30 Apr What is Esketamine for Depression?
For such a serious and debilitating condition, depression is a surprisingly common disease. Consider some statistics:
- In the United States alone, some 17.3 million citizens have experienced at least one major depressive episode, which equals about 7.1% of the adult population
- Worldwide, around 300 million people are believed to have depression
- Among the adult population of the United States, an estimated 15% of people will experience depression in their lifetime
Treating the disease is also notoriously difficult, mostly because researchers and physicians haven’t identified an underlying cause. Other mental illnesses, like bipolar disorder, can be explained through hormonal problems, but when it comes to depression the most common explanation is “chemical imbalances,” which is possible but also a vague description.
Enter Esketamine, the latest treatment option for people struggling with treatment-resistant depression. According to Dr. Dennis Charney, dean of the Icahn School of Medicine at New York’s Mount Sinai, in an interview with NPR, “This is potentially a game changer for millions of people. It offers a lot of hope.”
Before diving into the details of this potential “game changer,” let’s take a look at the people who stand to benefit from this new treatment option.
Despite several attempts at treatment, either through the administration of antidepressants or psychotherapy, some people find themselves incapable of fighting back their depression. This condition is called treatment-resistant depression, one of the most pernicious and challenging forms that the disease can take.
Thankfully, this is exactly the form of depression that Esketamine targets.
Typical Symptoms of Treatment-Resistant Depression
Depression may manifest in different ways, but there are some global symptoms that most individuals experience. Some of the most common symptoms include:
- Inexplicable Emotions: Most people experiencing treatment-resistant depression may feel sad, tearful, anxious, or hopeless for no apparent reason.
- Sleep Disturbances: People experiencing treatment-resistant depression often have trouble both falling asleep and staying asleep.
- Loss of Interest: Perhaps the most common symptom of treatment-resistant depression is the loss of interest in everyday experiences, hobbies, or even activities that the individual typically takes pleasure in.
- Fixation: While in a depressive state, many individuals fixate on past mistakes or failures. These memories evoke feelings of guilt or self-blame that can be both painful and overwhelming.
- Disturbing Thoughts: Common among sufferers of treatment-resistant depression are thoughts of suicide or death.
It’s important to remember that in the course of a typical depressive episode, these symptoms may occur but will eventually fade with time, treatment, or both. In the case of treatment-resistant depression, these symptoms will continue unabated.
Symptoms in Children and Teens
Most people think of treatment-resistant depression as an illness that affects adults, but children and teens can also experience the illness. However, because treatment-resistant depression is not commonly thought of as a disease that affects the young, it’s often the case that symptoms are overlooked and believed to be caused by natural hormonal changes.
In children and teens, the symptoms of treatment-resistant depression are generally consistent with those experienced by the adult population, but the outward signs are generally more specific:
- Young children may be overly clingy to both parents and others, may have little to no appetite, may have unexplained bodily aches and pains in conjunction with being irritable or sad
- Teens and young adults experiencing depression may be performing poorly in classes and in school, experiencing feelings of worthlessness, may attempt to harm themselves by “cutting,” avoid chances to socially interact with peers or display a general disinterest in activities
If observed or experienced, these symptoms should never be taken lightly.
Even though the underlying causes of depression and treatment-resistant depression remain mysterious to both researchers and physicians, a handful of common risk factors seem to precede the illness. It’s also important to note that, on the whole, more women than men are diagnosed with depression, though this can possibly be explained by the fact that women are more likely than men to seek treatment for mental illness.
Among risk factors, some of the most common are:
- Trauma or Stressful Experiences: It’s important to note that trauma does not need to precede depression, but many times it does. Sexual abuse, financial issues, a difficult breakup, or the death of a loved one can all trigger a depressive episode.
- Genetic Predisposition: Many people who experience depression have family members who have also suffered from the same disease.
- Personality Traits: Certain personality traits can increase the chance that an individual experiences depression, such as low self-esteem or chronic pessimism.
- Mental Health Disorders: Individuals who suffer from mental health disorders, such as bipolar disorder or PTSD, have a higher chance of experiencing depression.
- Drug or Alcohol Abuse: The abuse of drugs or alcohol, both of which alter brain chemistry, can lead to depression.
- Medications: Some medications, such as those that are used to regulate high blood pressure, have been known to induce depression.
Before diagnosing treatment-resistant depression, physicians will ask a series of questions that aim to help doctors and the patient better understand the scope of the illness. Even though all cases of treatment-resistant depression share the quality of longevity, not all cases manifest in the same way. Understanding the nuances of each case helps doctors better understand how to help a patient.
To evaluate each individual case, the physician will ask the patient to discuss:
- Life Details: To help identify potential catalysts for depression, physicians need to know as much as they can about the life of a patient.
- Medical History: It’s important that physicians know about any medications that an individual may have taken. If a patient has a history of other mental illnesses, or a family history where mental illness is prevalent, that may also provide a bold clue as to why an individual may be experiencing depression.
- The Duration of Depression: Treatment-resistant depression is only diagnosed after initial attempts to treat depression have repeatedly failed. Before a diagnosis of treatment-resistant depression is given, patients should have tried different antidepressants, increased their dosage, and given each medication enough time to work.
If a physician diagnoses a patient with treatment-resistant depression, they may be eligible for Esketamine.
What is Esketamine?
Of the many ways doctors have traditionally helped patients manage depression, one of the most common has been the administration of oral antidepressant pills like Prozac. These pills take 1-2 weeks to start showing effects, and 6-8 weeks to fully kick in. For those suffering from treatment-resistant depression, the benefits of the medication are never experienced.
