Spravato (esketamine) is the newest form of medical treatment for moderate to severe depression.
Spravato is a radical shift in the approach to treatment of depression and is changing the way that psychiatrists approach what is a very difficult condition to treat.
How does Spravato (Esketamine) work?
Treatments in the past have been based on the so called “monoamine hypothesis.” That approach was based on the premise that individuals with depression have a deficit in at least one of the following neurotransmitters: serotonin, norepinephrine, and/or dopamine. That approach to the treatment of depression began in the 1950s! Since that time antidepressant medications have been developed and adjusted to improve upon that model. But that has not resulted in any major changes.
While antidepressants based on the monoamine hypothesis have shown significant success over the years they have always had significant limitations regarding efficacy and side effects. Typical antidepressants generally take several weeks to months to have any effect. That delay prolongs the suffering a person feels when going through depression.
Spravato has been a game changer in the field of antidepressant medications. Its mechanism of action is not based on the monoamine hypothesis. Rather than augmenting serotonin or norepinephrine or dopamine, Spravato is an antagonist of the NMDA glutamate receptor. Glutamate is a different neurotransmitter and is prevalent in many parts of the brain. While the exact pathway by which the antidepressant effect is unknown this approach is a completely novel one which has shown profound results thus far.
How effective is Spravato compared with typical antidepressants?
Conventional antidepressants are not always effective. Typical antidepressants such as Prozac, Lexapro, or Cymbalta follow what psychiatrists know as the 1/3rd rule. 1⁄3 of patients taking them achieve full remission, 1⁄3 of patients get some response from the medication, and 1⁄3 of patients have no response from the medication. Those numbers have been a constant frustration in the field which has maintained the research effort to develop better medications. Spravato differs from the typical antidepressants in several ways. Perhaps the most striking is that it oftentimes creates significant improvement within hours to days. This nearly instantaneous effect is a remarkable phenomenon. Patients treated with Spravato oftentimes do not have to suffer for weeks to months waiting for the medication to take effect. This rapid onset does not happen for all patients, but a significant proportion do.
In addition, Spravato has been shown to reduce suicidal thoughts. Spravato now has an FDA indication for treatment when a patient is having acute suicidal thoughts.
How does Spravato compare regarding side effects?
Conventional antidepressants have common side effects. SSRIs and other typical antidepressants are well-known for causing weight gain and sexual side effects. The weight gain can be significant at times and is often a deterrent for patients to start the medication. Sexual side effects can manifest as decreased libido, erectile dysfunction, or difficulty achieving orgasm. Those side effects can be profound at times. Spravato does not cause weight gain or sexual side effects.
During each treatment with Spravato a patient may experience sedation, a modest increase in blood pressure (average 10 points), and what is known as dissociation. This is what patients oftentimes describe as feeling high which can vary in intensity. All three of these side effects generally persist for less than two hours. That is why each treatment session lasts two hours. Due to the potential for prolonged sedation a patient is not permitted to drive until the day following treatment.
How are there any contraindications to Spravato?
The only contraindication to Spravato (aside from previous sensitivity to the medication or ketamine) is a history of aneurysm or aterio-venous malformation (AVM).
How do I receive treatment?
Spravato is provided only by certified treatment centers. IBH is the largest Spravato treatment center in the Gulf South. We have treated the highest number of patients thus far in the area.
Spravato is a controlled substance and cannot be obtained directly from the pharmacy. Due to the potential for abuse and the common side effects that occur during the treatment itself, the medication is provided in the doctor’s office only.
To start Spravato you require a consultation with an IBH doctor to see if you qualify for the treatment. After that we work with your insurance company to get authorization and can generally start treatment within 1-2 weeks.
Does insurance cover Spravato?
Yes. Spravato is FDA-indicated for moderate to severe depression and acute suicidal thoughts. Therefore almost all insurance companies cover the treatment. Intravenous generic ketamine treatments are not approved by the FDA for depression and are therefore not covered by insurance.
How much is Spravato likely to cost?
The cost of treatment is broken down into the cost of the medicine and the cost of the treatment. Not surprisingly, the cost of the medicine itself is high. If you have a high deductible that can be a significant expense. However, Janssen, the manufacturer, has a rebate program that reduces the cost of each medication dose to $10 per treatment. Most people are eligible for this rebate. The other cost is that of a typical office visit and depends on the details of your insurance plan.