Unlike many other medical illnesses, the treatment for psychiatric disorders, including Major Depressive Disorder (depression), is not one-size-fits-most. Currently, depression is understood to involve some type of dysfunction of the serotonin system: a neurotransmitter, or signal, responsible for regulating many of the vital aspects of higher-order functioning including mood, sleep, and cognition. The current gold standard, second generation antidepressants, are effective in reducing symptoms in about 70 percent of cases. However, given that nearly 15 million adults in the US between ages 15 and 45 will be diagnosed with depression at some point in their lives, this leaves a staggering number of people with depression that does not respond to typical medication.
Surprisingly, the newest medical advancement in the treatment of this disorder has long existed in the veterinary community, as well as on the streets. Ketamine, classified as a dissociative anesthetic, is normally used on animals due to its strong tranquilizing and anesthetizing effects, but has earned another reputation as a street drug known as “special K.” When used recreationally at high doses, special K can produce a dream-like state in which the user may hallucinate or feel as though she is having an out-of-body-experience. Because this drug-induced state is often not remembered by the user, ketamine is sometimes used as a date-rape drug.
The newest medical advancement in the treatment of this disorder has long existed in the veterinary community, as well as on the streets.
Esketamine, a derivative of ketamine, is now being effectively administered in the form of nasal spray to depression patients who have not responded well to any other treatments, and is usually taken alongside oral antidepressants. While typical antidepressants take four to six weeks to produce a noticeable change in symptoms, esketamine may produce symptom relief in as little as a few hours, and has been found to dramatically reduce suicidal ideation. Additionally, the effect appears to be lasting and continues to provide symptom relief even after the initial euphoric effect wears off. Beyond the initial dose, half of participants of a clinical trial showed continued improvement after a month of sustained use.
Like other antidepressants, esketamine works by binding to specific neuroreceptors in the brain called NMDA receptors. While the entirety of the drug’s mechanism of action is not understood, it is hypothesized that binding and blocking these NMDA receptor sites contributes to the overall antidepressant effect in the brain. Additionally, esketamine is thought to enhance overall connectivity and plasticity at neural synapses, the gaps between neurons in which neurotransmitters cross to continue the flow of information.
As with any medication, it has its drawbacks. While ketamine has long been used in veterinary medicine for its anesthetic properties, its recreational use for its addictive, dissociative, and euphoric properties highlight its potential for abuse. These side effects are not absent in esketamine spray: about 40 percent of those that participated in clinical trials reported dizziness and dissociation following the administration of the drug. With this in mind, the use of this new breakthrough will, for now, only be permitted at certified treatment centers where it can be administered by trained professionals.
The price of SPRAVATOTM currently comes between $600–900 for a single treatment.
Esketamine nasal spray, commercially sold as SPRAVATOTM, has very recently become the first FDA-approved drug of its kind and is patented by the pharmaceutical company Janssen. Drug patents generally last 20 years, during which time the price of the drug is often extremely high due to lack of competition from other pharmaceutical companies. The price of SPRAVATOTM currently comes between $600–900 for a single treatment, depending on dosage and number of sessions. Each dose is taken 1–2 times per week during the first month, and may be continually needed long after this time period to maintain the antidepressant effects, which makes the cost of this treatment insurmountable for many people. Though the only people who will have access to this breakthrough treatment are cash-payers, since insurance cannot be used to cover the cost.
Despite its risks and drawbacks, this breakthrough will be the first new treatment option for depression in decades. Although it will not be the cure-all, it represents new hope for many individuals who have been living with the burden of incurable depression.