Esketamine nasal spray (brand name: Spravato) is a treatment for adults with treatment-resistant depression or major depressive disorder with acute suicidal ideation. Approved by the FDA in 2019, it is administered under medical supervision at certified healthcare facilities. Unlike oral antidepressants, which can take weeks to show results, esketamine works on the brain’s glutamate system, often providing relief within hours or days.
Key Points:
- Eligibility: For adults who haven’t improved after trying at least two antidepressants.
- How It Works: Targets NMDA receptors in the brain to regulate mood.
- Dosing: Initial sessions are twice a week, followed by weekly or biweekly maintenance.
- Supervised Treatment: Patients self-administer the nasal spray at a clinic and are monitored for 2 hours post-treatment.
- Common Side Effects: Dissociation, dizziness, nausea, and temporary blood pressure increases.
- Limitations: Requires frequent clinic visits, and driving is prohibited for 24 hours post-treatment.
Esketamine offers a new option for those who haven’t responded to other treatments, but it requires commitment to safety protocols and regular clinic visits.
How Esketamine Nasal Spray Works
How the Medication Works in Your Brain
Research shows that esketamine interacts with the brain’s glutamate system, leading to a rapid improvement in mood. This makes it especially helpful for individuals struggling with treatment-resistant depression.
Treatment Process and Dosing
Esketamine treatment is provided under the Spravato REMS Program, which prioritizes patient safety throughout the process. Here’s what to expect during treatment:
- Before Your Session: Avoid eating for at least two hours and drinking liquids for 30 minutes before your appointment. If needed, use a nasal decongestant or steroid spray at least one hour prior to dosing to ensure clear nasal passages.
- Dosage: Each spray device delivers 28 mg of esketamine. Your healthcare provider will determine whether you need a dose of 56 mg or 84 mg, depending on your response to the treatment.
- How to Use: Start by blowing your nose to clear your airways. Tilt your head back slightly, insert the spray device into one nostril, press the plunger, and breathe in slowly. Repeat the process for the other nostril.
After the dose, you’ll remain at the treatment facility for at least two hours. This observation period allows medical staff to monitor for any side effects, such as sedation, dissociation, or changes in blood pressure or breathing. It’s important to arrange transportation home, as driving is not permitted until you’ve had a full night’s sleep.
Who Can Receive Esketamine Nasal Spray
Patient Requirements for Treatment
Esketamine nasal spray isn’t a one-size-fits-all treatment. The FDA has outlined clear guidelines to determine who qualifies for this therapy.
To be eligible, patients must have a diagnosis of treatment-resistant depression or major depressive disorder with acute suicidal ideation. This means they’ve tried at least two different oral antidepressants, from different classes, at proper therapeutic doses, but didn’t experience sufficient improvement in their symptoms.
Esketamine is approved for adults aged 18 and older.
Your healthcare provider will assess your medical history and current health to ensure this treatment is safe for you. Certain conditions, such as aneurysmal vascular disease (in the thoracic or abdominal aorta, cerebral or peripheral arteries), arteriovenous malformations, or a history of intracerebral hemorrhage, make esketamine unsuitable.
If you meet the criteria, you can move forward with the treatment process.
Getting Started at Bright Horizons Psychiatry
At Bright Horizons Psychiatry, the treatment process adheres to the Spravato REMS Program. Your journey begins with a consultation with Dr. Amir Etesam, an expert in treating patients with resistant depression.
During this first visit, Dr. Etesam will carefully review your medical and psychiatric history, including your experiences with previous antidepressant treatments. To make the process smoother, bring detailed records of the medications you’ve tried, including dosages, how long you took them, and why they were discontinued. This information helps confirm whether you meet the criteria for treatment-resistant depression.
In some cases, additional tests may be ordered to ensure esketamine is both safe and appropriate for you. Once you’re cleared for treatment, you’ll receive a thorough overview of what to expect, including session protocols, potential side effects, and the mandatory observation period following each dose. You’ll also be reminded to arrange transportation, as driving is not permitted after treatment.
