.
“I felt like just driving off a bridge. Like what is the point anymore if it’s going to be so hard to finally find something that works and then it’s all going to be taken away?”
The college itself made Amanda believe her ketamine lozenges were now prohibited. In response to letters and phone calls from Amanda and her mother, the college’s manager of drug programs wrote on Dec. 23 that “ketamine administration by any route including oral, intranasal, intramuscular, subcutaneous, and intravenous must only be performed in an accredited non-hospital facility.”
This was devastating for Amanda when she received it. It seems even more troubling now because it appears to have been wrong. Recently I asked the college to provide a clear and unequivocal statement about oral ketamine. The first response I got from college spokesperson Susan Prins surprised me.
“We are not aware of oral forms of ketamine being available by prescription in B.C.”
Wait… what? I had to read the reply several times to make sure I understood it. No oral ketamine in B.C.? How could that be? I’ve interviewed doctors who’ve prescribed it. I’ve talked to patients who’ve had their prescriptions filled. I asked again, pointing out the contradiction. The answer changed.
“Sorry to confuse you,” Prins wrote. “I checked with the College of Pharmacists as we have received conflicting information about oral ketamine ourselves.”
The true answer is that ketamine can be prescribed by a doctor, made into lozenges, and dispensed through a pharmacy. That was true when I asked. It was true when Amanda asked and got a different, disheartening answer.
Prins added that “the college is not prohibiting physicians from administering ketamine in the community or asking them to stop or change what they are doing.”
That is certainly encouraging to anyone reliant on ketamine for relief. Except that’s not what the college’s position statement on ketamine has said at all.
And it’s not what Amanda was told when she pleaded for clarity over the only drug to put a dent in her depression. The more time I spent retracing Amanda’s efforts to find relief, the more I began to appreciate just how frustrating it must have been for her.
Amanda didn’t stop trying, though. At the end of December, she wrote to Judy Darcy, B.C.’s minister of mental health and addictions. In her email Amanda literally begged Darcy to use her authority to reverse the Sechelt Hospital’s decision.
“I am now backsliding and what am I supposed to do?” Amanda wrote.
“How are you going to help me? A decision like this will force people to buy street ketamine (I have considered it). What that will do is increase the already staggering overdose numbers. I don’t think VCH wants this.”
But Vancouver Coastal Health was unwilling to change course.
That was spelled out in an internal memo written by VCH medical director Dr. Lakshmi Yatham and fellow psychiatrist Dr. Lance Patrick, following a meeting with VCH leadership that was held “In light of the concerns and complaints brought forward to the Ministry of Health and the VCH CEO.”
The memo makes it clear that only a “small subset of patients” will get ketamine, and only then as a maintenance dose, once a month.
Yatham writes that “given the current resource limitations within the Coastal communities, acute ketamine infusion cannot be provided.”
The memo suggests that resources, i.e. cost, were driving the decision to deny treatment to people like Amanda. The decision-makers weren’t disapproving of ketamine as a treatment. But after nearly a year of withholding it, they were only now getting around to endorsing the idea of creating a working group, to explore the possibility of whether they should offer it more widely.
The memo also instructs doctors to tell their patients to go to a private Vancouver clinic if they want ketamine that bad.
That’s what Amanda’s psychiatrist told her to do. In a voicemail message Eksteen said, “I do want to help” and repeated his offer for ECT.
As to why Amanda wasn’t one of the “small subset of patients” receiving ketamine, Eksteen told her he didn’t know. “I can’t comment on that. I wasn’t involved in the process.”
He half-heartedly suggests the private clinic idea. “I’m only aware of one clinic in Vancouver who gives ketamine, but it’s quite pricey,” he says.
The ChangePain clinic charges $750 per infusion. Paying for five or 10 treatments upfront knocks the price down to $650 each. Amanda was surviving on a disability benefit, caring for her 12-year-old daughter. There was simply no way she could afford what VCH’s senior leaders for mental health were suggesting.
The response from Minister Darcy’s office was just as unhelpful. Darcy’s executive director Thomas Guerrero wrote that the “new requirements by the College of Physicians and Surgeons of B.C. are being considered to ensure the safety and protection of patients.” The letter reads like VCH and college talking points: no new patients; ECT is an option; a private clinic is an option; talk to your doctor; this is for your own safety.
