Esketamine is a new type of treatment for depression, available since 2019. In 2006, ketamine was found to provide fast dramatic reduction in depression symptoms for treatment-resistant patients. Since then, numerous studies have consistently repeated the same results.
Esketamine is one of the 2 isomers in the ketamine chemical, the “S” isomer, which is thought to be more potent. After this isomer was isolated, it was developed into a separate treatment given as a nasal spray which has been FDA-approved for treatment-resistant depression.
How it Works
Like ketamine, esketamine works primarily on the glutamate system. Specifically, it works as an antagonist (or blocker) at the NMDA glutamate receptor. Downstream effects include increases in BDNF (brain derived neurotrophic factor), which triggers growth of new neuronal synapses. This growth is thought to underly ketamine’s quick antidepressant action.
How Effective is it?
Similar to ketamine, esketamine provides quick relief to many, with about 65% of people with treatment-resistant depression respond.
What Other Options are There?
If esketamine does not work, or if it is not the right choice for you, there are many other options for treatment-resistant depression. One of these is continuing medication trials with different medications. Unfortunately, once you have not responded to 2 standard medications, the chance of response goes down dramatically, to about 15%. At this point, it may be appropriate to consider several other treatment options as well:
transcranial magnetic stimulation or TMS
electroconvulsive therapy or ECT
vagus nerve stimulation (VNS)
ketamine (link to ketamine page)
We do not provide TMS, ECT, or VNS at our office, but we refer to other local providers who deliver these services. (However, VNS is very difficult to find, and we are often unable to find an appropriate referral for this treatment.)
What is the Treatment Like?
At LBH, the process starts with a screening phone call for you to gather information and explain your symptoms and treatment history. Following this, you will be scheduled for a formal evaluation with one of our licensed providers within a few days. During this psychiatric evaluation, you will meet one on one with our professional psychiatric provider to understand your history and make a diagnosis. At the end of this process, we will review our findings and discuss treatment recommendations. If esketamine is recommended, we will also review more details about the risks and benefits of esketamine treatment.
Before starting treatment, we will send an application for coverage to your insurance company and wait for their approval, which may take several weeks.
Upon starting treatment at LBH, patients will be welcomed by the caring staff, then escorted to a private treatment room. Esketamine (Spravato) nasal spray will be administered in a calm, quiet environment. During this time, your vital signs will be checked and staff will monitor your progress. Afterward, you will be able to recover peacefully as the medication gradually wears off. The whole process typically lasts just over 2 hours.