The Bright Horizons team will assist with insurance verification, helping you understand any out-of-pocket expenses and available payment options. Before your first session, you’ll also get preparation instructions, such as dietary recommendations and tips for clearing your nasal passages to ensure effective treatment.
Benefits and Drawbacks of Esketamine Treatment
Treatment Benefits
Esketamine nasal spray offers a fast-acting solution for individuals with treatment-resistant depression. Unlike traditional antidepressants that can take weeks to show results, esketamine often alleviates symptoms within just 24 hours. This is because it works by targeting the glutamate system rather than the serotonin pathways, providing a new option for those who haven’t responded to other treatments.
Long-term research, spanning up to 6.5 years, has shown that esketamine remains effective over time while maintaining a stable safety profile. Studies highlight that patients using esketamine report better quality-adjusted life-years compared to those relying solely on oral antidepressants. Clinical trials also reveal higher response and remission rates, with fewer patients stopping treatment due to side effects.
Still, these benefits come with certain challenges.
Treatment Limitations
Despite its effectiveness, esketamine treatment is not without hurdles. It’s only available through the REMS (Risk Evaluation and Mitigation Strategy) program, which limits access and requires administration at specialized healthcare centers. Patients must also remain under supervision for two hours after each dose, which can be inconvenient for those managing work, family commitments, or transportation issues.
The treatment itself isn’t risk-free. It can elevate blood pressure and cause side effects like dissociation, sedation, dizziness, and nausea – though these effects typically subside within two hours. Access is also a significant barrier. Not all healthcare facilities offer the treatment, and for those in rural areas or without reliable transportation, the repeated visits required during the initial phase can be particularly burdensome.
Benefits vs. Limitations Comparison
Here’s a quick breakdown of esketamine’s advantages and challenges:
| Benefits | Limitations |
|---|---|
| Rapid symptom relief (within 24 hours) | Requires administration at specialized facilities |
| Targets glutamate system (alternative to serotonin-based treatments) | Mandatory 2-hour observation post-dose |
| Effective for treatment-resistant depression | Side effects like dissociation, nausea, and dizziness (usually transient) |
| Proven long-term efficacy (up to 6.5 years) | Access restricted through REMS program |
| Higher quality-adjusted life-years than oral antidepressants | Risk of elevated blood pressure |
| Fewer treatment discontinuations due to side effects | Transportation and scheduling difficulties |
| Consistent safety profile in long-term studies | Limited availability at healthcare centers |
| Outperforms other augmentation strategies |
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Side Effects and Safety Information
Most Common Side Effects
Esketamine’s side effects are generally short-lived, often resolving within two hours. The most common one is dissociation, where patients feel disconnected from their body or surroundings.
Other frequent side effects include dizziness and sedation, which is why you’ll need to stay at the treatment facility for observation after your session. Drowsiness and unsteadiness are also typical, often occurring shortly after the medication is administered. Some patients experience nausea, but this usually fades as the drug wears off.
Temporary increases in blood pressure are common, particularly in patients with cardiovascular issues. While this rise is short-term, individuals with pre-existing heart conditions require careful monitoring.
Additional side effects include headaches, anxiety, and a metallic taste in the mouth. Some patients report blurred vision or confusion during the first few hours after treatment. These symptoms are typically mild and don’t require further medication.
As your body adjusts to the treatment over time, the intensity of these side effects often diminishes. However, if you notice severe or lingering symptoms, it’s important to notify your healthcare provider right away.
The following safety warnings highlight additional precautions to consider during treatment.
Important Safety Warnings
Beyond the common side effects, there are several critical safety considerations when using esketamine.
Pregnancy and breastfeeding require special attention. Esketamine may harm an unborn baby or pass into breast milk, so women of childbearing age should discuss contraceptive options with their healthcare provider.
If you have a history of substance use disorders, be sure to inform your doctor. Esketamine has the potential for misuse, which is why it’s strictly regulated through the REMS program and only administered at certified treatment centers.
