Steve Martorano 

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The Behavioral Corner 
Hi, and welcome. I'm Steve Martorano, and this is the Behavioral Corner; you're invited to hang with us as we've discussed the ways we live today, the choices we make, the things we do, and how they affect our health and well-being. So you're on the corner, the Behavioral Corner. Please hang around a while.

Steve Martorano 
Hi, everybody, welcome again, in the Behavioral Corner. It's me, the "King of the Corner," Steve Martorano. We're here talking to interesting people, we hope you find them interesting. We do. And they cover everything. As a matter of fact, because everything affects our behavioral health. The Corner is made possible by our underwriting partners Retreat Behavioral Health, you'll hear more about them down the road. I want to address this real quick at the top of the program. the young'uns out there maybe some young'uns watching the podcast and listening to the podcast, I'm going to tell you a story that you probably may have never heard about. There was a time when if you were of a certain age, doctors made house calls. Now I know what you think a call is. But this is different. This is a doctor that you called your family physician and said, "That's not feeling well" or "The kids are out of school, they're not feeling well. Can you come on by and take a look at them?" And believe me, kids that doctors used to do it. It was a venerable part of medicine, the house call, if you don't believe me, go check out, Leave it to Beaver, and you'll see their family physician show up. It happens. I'm sure it still happens. My guest is saying it does not happen the way it did in my youth, believe me, although having said that, doctors now do make house calls. But they don't do it...in fact, they do it virtually the way we're doing this interview, they do it over the internet. It's telemedicine, it has exploded out of use, initiated or hyper-initiated because of the pandemic and a public health emergency declaration that the CDC made that allowed doctors to do this. We have that story to tell you very quickly. And then what has grown up around telemedicine that presents perhaps problems we, in fact, know it can present problems to join us in filling in some of those blank spaces for me as our great friend, Dr. Jonathan Beatty. Dr. Beatty has contributed to the program in the past. And I hope he continues to do that he's a great source of information. This doesn't do his resume or his background justice. But succinctly he is an addiction psychiatrist. And we welcome him back to the Behavioral Corner. Dr. Beatty, thanks for joining us. Did I get most of that right?

Dr. Jonathan Beatty 
You did, Steve, and thanks for having me back to the show. It's a pleasure to be here. And I'm looking forward to talking about this very interesting topic. And just to say, for the record, I actually made a house call probably about two weeks ago. So I do on occasion, in real life make non-virtual but actual house calls, but it is definitely, you know, much less common than it was in the era that you're talking about and describing.

Steve Martorano 
Yeah. And then it was just a normal course of affairs that doctors would come to your house. And they do now but they do it virtually like everything else. And therein lies our story. I mean, I knew people were using telemedicine, I'm sure for a very long period of time prior to the pandemic, but it wasn't the pandemic that put this thing into hyperdrive. Tell us a bit about that.

Dr. Jonathan Beatty 
Absolutely. And you're correct in that telemedicine existed long predated the pandemic. So virtual, what they call "synchronous telemedicine," meaning that it's a live video and audio feed between a patient in a remote location can be their home or anywhere. And then the clinician or usually the physician, you know, from their office, or I guess theoretically from wherever they might be. And so the idea of expanding care and access to care by doing this led to the development I think it's the American Telehealth Association or something ATA, I believe whatever that stands for. So they created guidelines behind how this is, again, way before the pandemic and there was a lot of hesitation for this to kind of get rolling because we're trained in hospital settings, were trained in office settings, we're not trained in virtual settings, and many of us are not all that familiar with, depending on how you know how old the physician is the technology behind it. And so, there are also some limitations in terms of tangible you know, the patient's not directly in front of you, and you may not, you know, so there's this hesitation in the guidelines, as I recall, and don't quote me but I think more or less where that initial visits were intended to be in person and follow up visits guidelines would suggest were adequately monitored and processed through the telemedicine platforms. So then you get to, let's say 2008, where there was a situation regarding an online pharmacy, I believe, and or doctor that was prescribing, there was a patient and I am not 100% certain of the I believe the patient is Ryan Haight, I can tell you that the act that was developed as the Ryan Haight, and that's H-A-I-G-H-T Act of 2008. My understanding is he was a patient who was prescribed from a few different locations, multiple prescription medications that were controlled substances. And subsequently, I guess succumbed to those, those medications and as a result of that, they identify that the DEA through the DEA that one of the requirements for prescribing controlled substances, is that you need to have met the person face to face prior to initiating any prescription for a controlled substance.