By using Esketamine, those experiencing treatment-resistant depression can experience relief within hours.
Before diving into the details, here’s a few facts about the medication as a whole.
- This is the first drug approved by The Food and Drug Administration that can treat depression in hours rather than weeks
- The FDA voted overwhelmingly to approve Esketamine
- The name might ring a bell, mostly because it’s a “chemical cousin” of the famous party drug called “Special K” or ketamine
- Esketmaine will be administered as a nasal spray with the brand name Spravato
- Its use will be restricted to people suffering from treatment-resistant depression
Who Will Use Esketamine?
Given the potency of the drug, the use of Esketamine, perhaps unsurprisingly, will be heavily restricted. Not only will those suffering from treatable depression be denied access to it (they can still rely on pills like Prozac and therapy to relieve their symptoms) but those suffering from treatment-resistant depression will not be allowed to take it home.
Doses of Eskatmine will be administered exclusively in “an office or approved health center”, and patients will remain under the constant supervision of healthcare professionals before, after, and during the administration of the drug.
The FDA has also stated that patients using Esketamine will also need to take an oral antidepressant. Patients will also be unable to drive their car until the day following Esketamine treatment.
While receiving Esketmaine, patients will be expected to report to an office or approved health center one to two times per week. The dosage they receive should not be enough to induce hallucinations, but it should be enough to mitigate depression with minimal side effects.
How Does it Work?
Although scientists have been studying depression for decades, the underlying causes are still unknown. That said, exactly how Esketamine improves the symptoms of depression is still vaguely understood.
Medications like Prozac work by altering the levels of serotonin, dopamine, and norepinephrine in the brain—all of which are influenced by the monoamine neurotransmitter system. Esketamine, on the other hand, is believed to have an effect on the glutamate neurotransmitter system.
What Makes It Different from Ketamine?
Esketamine and ketamine, a popular party drug that is commonly referred to as “Special K,” are extremely similar to each other. The most apparent difference between the two is that their respective molecules spin in different directions. This makes them “chemical cousins,” though not technically identical.
Also, according to Dr. Demitri Papolos, the director of research for Juvenile Bipolar Research Foundation and a clinical associate professor at the Albert Einstein College of Medicine, “…animal studies show it’s possible that old-fashioned ketamine is a more potent antidepressant than esketamine.”
But given the stigma surrounding Ketamine and the intensity of its effects and potential for addiction, Esketamine has been given the vote of confidence by the FDA and medical practitioners.
What are the Esketamine Side Effects?
Clinical trials have showed that the effects of Esketamine closely mirror the effects of Ketamine, though it produces a slightly less potent reaction. The drug is being produced by the pharmaceutical company Johnson & Johnson, who have promised to continue studying and monitoring the effects of the drug as it makes its way into the market.
So far, the side effects that may be produced by Esketamine include:
- A feeling of disassociation and disconnectedness from reality
- Intense dizziness which may be accompanied by nausea or vomiting
- Sedation and relaxation
- Conversely, patients may experience anxiety
- Increased blood pressure
- Lethargy and the feeling of inebriation
The FDA is also suggesting that, following the administration of Esketamine, patients do not drive cars or operate heavy machinery for the rest of the day.
How Much Will Esketamine Cost?
Insurance policies should help make Esketamine more affordable for consumers, but the drug isn’t poised to be cheap.
According to Johnson & Johnson, the drug will be sold at wholesale prices somewhere between $590 to $885. Because of the high pricing, use of the drug may be cost prohibitive for some medical centers.
Alternatives to Esketamine for Treatment-Resistant Depression?
If, for whatever reason, Esketamine treatment cannot be accessed by a person struggling with treatment-resistant depression, there are several alternative options that have been shown to be effective.
Among these solutions, some of the most popular include:
- Talk Therapy: While many physicians may recommend that talk therapy is coupled with antidepressant medication or Esketamine treatment, talk therapy can still prove effective when utilized in its own.
- VNS or Vagus Nerve Stimulation: The vagus nerve is believed to affect the brain region which governs our mood. VNS treatment involves equipping a patient with a pacemaker-like device which sends electrical currents into the nerve.
- ECT or Electroconvulsive Therapy: ECT therapy works by shocking the brain with electric currents, inducing brief seizures that are believed to reconfigure brain chemistry.
- Trying Further Medications: Just because several different drugs seemed to have no effect on a patient’s depression, doesn’t mean that another drug might not help. Many doctors will continue to cycle through drugs until one takes effect.
Final Thoughts on Esketamine
The medical field has struggled to identify a remedy for curing treatment-resistant depression. This has been a struggle that’s stretched on for decades.
“There has been a long-standing need for additional effective treatments for treatment-resistant depression, a serious and life-threatening condition,” said Dr. Tiffay Farchione, director of the Division of Psychiatry Products for the FDA, in an interview with NPR.
Granted, the drug possesses a range of limitations, but more importantly it has given hope to people who believed they would be stuck experiencing the symptoms of depression indefinitely.
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Harvard Health Publishing. (2009, June). What causes depression? Retrieved April 11, 2019, from https://www.health.harvard.edu/mind-and-mood/what-causes-depression
May Clinical Staff. (2017, July 21). Treatment-resistant depression. Retrieved April 11, 2019, from https://www.mayoclinic.org/diseases-conditions/depression/in-depth/treatment-resistant-depression/art-20044324