Allergic reactions to esketamine or ketamine, though rare, can be serious. Symptoms such as difficulty breathing, facial or throat swelling, or severe skin reactions should be reported immediately. Let your provider know if you’ve had past reactions to anesthetics or similar medications.
Avoid driving or operating machinery for at least 24 hours after treatment. The sedative effects and potential for delayed reactions make activities requiring full alertness unsafe. Be sure to arrange transportation to and from your appointments.
Patients with heart conditions need extra caution due to the drug’s impact on blood pressure. Those with uncontrolled hypertension, recent heart attacks, or certain heart rhythm disorders may not be suitable for esketamine treatment. Your cardiologist may need to give clearance if you have existing heart issues.
Finally, liver problems can influence how your body processes esketamine. If you have liver disease or take medications that affect liver function, your healthcare provider might adjust your treatment or monitor you more closely.
Summary
Key Takeaways About Esketamine Nasal Spray
Esketamine nasal spray has emerged as a promising option for those battling treatment-resistant depression. It works through a distinct brain pathway, often delivering fast relief from symptoms when other antidepressants have failed.
However, this treatment requires close clinical supervision due to potential side effects like dissociation and temporary blood pressure changes, which typically subside within two hours. To ensure safety, the REMS program mandates that esketamine be administered only at certified treatment centers by trained healthcare professionals.
Who qualifies? Patients must have tried at least two different antidepressants without success and meet specific health criteria. Certain conditions, such as heart issues, uncontrolled high blood pressure, or active substance use disorders, may disqualify individuals to prioritize their safety.
At Bright Horizons Psychiatry in Rockville, MD, Dr. Amir Etesam and his team specialize in esketamine therapy, offering a personalized approach to care. Their process includes thorough eligibility evaluations and attentive monitoring during treatment sessions to ensure the best outcomes.
This evidence-supported therapy provides new hope for those enduring persistent depression. It does, however, require a commitment to regular clinic visits and strict adherence to safety guidelines, which are critical to its effectiveness in improving patients’ quality of life.
If you’re 18 or older and exploring treatment-resistant depression options, consider reaching out to Bright Horizons Psychiatry for expert guidance and care tailored to your needs.
Esketamine nasal spray for depression: Mayo Clinic Radio
FAQs
Who is not eligible to use esketamine nasal spray for treatment-resistant depression?
Esketamine nasal spray isn’t suitable for everyone, especially those with specific medical conditions. For instance, it’s not recommended for individuals with aneurysmal vascular disease, uncontrolled high blood pressure, or conditions that elevate intracranial pressure. It’s also crucial to avoid this treatment if you have a known allergy to esketamine or ketamine.
Before considering esketamine, make sure to share your complete medical history with your healthcare provider. This step is essential to ensure the treatment is both safe and right for your situation.
How does esketamine compare to traditional antidepressants in terms of long-term effectiveness and safety?
Esketamine nasal spray provides a fast-acting relief for depression, often working within just 24 hours. This is a stark contrast to traditional antidepressants, which typically need 4 to 6 weeks to take effect. Research indicates that when used as prescribed, esketamine remains effective over time and is generally well-tolerated, with most side effects being mild and short-lived.
When it comes to safety, esketamine’s profile is similar to that of traditional antidepressants, with no major new safety issues reported even after a year of clinical use. On the other hand, traditional antidepressants might carry a greater risk of long-term side effects for some people. It’s important to discuss your options with your healthcare provider to find the treatment that works best for you.
What should I do if I experience severe side effects from esketamine nasal spray?
If you notice severe side effects after using esketamine nasal spray – like trouble breathing, chest pain, fainting, or losing consciousness – don’t wait. Get emergency medical help right away. These symptoms are serious and need immediate attention.
For other side effects that might not seem as urgent but still concern you, reach out to your healthcare provider promptly. They can assess your symptoms and advise you on what to do next to keep you safe. Acting quickly is crucial to managing any issues that may arise.