Steve Martorano 
Was this Ryan Haight? Was he being treated for a psychiatric disorder?

Dr. Jonathan Beatty 
I'm not certain of that. So I don't, I'm not positive. But regardless of the purpose of their treatment, the controlled substances, my understanding, or were, at least in part, if not entirely behind...

Steve Martorano 
There was a bright line with what the physician could do in a virtual capacity and it stopped at prescribing drugs.

Dr. Jonathan Beatty 
You could, let's say, at any point in time, I've never met you before. And you say, "Hey, I think I have strep throat." or I really, you know, whatever. And I might say, Oh, I'm gonna give you this antibiotic. And I can prescribe that from evaluation, I can maybe even be able to see your throat, if you can shine a light there, I might be able to see it virtually. And identify, you know, that it's very red and irritated. And there's mucus and so forth, plus, whatever, and be able to treat it that way, and send the electronic prescription for an antibiotic. That I don't have to meet you face to face for and still don't. But as a result of this outcome, if it were, hey, I'm really anxious, and I need Xanax, I mean, paraphrasing, obviously, or I felt you needed Xanax, I would have to, up until the pandemic as a result of this act, I'd have to see face to face and then subsequently at least once a year in person. So we could meet any number of times during that year, but at least once a year would have to be in person, the rest could be virtual.

Steve Martorano 
And the logic behind that is obvious. It's in the description of the drugs that you couldn't do that too, they are controlled, right? And if you were to be able to do that without actually seeing the patient, then you're losing control over what potentially could be a dangerous drug. And also, I suspect, can lead to abuse of that drug. Correct?

Dr. Jonathan Beatty 
Very much. So those are two important distinctions. And then there was another element of the guidelines, which remain in effect until the pandemic that had to do with state lines. And so generally speaking, a physician is licensed in the state where he or she practices medicine, I mean, they have to at least have that sometimes they do have additional licenses, for example, I'm in Pennsylvania, a lot of patients come from New Jersey, a lot of doctors in Pennsylvania think it makes sense to have a jersey license as well. So I happen to have one, although I don't know that I ever actually use it, I have it. That being said the patient's location defines the state licensure requirements. And by that, I mean, if a patient is in Pennsylvania like you're in Pennsylvania, if you were my patient, I'm licensed to treat patients in Pennsylvania, I can do that remotely because you're in Pennsylvania. Likewise, if you were in New Jersey, I could because I happen to have that license. If you were in Alaska, I would not be able to practice medicine in Alaska, because I'm not licensed there. So I would not be able to have a telehealth visit with you. If you were in Alaska. Now I could be a physician, I could be anywhere in the world theoretically. But the patient I'm treating has to be in a state in which I'm licensed.

Steve Martorano 
Again, for obvious reasons. When the pandemic hits, what changes?

Dr. Jonathan Beatty 
We are entering into what they refer to as a state of emergency which there the Emergency Use Authorizations, the E U A, that allowed for a lot of the rapid tests that were developed for COVID-19. Some of the treatments for COVID-19, at least initially, even the vaccines initially, are now fully FDA approved, but at the time they were emergency use authorized. So what that means is, during that time period, there are lots of exceptions because they don't want to delay access to care, they don't want to limit access to care. And so in order to, you know, the greatest common good would be to make sure every patient is able to get to their doctor. So the compliance of the software that you would use for the telemedicine was also lifted somewhat the requirement that it had to be HIPAA compliant so that there's encryption between you and me so that no one a third party wouldn't be able to intercept that because it's protected health information. That changed to a point where you could theoretically use like Facebook Messenger or an iPhone, FaceTime, or one of these things, just during the pandemic and I suppose technically until May of this year when they end the state of emergency might be able to do that. I never did that. I didn't think it was a good idea. But I was able to incorporate a telehealth platform that I had already been using ahead of the pandemic in a much more limited capacity to roll that out into a major part of my practice.

