Guiding Appropriate Ketamine, Esketamine Use in Psychiatry

A recommendation published by The American Journal of Psychiatry last December set expert-informed precedence for the use of ketamine and esketamine in eligible patients with treatment-resistant depression.

The recommendations, organized by 2 dozen psychiatrists and investigators in the field, provided answers to key questions surrounding the much-discussed anesthetic drug group, including its place among viable therapies, its role in treatment paradigms, its sequencing, the suitable treatment candidates, and the ideal treatment setting and care team.

Six month since the publication, the lead author reviewed the still-evolving state of ketamine and esketamine use in psychiatric care.

In an interview with HCPLive during the American Psychiatric Association (APA) 2022 Annual Meeting in New Orleans this week, Roger S. McIntyre, MD, professor of psychiatry and pharmacology at the University of Toronto, emphasized the importance of introducing—and continually guiding—ketamine and esketamine into the paradigm of major depressive disorder treatment.

“The state of the union is that we’ve had conventional antidepressants since the mid 1950s, many people have done extremely well, but most haven’t,” McIntyre said. “The need for a novel, innovative treatment is significant. And ketamine/esketamine have provided not just an alternative, but a treatment that works rapidly—within a day—and a treatment that’s able to actually help people with treatment-resistant depression.”

While McIntyre emphasized the importance of “safety and professionalism guiding its implementation,” he believes enough evidential data exists to consider their position already in the armamentarium of depression treatment.

“Certainly, there is a case to be made—something that would be based on FDA approval of esketamine—that esketamine would be positioned as a third-line strategy, after a person with properly diagnosed depression has tried at least 2 antidepressants or antidepressant options,” McIntyre said. He added the drug’s indicated use for patients with depression with suicide ideation, and the surrounding data for that use, would support its role as a first-line treatment in those patients as well.

McIntyre expressed interest in learning more about the drugs’ benefit for bipolar depression or post-traumatic stress disorder (PTSD)—2 fields for which they are being investigated. All the same, he emphasized continued deliberation and clear communication for the sake of assured benefit and safety in eligible patients.

“To be perfectly blunt, I was in part motivated to lead the guidelines out of my concern that there was really a lack of cohesive, coherent, evidence-based parameters to guide who’s the appropriate patient for ketamine/esketamine, what’s the appropriate setting, what’s the appropriate personnel overseeing the implementation, and what’s the appropriate surveillance of the person receiving the treatment,” he said.

“It’s important that people have options, and optionality has been created by ketamine and esketamine.”