Medication Monday: Esketamine

Given that it is still suicide awareness month, I wanted to use this week’s Medication Monday to talk about one of the newest players on the market. And one of the oldest. And perhaps one of the least understood. The drug I am talking about is esketamine, which may also be recognized by the brand name Spravato, put out by Janssen Pharmaceuticals. 

Esketamine was recently approved for patients suffering from treatment-resistant major depressive disorder (MDD). These are patients who have tried other antidepressants and experienced no relief. These are also patients who may be the most vulnerable, suffering from frequent or even constant suicidal ideation. 

And while the FDA’s recent approval does make it one of the newest drugs, the fact is that it is derived from the drug Ketamine, also known as in the club scene as Special K, which has been around for decades. Ketamine was first developed in the mid to late 50’s, with approved usage as an anesthetic and pain management medication starting in the early 60’s. It was particularly helpful in combat use. However, because of the psychoactive properties, which includes dissociative feelings, a sense of intoxication, and possible auditory and visual hallucinations, it also became popular with party-goers. It does have a few other side effects, but obviously those impacts weren’t enough to deter party-goers. And perhaps it is the abuse of Ketamine that occurred in the club scene that created part of the stigma around it, and is one of the reasons a drug from the 60’s is only now being looked at as a treatment for depression and suicide. 

However, there is another reason it hasn’t been tested and approved before recently. It has to do with ethics. Because of the severity of the cases esketamine is typically used on, and the increased risk of suicide, it does raise an ethical question. Should such a psychoactive medication be given to those already on the edge? 

And this is where I want to stop and look at suicide itself. Suicide isn’t a choice, but a symptom of depression. It is a symptom caused by a brain that convinces an individual that life will never get better. It is a symptom caused by constant pain so unbearable that not existing seems the better option. The patient may not want to die per se, but they don’t want to exist. And there is a difference. 

And given that description, which is still a poor substitute for the depth of depression’s pain, it is not surprising that people were concerned. Indeed, some critics have raised red flags since three of the trial patients receiving the medication still committed suicide, as opposed to none in the control group. However, it is possible (and I fully admit I don’t have evidence to support this, it is just my suspicion) that esketamine simply doesn’t work for all patients, or that it produces rare adverse reactions. A comparison with the improvement experienced by the rest of the trial group offers a possible explanation for why the medication was approved despite those three deaths. And the improvement some of those patients experienced is notable, with some of them coming back from the edge after only one treatment. 

That said, the fact that these patients are so vulnerable highlights a real risk. And the psychoactive nature of esketamine in general, is why esketamine should only be administered by a doctor, and its impact overseen by medical professionals. Despite the promising results, you should not, I repeat not, just go out and find some Special K on the street to use. As with all medications, proper medical supervision is important. And as with all Medication Monday posts, this isn’t meant to serve as medical advice, but rather as a brief and informative introduction to esketamine. If you have any questions about this drug, or any other mental health medication, I urge you to talk to your doctor. 

 

So thank you, as always, for stopping by and learning about esketamine. Come back all week long for more new posts, and be sure to check in again next week for another Medication Monday. 

 

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