Steve Martorano 
People had to be confident that while they meet their doctor and are treated by him, or her, virtually over the internet, it was protected so that no third party could see what drugs you're taking.

Dr. Jonathan Beatty 
Or whatever the conversation or whatever they could theoretically hear you talking about, you know, whatever disease state you're, you know, all that is confidential. And so it's important to maintain that confidentiality. I mean, it's always important, but because of the emergency state, they were making it a little less stringent, you were obviously supposed to do the best you could under the circumstances.

Steve Martorano 
Yeah, we don't need to go over the history of the pandemic, we know that as you've already pointed out: Guardrails went down, was full speed ahead on getting certain things done, we'll worry about whether or not there's any efficacy to this stuff, later on. We got to get out in front of this national -- international critical emergency. And so telemedicine, found itself on steroids, doing all sorts of things it was really never intended to do. The problem now arises with regard to I guess any number of doctor-patient interactions, but specifically, what piqued our interest is I see online every day, ads for the use of certain for a better lack of better terms that will define later psychedelic drugs or mood drugs to treat things like depression and bipolar anxiety and stuff like that, that are now not only diagnosed virtually but you can be prescribed specific drugs to treat these and never have to leave your house. That's a problem. Right?

Dr. Jonathan Beatty 
Well, it's certainly a potential problem. It remains to be seen on some level. But I think it's important to identify that psychiatry and mental health in general, are well positioned, I think for telehealth visits because of the fact that there's not as much of a physical examination necessary. Although I would argue there are certain things that aren't necessary, such as checking vital signs, you know, identifying drug screens and other things to identify what else might be going on, that you can't pick up through a video call, I mean, even the smell of alcohol, frankly. So there are limitations. But nonetheless, compared to say, cardiology, and the need to listen to a heartbeat, that would be somewhat difficult, although there are ways that they can now do that.

Steve Martorano 
I'm looking into the future. And I can see a situation where first of all, this won't be foreign, right be a common experience. Technology will catch up to it. And you probably will be in fact, probably can now...

Dr. Jonathan Beatty 
There are types of hardware now available that go to the patient's house, you can mail them theoretically. And so there are ways of monitoring remotely, things like vital signs, but...

Steve Martorano 
So that people understand. So where we're on the cusp of sort of an inflection point, what we're talking about as a potential problem is in its infancy right now. But going forward as virtual healthcare, and telemedicine become more ingrained, there's gonna be generations who grew up with no other relationship to their physician, than this, what we're doing.

Dr. Jonathan Beatty 
The so-called "New Normal" that we heard about all along is ongoing.

Steve Martorano 
Exactly. We have the accident of birth will be at the moment when it's being figured out.

Dr. Jonathan Beatty 
Right. Let me give you a quick, just a quick sort of example, which would be an appropriate use of telemedicine in psychiatry. So let's say, for example, somebody is depressed, they contact our office, and they'd like to get evaluated for what they think is depression. We might be able to do that virtually by a telemedicine appointment, visually seeing the patient and then collecting the history as we do identify certain symptoms and trying to funnel that into some form of diagnosis to oversimplify it. And that treatment plan might then be an anti-depressant medication to be prescribed. I mean, there are some potential limitations. But for the most part, that's a pretty reasonable approach -- especially when you consider how debilitating depression can be, and somebody might not be able to leave their home and the thought of having to get a ride or get themselves to you or even get out of bed and get a shower and get dressed might be daunting. So other than the potential risk of suicide, which of course, is a very grave concern. The idea that we could increase their access to care by doing it remotely is potentially a win. So let's say that in that scenario, the person is depressed and not suicidal, we give them an antidepressant medication prescription electronically, and they start the medicine and they start feeling better and maybe when they're feeling a little better, they're able to come in for an actual in-person visit. That's a slam dunk. Right? I mean, that's like what we would hope for. Now let's add to that a little bit of anxiety. Now let's say they are I'm not responding to the anti-depression medication as much for the anxiety as they are for the depression. And maybe you're considering something called a benzodiazepine. Well, now you're dealing with a controlled substance. So now in the pre-pandemic era, we would have to have the face-to-face evaluation prior to that. There are a lot of advantages to that when you see somebody in real life, again, as I alluded to, you can evaluate and assess, you can collect urine drug screen, you can do other things to try and identify if there's a greater chance of this person abusing the substance down the road, or if they're already abusing something else, quite frankly, I mean, a patient could tell you know, "I've never taken a benzodiazepine in my life." And then you do a urine drug screen, and they have, you know, three different benzodiazepine-positive results in their drug screen. So there is value, obviously, in the in office. And I would never diminish that. But there are scenarios like the first one where it can be very helpful to have telehealth.

