Esketamine

There have long been anecdotal reports of rapid antidepressant effect from ketamine, but everyone has proceeded very cautiously because of its nasty side-effect profile in all forms.  The variant settled on for treatment is Esketamine.  It has gradually come into use for treatment-resistant depression, but I had never had one of my patients on it until now.  I am very impressed with the result for this one person. She carries diagnoses of both Bipolar Depression and Borderline Personality*, which is not that unusual but does create difficulties of sorting out exactly where any symptom comes from. She had been tried on numerous antidepressants with limited relief. ECT’s were effective at first but have become less so and the worsening memory loss was eventually intolerable.  She has been in both DBT and CBT therapy and has a lot of physical interventions such as breathing and grounding techniques for her dissociation. This is a very capable woman who was working full-time despite serious suicidality with two near-lethal attempts. 

When last I covered here, I was part of the decision to have her civilly committed, as she was still evasive about her thoughts while occasionally tying a sheet around her neck at night between checks. She has been here since early March (I happened to be covering and did the admission), with in-hospital suicide attempts. Our hospital and most insurance companies do not have esketamine on formulary, and we were going through the steps to get her approved . She started with a nasal administration on 6/3, with a second on 6/7. I came in to cover on 6/10 and we are planning to discharge her tomorrow, 6/12.  If we hadn't had to clear with with an administrative risk committee, we might have sent her 6/10 after her third treatment. The person writing out coverage notes for me Friday 6/7 did not even hint that discharge might be possible.  The patient still has thoughts of suicide but greatly diminished, with no impulses to act on them.  She laughed during discussion today, which I have never heard from her, over two years of admissions. This is unprecedented, even faster than ECT’s.  The treatment will not affect the personality disorder (that we know of), but reducing the depression should help greatly on that. This is similar to the feeling that I had when Clozapine came on the market decades ago, and patients with schizophrenia who I had long known as very sick showed remarkable improvement and were discharged. Then, as now, it’s going to be all about the side effects going forward.

*For clinicians scoring at home, she carries Bipolar II depressed type vs MDD refractory, PTSD, BPD.