Nasal spray for severe depression – Radboud university medical center

Patients with depression that is difficult to treat can go to the Psychiatry department for treatment with esketamine nasal spray. This new treatment is offered at Radboudumc and reimbursed by all insurers.

Esketamine is a form of ketamine, the drug used for anesthesia. Research into esketamine showed that it has an influence on difficult-to-treat or treatment-resistant depression. The dosage form has been converted to a nasal spray, so that it cannot only be administered via an infusion. It works differently than conventional antidepressants and the patient often notices an effect within a few weeks. This relatively new, innovative psychotropic drug – the drug has been registered since 2021 – may only be used in a hospital and under the supervision of a healthcare professional. Psychiatrist Eric Ruhe: ‘That has to do with the risk of abuse and addiction, esketamine is also used in the party scene. In addition, this is the first expensive medicine in psychiatry, so insurers can designate treatment centers for this treatment through their contracting. Radboud University Medical Center is one of 20 centers in the Netherlands that offers this treatment. We are also coordinator of a national consortium that is further investigating treatment with esketamine.’

For whom?

You can refer patients for treatment with esketamine nasal spray for whom the following applies:

• There is a (severe) unipolar depression.
• There has been no response to at least 3 pharmacological treatment steps with antidepressants, including at least 1 augmentation strategy (lithium, atypical antipsychotics or mirtazapine augmentation).

A patient is not eligible for treatment with esketamine in the case of:

• depression in the context of bipolar disorder
• recent myocardial infarction or cerebrovascular accident (<6 weeks)
• untreated (unstable) high blood pressure
• pregnancy

The treatment and cooperation with the GP

After referral, an intake first takes place, followed by treatment advice and an explanation of the treatment to the patient. ‘We contact the GP or practitioner after referral. They often know the patient better than we do and together we want to estimate what further care is needed for the patient,” says Eric Ruhe. An adjustment phase then first takes place: the patient is administered esketamine nasal spray twice a week for 4 weeks. Only if the patient responds well to the treatment will we continue it: then the patient will receive the treatment for another 4 weeks, in principle once a week. Eric: ‘During the treatment, even during the adjustment phase, we have discussions with the patient about the changes experienced. If necessary, we will call or video call the GP or practitioner together. We then look at whether and how we can help the patient even more. Perhaps the patient can then start psychotherapy again, for example.’ After this, the frequency of the treatment is reduced to a minimum frequency. This varies from once a week to once every 3 weeks. Read more about the treatment with Esketamine nasal spray on our website.

Good effect

‘We see good results here in treatment-resistant depression that is difficult to treat, in patients who have sometimes been depressed for years and who have regularly undergone electroconvulsive therapy. The side effects are mild in most cases and the treatment is generally well tolerated. About 50% of patients respond to treatment. In approximately 30-40% of those patients we see a positive effect after the first 4 weeks. There are many people who could benefit from this.’

Reference

Referral for this treatment is done via Zorgdomein. Referral by registration letter is also possible, the explanation for this can be found on our website.