Steve Martorano 
So as you pointed out, in your initial remarks, there are people who, because of their circumstances, would just be cut off from care, because they're unable to come to the doctor. So this was a boon to a lot of people. But it was born out of an emergency. That emergency directive is about to lapse, is it not?

Dr. Jonathan Beatty 
Right? So the idea that it was it did exist prior to that, but then it accelerated to the point where, you know, five or 10% of physicians had the capability of telehealth, and I don't know that exact number, that's just a guess. And then among those percentages, maybe, you know, I'll use myself like so I had the capability, I would say, less than 5% of my patients pre-pandemic, I would visit through telehealth. And now it went up, I guess there was a brief period of time when it was nearly 100% because it was almost the only way to conduct health care. I mean, our doors were always open, and we had a lot of precautions in place. But a lot of facilities don't have the capabilities to do so. And as you recall, the protective equipment, the personal protective equipment, wasn't available. So yeah, the pandemic accelerated -- I mean, it threw gasoline on this fire, so to speak, and made it really available, which again, is a good thing, and probably even most ways, but then I think what we're getting at is what else could you use to treat depression? And there are some other medicines that are around to treat depression that is that were not considered to be safe to do it to be treated at home prior to the pandemic. And that has since shifted. And so what I'm talking about more specifically is ketamine, and a more novel compound, which is really just a portion of ketamine called S-ketamine. So as ketamine, branded as Spravato by Johnson and Johnson, was approved as an in-office treatment for depression, what that means is the patient would come into the office and receive the dose of medicine that was kept under lock and key in the doctor's office, there are all kinds of DEA requirements to protect against diversion. It has to be a certain number of keys locking, it can only be there for two weeks ahead of the appointment, it has to be used within that period, and so forth, we have to confirm after the dose is given to the DEA that it was given and to whom it was given and so forth. So here's what they call a REMS criteria, which is something that the DEA has for a lot of different controlled meds. So that's Risk Evaluation Mitigation Strategy. And that's many times a much simpler method of identifying where's this medicine going, you know, who's getting it and so on. And I participate in those REMS as required for many different medications. The one for private, which is this S ketamine is by far the most complex, even though it's a schedule three drug and there are many schedule two drugs which has a higher level of security or risk of abuse, as the DEA perceives it, that have fewer requirements, let's say. But nonetheless, ketamine, and S-ketamine, were being used in the office to treat depression and other things. But we'll talk just about the case today about depression.

Steve Martorano 
And in your practice, you have treated people with ketamine, as you just described.

Dr. Jonathan Beatty 
I have with both molecules the racemic ketamine, which includes S-ketamine, and then the isolate. S-ketamine, which is branded as Spravato. And so I've been using those ahead of the pandemic. They were approved very shortly before the pandemic, if I remember the timing exactly. So I started using both treatment options. And prior to that, I'd used ketamine in hospital settings for a variety of different circumstances. So pretty familiar with the medication. And I was pleased to identify these options in the office. One of the reasons that it's in the office is that you have to monitor blood pressure and other vital signs needed to be sure the patient...

Steve Martorano 
During the treatment?