Amanda wasn’t the only patient struggling. Daniel Kokolus was cut off last year too. The 66-year-old former heavy-duty mechanic and technician wrestled for years with treatment-resistant depression. Like Amanda, he’d been hospitalized. He’d been suicidal. Antidepressants and ECT didn’t work.
“I was on the ketamine for 18 months,” he says of the program at the Sechelt Hospital. “It was really amazing… my depression was totally under control. They stopped it without consideration of possible side effects.”
But unlike Amanda, Daniel was given ketamine lozenges when the infusions were cancelled. Yet he also found they didn’t work as well. Out of desperation, he went to ChangePain. Even though he paid for his own treatment, he said he couldn’t get appointments close enough together to be clinically useful.
When the Sechelt Hospital quietly restarted the ketamine program in December, Daniel was chosen to be part of the exclusive group of patients to get a monthly infusion. But Daniel says that nine months without treatment had the effect of erasing the benefit of the drug’s antidepressant effects.
“If the treatment for treatment-resistant depression is not available, then medical-assisted suicide should be an option,” he says matter-of-factly. “People who have not experienced that don’t realize how devastating and how disabling it is. Not only for myself but also for my family.”
It was Daniel’s wife Stephanie who found a hospital in Kingston, Ontario that was willing to accept Daniel as a patient as part of a research program. The treatment was covered, and they came up with the $5,000 or $6,000 it cost to fly there and rent a studio apartment for a month.
“If it weren’t for this option of Kingston,” Stephanie says, “I was mentally preparing myself to lose him sometime this year from suicide. I could see that coming. He’s attempted once before. He’s told me that he can’t live this way and he’ll make sure he succeeds next time so, you know, I was sort of mentally preparing myself that sometime this year, I might be a widow.”
The couple returned to B.C. last month, but they plan to move to Ontario permanently, primarily to be able to access affordable treatment to manage Daniel’s depression.
Amanda didn’t have that option.
She had spent months pleading for the only treatment that helped, to no avail. So, without telling anyone, Amanda went online and bought something being sold as ketamine. When the packet arrived in the mail, Amanda ran a bath. She brewed a cup of tea and placed it near the tub. She measured out a small amount of the mail-order powder, melted it in a spoon, and put it into a syringe.
It was Amanda’s daughter who first raised the alarm. Her mother had gone silent on the other side of a locked bathroom door. The girl texted Amanda’s mother.
“Grandma, help,” Judi Leech says her grandchild wrote. “I can’t get a hold of mommy. She’s in the bathroom and she won’t answer. Something is wrong.”
Judi called Joel, Amanda’s fiancé. He rushed to the house from work. Paramedics tried to revive her.
“The police have said it obviously was an accident,” Joel tells me, through tears. “She had a bath run. She had brand new sheets she had washed, that she had talked about enjoying a nap in them. She had a hot tea by the tub…”
Joel says Amanda had become so desperate for relief that she took a risk, thinking the reward might be worth it.
“When she had her treatments at the clinic, she had seven days or so of a little sparkle in her eye. It was something you could even see. You could even get her to laugh once in a while.”
Judi tells me the coroner told her what killed Amanda was fentanyl.
“It is heartbreaking. I mean, this should never have happened to her. She was a wonderful person. Our granddaughter is having a really terrible time. We’re all just struggling.”
Both Judi and Joel are certain Amanda would be alive if she hadn’t been denied treatment.
“She must have been so despondent,” Judi says. “It just breaks my heart to think what she went through, and I think needlessly. It just is mind-boggling to me how she could be not with us anymore.”
‘It’s just totally awful’
The story I wrote last fall that caught Amanda’s attention and initially prompted her to write to me touched on the idea that withholding ketamine treatment over concerns about it being “novel,” clinically unproven or unsafe, could actually cause more harm.
A number of physicians in B.C. raised that point in a letter they sent this past January to the college, warning that “unnecessarily restrictive measures that impede access to a successful long-standing treatment are inconsistent with our medical ethos to do no harm.”
I wasn’t surprised that some of those B.C. doctors didn’t want to be quoted about the tragic death of Amanda Leech.
University of Toronto psychiatrist Dr. Paul Grof added his signature to the letter. Grof is renowned for decades of practice and research, including his time as an expert on psychotropic drugs with the World Health Organization.
