Application of Intranasal Esketamine (Spravato) in Clinical Practice – Optimising Patient Outcomes – Discussion with A/Prof Scott and Prof Hickie
In this video, Dr Sanil Rege, Consultant Psychiatrist and Academic Lead of Psych Scene talks to Prof Ian Hickie and A/Prof Liz Scott about the Practical aspects of Intranasal Esketamine (Spravato) with a view to optimising patients outcomes in treatment-resistant depression (TRD).
Associate Professor Elizabeth Scott has expertise in youth mood disorders, service developments for youth mental health, as well as sleep and circadian dysfunction. Until January 2021 she was the Medical Director of Uspace – inpatient services for young people with emerging psychiatric disorders at St Vincent’s Private Hospital. Associate Professor Scott is a Principal Research Fellow at the Brain and Mind Centre, University of Sydney. Through her work there and with the Headspace programs in Central and Eastern Sydney, she has extensive experience in developing and evaluating comprehensive assessment and management programs for young people with mental health problems.
Ian Hickie is a Professor of Psychiatry and the Co-Director of Health and Policy at the Brain and Mind Centre, University of Sydney. He has led major public health and health service developments in Australia, particularly focusing on early intervention for young people with depression, suicidal thoughts and behaviours and complex mood disorders. He is active in the development through co-design, implementation and continuous evaluation of new health information and personal monitoring technologies to drive highly personalised and measurement-based care.
Studies show that only 30-40% of patients experience a partial remission of depressive symptoms after taking antidepressants. Approximately a third don’t respond to antidepressant treatments at all. Treatment-resistant depression (TRD) is associated with poor social functioning, medical co-morbidity and increased mortality. The burden of TRD makes it essential to continue to try to find strategies that can bring relief to patients.
While evidence suggests that esketamine is effective in patients with TRD, a more precise understanding of access, treatment costs and logistics regarding the implementation and use of intranasal esketamine is required.
The Australian TGA approved intranasal Esketamine (SPRAVATO) for TRD in 2021. According to the TGA:
Spravato is indicated for treatment-resistant depression (Major Depressive Disorder in adults who have not responded adequately to at least two different antidepressants of adequate dose and duration to treat the current moderate to severe depressive episode).
Spravato is to be initiated in conjunction with a newly initiated oral antidepressant.
The discussion covers the following important questions.
- How do we as clinicians define treatment-resistant depression?
- What in your opinion are the barriers to accessing care currently in the landscape in treatment-resistant depression?
- What would be a succinct definition of treatment-resistant depression?
- Where does Esketamine / Spravato fit in on this particular landscape?
- How can we get the RANZCP to facilitate access to these new approaches?
- Where would Esketamine fit on the journey of a patient? At what point does a clinician have to think about Esketamine?
- In your experience, what is the rapid response? What does it actually look like and how soon are you seeing it?
- Ketamine, Esketamine and TMS – Could you provide a summary of what are the differences between these agents or the neurostimulation?
- What is the group that we shouldn’t consider Esketamine for?
- What are the common side effects that you would normally explain to a patient to look out for and what have you actually seen?
- From a long-term perspective, have you seen any evidence of the typical phenomenon of dependence because of the use of Esketamine or ketamine?
- What does the patient journey look like? What is the dosing and the length of treatment?