Dr. Jonathan Beatty 
Right, so they have to be in the office for at least two hours from the point when they start the medication. And that's so that the medicine can fully wear off so to speak, almost like a Post Anesthesia Care Unit. So these drugs are really anesthetic as they're classified. And so we're using sub-anesthetic doses meaning they're not going fully to sleep. But the policy and protocol around monitoring are the same meaning they can't drive afterward. They have to be given a ride home, and they need to be monitored until they're sort of clear from the medication.

Steve Martorano 
The backstory of ketamine is fascinating because we're talking about a use that grew out of its initial purpose, which was as an anesthetic.

Dr. Jonathan Beatty 
Right.

Steve Martorano 
We've covered that and we'll cover it in the future, again. We're talking to Dr. Jonathan Beatty, he is an addiction psychiatrist. And he and I saw several articles in a rush of the mainstream news in the past week or so, and immediately began contacting each other because we both saw a problem here, at least in terms of information for the public. This is the classic buyer beware, or know what you're getting into and what the situation is before you fall into the easy pattern of listening to claims that you're bombarded with about these drugs that have some very wonderful results, treating depression and even bipolar and anxiety. But you got to be careful. You've painted a picture in the history of telemedicine, that sort of is a brave new world. It sounds terrific. Where's the problem started?

Dr. Jonathan Beatty 
Well, in general, I think some of the limitations of telemedicine as it pertains to say abuse and diversion of medications, and the inability to fully assess a patient and their response to medications. But I think in specifics when we're talking about this particular medication, the ketamine or S-ketamine, the idea that you're so first of all the DEA requirements for the S ketamine, this rems thing I talked about, they're worried about diversion. So if you're mailing this medication to someone's home, as some of the programs are doing, it's possible that medication could get diverted, obviously, now, it's possible that any prescription for a controlled medication could get diverted. And so there's not necessarily a difference or a difference in risk about this drug versus another drug in terms of diversion, but because of this monitoring that's necessary. There are some other risks that are inherent to ketamine and S-ketamine. And so...

Steve Martorano 
And one of them is its history as a recreational...it's club drug. Special K was a drug you took and went to a rave and had a wonderful time. So in arise...ketamine arrives into the story with a rep. And so I can see where the concern would be that it would be used that way again,

Dr. Jonathan Beatty 
Sure. But again, I mean, lots of other medications are used in illicit ways that are prescribed and then not use appropriately. So I don't know if it's, maybe there's just more of a sort of conception of this medicine in ways that made that concern greater.

Steve Martorano 
I think we understand the diversion of concern and the potential to abuse the drug or not use it properly. But assuming all of that is taken care of, what are the...are there any dangers...you described a beautiful setting for how you treat patients with this...with ketamine. They're in there, they're monitored, professional people are always around, leave in an orderly time. That's a far cry from the ads I see on the internet, which are taken at home. What about the dangers to the patient? What are the potential drawbacks to telemedicine in that context?

Dr. Jonathan Beatty 
So I think one of them, which is not insurmountable or it is surmountable, is there should be another person, in my opinion, in the setting where the patient is taking the medication. So, you know, for lack of a better term, a caregiver. Somebody that's at least aware that they're there and that they're on this medication, and they have some sense of what's going on. So I think if you have somebody there, that is a trusted confidant of the patient, and you, the provider, have had an opportunity to have a conversation with the caregiver and say, "Okay, this is what I, you know, if anything goes on, and you call me directly." You know, if we get disconnected, let's say we're doing a therapy session with the patient, but they're at home, then I can contact you can go check on them. So that can really help reduce a lot of the potential concerns. But these are impairing substances. So if somebody's at home, and there's no real oversight of what they're doing, they could potentially become subject of abuse of some sort, meaning like if there was somebody if they weren't in a safe place where they took it, somebody could take advantage of them. Because they're anesthetized. I mean, they're awake, but they're, you know, their, their guard is down certainly from the medication and so they need to be in a safe setting. And then, of course, if the blood pressure were to go above a certain threshold, that could be dangerous, depending on the age of the patient. High blood pressure acutely high blood pressure can lead to strokes and heart attacks, and other serious consequences. So there are some very significant considerations.

