Effective treatment for depression that has not improved with antidepressants.
|Anxiety / Panic Attacks|
|Post-traumatic Stress Disorder (PTSD) / Trauma||Journal of Psychiatric Research|
|Bipolar Disorder||Journal of Affective Disorders|
|Addiction / Substance Use Disorder||World Psychiatry|
|Pain||Neuroscience & Biobehavioral Reviews|
|Schizophrenia / Hallucinations||Schizophrenia Research|
|Attention-deficit Disorder (ADD) / Attention-deficit Hyperactivity Disorder (ADHD)||NeuroImage: Clinical|
|Multiple Sclerosis||Brain Stimulation|
|Eating Disorders||European Eating Disorders Review|
|Alzheimer’s Disease||Journal of Experimental Neuroscience|
|Dementia||Proceedings of the National Academy of Sciences of the USA|
|Mild Cognitive Impairment / Cognitive Decline||Frontiers in Aging Neuroscience|
Intranasal Esketamine (brand name Spravato), is the first available fast-acting therapy approved for adults suffering from treatment-resistant depression. Spravato is a prescription medication that is administered via nasal spray and used in conjunction with a traditional oral antidepressant such as an SSRI (for example, sertraline). Treatment with esketamine has been found to rapidly reduce symptoms experienced among adults suffering from moderate to severe major depressive disorder.
Receiving treatment with intranasal esketamine is different from other antidepressant medications. First, patients who are receiving intranasal esketamine treatment are required to follow a restricted distribution program called the Spravato Risk Evaluation and Mitigation Strategy (REMS) Program. This is to ensure safety while receiving the medication. Patients are treated on-site for each dose of esketamine.
Esketamine is given to people intranasally, which means it is sprayed up the nostril. Each nasal spray device contains 2 sprays; one for each nostril. Patients self-administer the nasal spray under the direct supervision of a health care provider. Directly following the spray, patients are required to remain under the supervision of a health care provider for 2 consecutive hours to monitoring of potential side effects.
If your healthcare provider believes you could benefit from esketamine treatments, they can refer you to ANSR for a suitability assessment and to learn more about the treatment.
Esketamine nasal spray contains a derivative of ketamine known as esketamine (or S-ketamine). Esketamine is the S-enantiomer of ketamine, and targets the N-methyl-D-aspartate (NMDA) receptors in the brain. Esketamine is believed to produce antidepressant effects by promoting growth and connectivity among neurons located within key brain regions associated with major depressive disorder. However, this mechanism is not yet fully understood.
Typically, esketamine treatments are administered twice per week for the first month, and once per week for the second month. This is often followed by once per week or once every second week for the subsequent months, while continuing to simultaneously take your oral antidepressant as prescribed.
Depending on how you respond to the treatment, and how stable that response is, your healthcare provider will determine the length of time you will continue esketamine treatment. Taking this and other factors into account, your health care provider may also choose to alter your course of treatment.
When used in conjunction with oral antidepressants, esketamine has been found to be effective in reducing major depressive symptoms among patients with treatment-resistant depression in a number of clinical trials. Esketamine has also been effective in reducing the rate of relapsing symptoms in patients suffering major depressive disorder. Some patients may require several treatments before experiencing notable results, however, other patients may see improvements following their first treatment. Although response to this treatment varies among patients, esketamine has generally been found to have a relatively rapid and significant effect on major depressive symptoms.
Esketamine, in conjunction with oral antidepressants, was recently approved as a therapy for adults suffering from treatment-resistant depression by the FDA in March, 2019 and for use in Canada in 2020. Esketamine is generally considered safe for use among the adult population. However, further research is required for use among paediatric and geriatric patients. Some dangerous side effects are associated with Esketamine use, and thus, it is important that patients disclose any history of drug or alcohol abuse to their health care provider. For the safest and most effective treatment outcome, it is crucial to provide your doctor with a thorough review of your medical history prior to beginning Esketamine treatment.
Esketamine, along with oral antidepressants, can be very beneficial for patients suffering treatment-resistant depression. This treatment approach has the ability to improve mood and other major depressive symptoms in a significantly shorter amount of time than any current alternative antidepressant therapy. Some clinical trials report significant improvement among patients within 4 weeks of treatment administration, while others report significant improvement among patients within 24 hours of treatment administration. Esketamine is one of few therapies available to those suffering moderate to severe symptoms of treatment-resistant depression that is relatively non-invasive and has relatively few side-effects.
The major and most common side effects of Esketamine treatment include sedation (sleepiness) and dissociation (confusion about identity, time, place), requiring the 2 hour monitoring period following each treatment administration. There is also a risk of abuse and misuse associated with Esketamine treatment, as well as an increased risk of suicidal thoughts and behaviours while taking Spravato. It is important to report any changes in mood, behaviour, thoughts, or feelings to your healthcare provider immediately when taking Spravato.
Other possible serious side effects include:
If these side effects occur, they typically occur immediately following administration, and subside that same day. Spravato may impair attention, judgement, thinking, reaction speed, and motor skills. Patients should not drive or operate machinery until the day following each treatment. It is important that patients weigh out the benefits and risks associated with Esketamine treatment with their doctor prior to beginning treatment.
Esketamine is typically prescribed to adult patients suffering treatment-resistant depression. This refers to patients experiencing moderate to severe symptoms of major depressive disorder that persist following the failure of at least 2 or more current antidepressant treatments (i.e. oral antidepressants, talking therapies, CBT, etc.).
Esketamine is not suggested to patients with active substance abuse disorder, current or past psychosis, liver problems, or bipolar disorder, and should not be used among patients who have not had adequate trials of oral antidepressants. Those with aneurysmal vascular disease, intracerebral hemorrhage, or a hypersensitivity to esketamine, ketamine, or any of its excipients should not take Esketamine. You should not use Esketamine if you are pregnant, planning to become pregnant, or breastfeeding. It is important to discuss all health conditions and medications with your health care provider when determining if Esketamine is a good fit for you.
Spravato is a new drug and as a result there is a cost associated with it. The drug itself is partially covered by some private insurance plans. If receiving esketamine treatment at ANSR, there is an additional administration fee for each treatment session. Please contact ANSR for more questions.
Bahr, R., Lopez, A., & Rey, J. R. (2019). Intranasal esketamine (Spravato) for use in treatment-resistant depression in conjunction with an oral antidepressant. Pharmacy and Therapeutics, 44(6), 340-342.
Canuso, C. M., Singh, J. B., Fedgchin, M., Alphs, L., Lane, R., Lim, P., Pinter, C., Hough, D., Sanacora, G., Manji, H., & Drevets, W. C. (2018). Efficacy and safety of intranasal esketamine for the rapid reduction of symptoms of depression and suicidality in patients at imminent risk for suicide: Results of a double-blind, randomized, placebo-controlled study. The American Journal of Psychiatry, 175(7), 620-630. doi: 10.1176/appi.ajp.2018.17060720
Daly, E. J., Madhukar, H. T., & Janik, A. (2019). Efficacy of esketamine nasal spray plus oral antidepressant treatment for relapse prevention in patients with treatment-resistant depression: A randomized clinical trial. JAMA Psychiatry, 76(9), 893–903. doi:10.1001/jamapsychiatry.2019.1189
Thomas, R., Cetin, M., Baker, G. B., & Dursun, S. M. (2016). Comment on FDAs breakthrough therapy designation of intranasal esketamine for the treatment of major depressive disorder with imminent risk of suicide. Clinic Psikofarmakoloji Bulteni-Bulletin of Clinical Psychopharmachology, 26(4), 329-331. doi:10.5455/bcp.20161027122045