What clinicians need to know about intranasal esketamine for treatment-resistant depression?

Judy Hope; David Copolov; John Tiller; Megan Galbally; Malcolm Hopwood; Richard Newton; Nicholas A Keks

doi:10.1177/10398562231211171

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What clinicians need to know about intranasal esketamine for treatment-resistant depression?

Journal article

Open access

Peer reviewed

What clinicians need to know about intranasal esketamine for treatment-resistant depression?

Judy Hope, David Copolov, John Tiller, Megan Galbally, Malcolm Hopwood, Richard Newton and Nicholas A Keks

Australasian psychiatry : bulletin of the Royal Australian and New Zealand College of Psychiatrists, Vol.31(6), pp.841-845

2023

DOI: https://doi.org/10.1177/10398562231211171

PMID: 37961848

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Abstract

antidepressants

intranasal esketamine

N-methyl-D-aspartate antagonist

treatment resistant depression

Objective To review the usefulness of esketamine for treatment-resistant depression. Method Pivotal trials of intranasal esketamine in treatment-resistant depression were synthesized as a narrative review. Results Esketamine is postulated to act through antagonism of N-methyl-D-aspartate (NMDA) glutamate receptors, but opioidergic effects may also be involved. Unlike intravenous ketamine, esketamine is given intranasally (under clinical observation), usually in addition to an oral antidepressant. Trials compared esketamine plus antidepressant versus placebo plus antidepressant. At 4 weeks, remission was 37% higher with esketamine/antidepressant than placebo/antidepressant. Speed of response and improvement in suicidality were comparable. In stable remitters on esketamine/antidepressant, 45% relapsed when esketamine was withdrawn over the following 6 months (whereas 25% relapsed on esketamine/antidepressant). Response appears less likely in patients with multiple antidepressant failures. Adverse effects include dissociation, dizziness, nausea, sedation, and headache but no psychosis. Hypertension affected 13%, especially older patients. Dose frequency is twice-weekly for 4 weeks, then weekly/fortnightly thereafter. No abuse has been reported. Unsubsidised cost may be beyond the reach of many Australians. Conclusion Intranasal esketamine plus antidepressant has been approved by regulators as moderately effective and acceptably tolerable for treatment-resistant depression. Cost is a drawback. Use often needs to be long-term and vigilance for abuse is essential.

Details

Title: What clinicians need to know about intranasal esketamine for treatment-resistant depression?
Authors/Creators: Judy Hope - Eastern Health
David Copolov - Monash University
John Tiller - The University of Melbourne
Megan Galbally - Monash Health
Malcolm Hopwood - The University of Melbourne
Richard Newton - Peninsula Health
Nicholas A Keks - Monash Medical Centre
Publication Details: Australasian psychiatry : bulletin of the Royal Australian and New Zealand College of Psychiatrists, Vol.31(6), pp.841-845
Identifiers: 991005634025307891
Murdoch Affiliation: Centre for Computational and Systems Medicine
Language: English
Resource Type: Journal article

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Collaboration types: Domestic collaboration
Citation topics: 1 Clinical & Life Sciences; 1.5 Neuroscience; 1.5.268 Glutamate and Ketamine
Web Of Science research areas: Psychiatry
ESI research areas: Psychiatry/Psychology