Steve Martorano 
Isn't another one of the considerations, you say "caretaker," it's obvious you'd be administered a drug in at home with no physician nearby. It's important just on that sort of garden variety stuff, blood pressure, and stuff like that. Isn't it also unique to something like ketamine, that you are also in an altered state of consciousness, so that a caregiver, Aunt Mini, who comes by three days a week, makes sure you're okay? Who's 82 years old and doesn't know what an altered state of mind is about might not be the right person to be with you while you're taking ketamine at home? Right?

Dr. Jonathan Beatty 
Yes, of course, the selection of the caregiver would be critical, in my opinion...

Steve Martorano 
...and different if you were just suffering from diabetes or something right?

Dr. Jonathan Beatty 
Very much, so. Yes. You know, I think it's important to have a, you know, a concept ahead of that what you're in for potentially as the caregiver, and make for that person is vetted and inadequately prepared for it.

Steve Martorano 
You know, children of the 60s know who that person is. That's "the guide." That's the person you have confidence in. The person that can keep you centered, and get the most out of this treatment, the altered state you're in.

Dr. Jonathan Beatty 
Right.

Steve Martorano 
So that becomes a problem right away. How many people have that person available?

Dr. Jonathan Beatty 
It would seem fewer than there should be. I think, given the way that the medicine has become available in these ways, these send-home or mail-home drugs that are prescribed and there's some sort of an evaluation, I guess, online ahead of that, those types of requirements are not necessarily being met, or even possibly considered or confirmed. And so it's hard to know. I can give you a vague example, without specifics, just to maybe drive the point home that I have a patient who was considering ketamine on his own or her own and ordered one of them, you know, paid for and, you know, signed up for one of these programs online and had some kind of evaluation that he said was basically, a few minutes and within, I don't know, a week or a few days, or whatever arrived in the mail, a pack of six doses of this medication or whatever the number was, and some visual aids, you know, descriptions of what to look out for, and a number to take, you know, like to let them know, there's a problem. I mean, not a lot of oversight. It didn't seem and frankly, the patient didn't feel comfortable doing it. And thankfully, he was able to tell me about it. So that was sort of my first learning about this type of program in this practice.

Steve Martorano 
Let me ask you about where the drugs are coming from. I've read about a new phrase to me, "compounding pharmacies." What are they? Are they reputable? Are they safe?

Dr. Jonathan Beatty 
That's a great point that we should talk about for a minute. The compounding pharmacies are licensed pharmacies. They, generally speaking, should be perfectly fine and perfectly legitimate with registered pharmacists or doctors of pharmacology who are licensed by the state as pharmacists who are able to compound these drugs. So if you look at over time, the beginning of time, you know, doctors would compound their own medications. And that's how things started with medicine. Later, the School of Pharmacy was developed as a way to try, and you know, broaden the ability to make different medications. And so, theoretically speaking, that's part of pharmacy training. And then there's a more specific pathway, I believe, for compounding pharmacists, or at least in there, in their subsequent training to be comfortable doing that. So all that is totally above board. And as long as they're following the requirements that are state-imposed, you know, they're licensed by whatever state they make the medications, and they're using, you know, certain recipes that are specific for whatever they're doing. That should be fine. Now, what's happening now and what you're talking about or getting at is the idea of off-label use. Now we use medicines off-label all the time, meaning it wasn't used in the manner that it was initially tested and approved through the DEA. So you know, even an antibiotic might be approved for a certain type of infection,. Then they might find that it also helps in a different type of infection and use it for that. That might be an off-label use. That doesn't mean it's a bad thing. Now with ketamine, the development of ketamine is intravenous use. So Ketalar, I believe, is the original brand name for ketamine. It's an intravenous, so in the hospital setting, as you alluded to, for anesthesia, it has since been used in other settings, but still in the intravenous preparation. And so that's being manufactured by the company that makes ketamine as opposed to a third party, which, again, might be perfectly fine, but it's just different. So compounding pharmacies are allowed to make things that are not commercially available. So if ketamine and the concentration of ketamine in the liquid suspension is available a certain way commercially, they can make it in a different ratio that's not commercially available, and they're licensed to do that. And again, that might be perfectly safe. And those are sterile products that are still for intravenous use in that context. But they can also make non-sterile products. And so what we're talking about in this way is ketamine that's being compounded into another preparation, say intra-nasal so that it's insufflated basically inhaled, which is how the Spravato was done. So the FDA-approved label major depressive disorder treatment with Spravato is a canister that you inhale through your nostril. It's not an intravenous route. Now ketamine was tested, and there was a nice NIH study done where they used six doses of intravenous ketamine to treat depression, it was ver...shown to be very effective. And so, in most cases, and so, the idea of can we compound IV ketamine, or the ingredients of ketamine, into this intranasal ketamine and use it? And the answer seems to be "yes." Now, that's not what they're typically shipping out to these patient homes. What they're typically shipping there is what's called a "troches," and that's basically like a lozenge that is sublingual, or under your tongue. And so there's a different type of absorption under your tongue. The bioavailability is greater than if you were to swallow it by mouth. So your GI tract has a first-pass effect and many other reasons why the drug doesn't get into your bloodstream as easily as it would sublingually or intranasal, or the best route would be intravenously. So they're sending these troches home, and that's how they're getting them. They're being compounded by these pharmacies. Now, that may or may not be appropriate. By themselves, the pharmacies aren't, you know, they're just responding to a prescription. They're not necessarily, you know, mishandling that prescription and making what the doctor was ordering.