A death such as Amanda’s, he told me, was foreseeable. “Those are dangerous consequences of wrong decisions of the regulatory bodies.”
Grof added he understands why a patient might take the risk Amanda took after being cut off from a treatment that worked.
“It’s one thing if you suffer for a long time,” Grof says. “But when you experience the freedom from the suffering and then the depression comes back, it’s a worse experience. Because you know the difference. You know what you lost. So I’m not surprised at all.”
American psychologist Dr. Raquel Bennett counts Yale and Stanford among the schools that have sought her expertise. Bennett founded the Kriya Ketamine Research Institute in the San Francisco Bay area, which holds an annual international conference on therapeutic ketamine.
Bennett sees no problem with the college wanting to develop standards.
“I think they are right to be concerned about medical and psychological safety with a powerful tool like this. Let’s create training programs to make sure that your concerns about physical and medical safety are addressed.”
There are risks with any drug, and ketamine is no exception. Along with occasional side effects such as dizziness and nausea, frequent and unsupervised used of the drug can lead to addiction. Over the long term it can cause bladder problems. Excessive and extended use can lead to a tolerance for its effects.
But Bennett suggests simply halting treatment until college-approved training is in place, is wrong.
“That’s totally unethical. In my opinion it is wholly unethical to withhold [medicine] that works for a serious illness.”
Bennett offered to consult with the B.C. college for free, months ago. She says no one’s contacted her.
Dr. Phil Wolfson also signed that letter to the college. Wolfson, who’s been a psychiatrist for half a century, literally wrote the book on the subject called The Ketamine Papers. Wolfson says it’s simply wrong for the college to characterize ketamine for mood disorders as either a “novel” treatment or unsupported by clinical studies.
“That’s complete horseshit,” he tells me. “There are probably now 100,000 or more who’ve received IV treatment. The evidence for its use is overwhelming. It comes out of established authorities like NIMH [National Institute of Mental Health] in the United States. There are thousands of papers of human studies.”
As for Amanda Leech’s death, Wolfson says, “That’s awful. It’s just totally awful.”
Wolfson considers ketamine to be the best antidepressant available, and he sees the restrictions on it over the past year in B.C. in stark terms.
“Would it be ethical to take away penicillin when it was first out there? This has been out there for 60 years. The safety of it is established for 60 years.”
Amanda Leech’s death is not hypothetical. The grief felt by those who knew and loved her is real. The RCMP has opened an investigation into the source of the substance that killed her. But the police aren’t looking into why it happened. They’re not talking about the case. Neither is the coroner.
Her family believes Amanda is dead because the people who talk about patient safety, and health officials who publicly champion the cause of mental health, failed her.
In the weeks since Amanda died, I’ve done what Amanda did when she was alive: I reached out to her doctors, the College of Physicians and Surgeons and the senior leaders at Vancouver Coastal Health.
I made numerous efforts to reach the physicians who treated her. I was unsuccessful. Doctors have ethical rules preventing them from disclosing patient information, but I wanted to ask them about the broader impact of the college’s order.
“This is a tragic situation,” wrote Vancouver Coastal Health spokesperson Celso Pereira in response to a list of questions I sent the health authority, “and we share our deepest condolences with the family and loved ones.”
VCH sidestepped most of my questions however, including those focused on the ketamine program in general, how it was run, who made the decisions and why.
VCH also declined to comment further on Amanda’s case, citing patient confidentiality, except to say that it is “conducting a review to examine the circumstances and processes associated with the care of this individual.”
The College of Physicians and Surgeons of B.C. told me that it “doesn’t have any data on whether or not physicians were influenced” by the college’s restriction on ketamine last year, adding that in any event the college has no authority over hospitals.
The college doesn’t have authority over street drugs either, yet in answer to my questions about legal, doctor-prescribed, administered and monitored sub-anesthetic doses of ketamine, I received a full paragraph of dire warnings. They included that ketamine is “a drug that is prone to abuse and non-medical use” and “is also considered to be a ‘date rape’ drug.”
The college added — with no irony intended I’m sure — that “it is sold illegally on the streets, having been stolen or diverted, and there is no guarantee of purity.”
I’m certain Amanda knew that already.