Steve Martorano 
And without getting into too much detail about the compounding pharmacies, as you say, they're licensed, and they have their guidelines and protocols to follow. Are they still as stringent on these compounding pharmacies when it comes to making the kinds of drugs you're talking about? I mean, are the guidelines they? Are people checking? Do they report to the government what they're doing?

Dr. Jonathan Beatty 
I honestly don't know the answer to that. My guess is that they are. I mean, the ingredients that they're using to prepare the medications are highly regulated ingredients. And so for them to access those ingredients. I'm sure they have to log how they're using them.

Steve Martorano 
There has to be a paper trail. Yeah. Well, so you can see what's happened here. A perfect storm has formed. And now what I've read -- some of the stuff you've sent me and stuff, I've found -- entire practices that didn't exist, medical practices are now popping up all over the country. They are driven by venture capital money because these guys see a potentially huge payday. And it's going to become easier and easier -- never to meet a physician never be seen by a physician to be diagnosed with some psychiatric disorder, like depression or bipolar, and have a prescription written and just filled out. This looks like, I'm sorry, it's a horrible term, but it looks like the formation of a gigantic, potentially a pill mill. We should be worried about that. Right?

Dr. Jonathan Beatty 
I think it's important to at least be worried about it. Yes. I'm not suggesting that's what's happening, although it's certainly a possibility. I think that in the pandemic, because of the restrictions that are lifted as a state of emergency, which are about to shift back, at least, they're supposed to that idea of that Ryan hate act that we talked about. So you would have to see the patient face to face, they're currently not required to do that, which makes a big difference when they're trying to grow a venture capital-driven business as opposed to medical practice.

Steve Martorano 
Do you think the guidelines will be rolled back? They're supposed to be rolled back in May? Right?

Dr. Jonathan Beatty 
Are they supposed to be rolled back in May? I think it's a little curious that, at least as far as I know, to date, the FDA and or DEA have not given us a clear answer as to whether there's going to be any change in the way they're currently defined.

Steve Martorano 
I don't know if you're a betting man, but I'm not. But I would bet that there will at least be a notification that the status quo will remain. While we take another look at this. I don't see where except the public and people like yourself, professionals who are saying, "slow down," why there would be any incentive to say, we're going to clamp down on this stuff. First of all, there are a lot of patients that are going to suffer.

Dr. Jonathan Beatty 
Right? So that's where you're right, I think in the way they'll suggest as well until we figure out, you know, if we just cut this off now suddenly 10,000 20,000, whatever the number is of patients that are receiving this kind of care or going to it might be hundreds of 1000s, frankly, are going to lose access to care. And that could be devastating.

Steve Martorano 
Many people are actually being helped through this process. And by the way, without getting too deep into the weeds on this thing, the growth has been nothing less than explosive. I mean, there are chat groups online where people are being treated this way. You know, two years ago, three years ago, there might be four or 5000 people in the chatroom; there are now 10s of 1000s of people in those chat rooms. So we know it's gigantic and getting bigger every day. I know we are pressed for time here. So we're gonna have to have you back then more of this. But just this final thing, if someone is looking for help and is inclined to look for help online, what did a couple of little two or three things they should be aware of before they decide this is the way to treat my problem?

Dr. Jonathan Beatty 
I think it's a difficult scenario when you're talking about somebody struggling with depression, especially if they're dealing with what's called treatment-resistant depression, or refractory depression, meaning it hasn't responded to the traditional medications, or several trials of the right dose, the right timeline, and all. So these are people that might be a little more, feeling a little more hopeless, like, "What am I going to do," and then they might genuinely be searching for a solution online. But because of the money backing some of these practices, let's say, for example, they might look for a psychiatrist who provides in-office ketamine. They probably wouldn't search that way. But maybe they would, ahead of that result might be one of these sorts of mail-order companies, and they might click on it without even really realizing what it is. And it'll promise, you know, a very streamlined, easy approach to an evaluation and medication treatment for your depression in that you can be feeling better, you know, by tomorrow or the next day. You take somebody who's been feeling depressed for maybe years, and hasn't responded to what you know traditional medicines have offered? That seems like a really obvious, like, let me try that. And so I think what you should look for if you're seeking out care and you aren't able to come into an office setting would be how sincere does the program or the practice seem? What sort of steps are they taking to safeguard you are the patient? Are they confirming, you know, even for just a regular evaluation, they can, confirm what type of safety is available to you? Do you have emergency contacts? Do you have the specific address of where the person? Do you or somebody else know where they are? Because in the mental health field, one of the ways that our patients die is through suicide. And so it's important to be able to assess that carefully. And I think having a psychiatrist as part of the process is important. Not all practices involve psychiatry, when they're doing these evaluations, or they may accept an evaluation from another provider. And so I think, looking at the practice, that you're, if you're vetting it as a patient, trying to find out and understand how involved they are in the treatment plan, do they offer psychotherapy. You know, there's more to this than medication. And I think it's we didn't really get into that. But it's important to understand that ketamine, S ketamine, are really good medications to help the process of treating depression, but they're not really meant, in the general understanding of how these things work, to be the only solution for treating depression. They allow and facilitate recovery from depression. But there are important other aspects of recovery that involve psychotherapy, good self-care, sleep, hygiene, nutrition, and all kinds of things that it's important for a practice to assess when they're treating a patient like this.

Steve Martorano  
It's all great advice. Dr. Beatty, I would just add the tendency to look at health care, and treat what's troubling us should not be confused with the ease of buying a sweater through Amazon. We live in an age now where if you want something, you can have it tomorrow.

Dr. Jonathan Beatty 
Right.

Steve Martorano 
And these ads that you will see online. They may be reputable people, but they are appealing to this same instinct, "Oh, I just push a button. And it'll be okay. Everything will be okay." This is not that.

Dr. Jonathan Beatty 
I agree with you. That's a very good way to kind of summarize the the issue at hand. The culture is adapting towards that desire and it's available in many other ways and I think that healthcare still requires a little more time and nuance.

Steve Martorano 
We thank you for your time. We're going to have to have you back, of course, a lot. We really just brushed the surface of this growing trend. Jonathan Beatty. Thank you so much. Appreciate your time. I'll let you get back to your important work, and we'll talk to you soon.

Dr. Jonathan Beatty  
 Okay, sounds good, Steve. Thanks again for having me.

Steve Martorano 
You guys, thank you as well. Don't forget the subscription. Look for the button. I'm going to make it bigger so you can find it, but it's there at the top of the page. Subscribe to the Behavioral Corner. We appreciate it. See you next time.

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