Esketamine

What is esketamine?

Intranasal Esketamine or brand name “Spravato” is a medication for treatment resistant depression and depression with suicidal features. It is a chemical isomer of Ketamine which is traditionally given Intravenously. Esketamine and ketamine vary due to small chemical changes but both can have robust antidepressant effect when administered, often with quicker onset then traditional antidepressants and sometimes with immediate benefit.

How do I get treated with esketamine?

Goodwin Health Cafe is currently accepting clients interested in intranasal esketamine. If you would like to be a client please visit the “Become a client” page.

What kind of patients are appropriate for esketamine.

The FDA has approved esketamine for treatment resistant depression (TRD) and depression with suicidal features (DSI). Clients with depression who have not estabolished treatment resistance are not likely to get this med approved. Also if you have a Bipolar disorder, even with depression, this medication won’t likely be approved for off-label use.

What is treatment resistant depression?

TRD was defined in the Spravato trials as have failed 2 antidepressants. Insurances however have been requiring at least 4 medication failures with at least 1 medication being a non-ssri/snri (like abilify or lithium). And some insurances are even wanting to see TMS or ECT trialed first.

If you are unsure if your insurance will cover esketamine, feel free to call 509-415-3507 and based on our experiences with different insurances we may be find out.

How does getting esketamine treatment work?

The medication is self administered by the patient intranasally. the device is inserted into the nostril and squirted into the nose by the patient. The clinic teaches the patient how to do it and monitors.

Treatments occur two times a week for four weeks, then are reduced to weekly. treatments can reduce less frequently as well depending on clinical response.

During treatment, the patient is monitored 2 hours after administration. After 2 hours if the client is doing well and doesn’t have any remaining side effects, they can go home.

Clients must have a ride home, and cannot drive again that day until they have received a good night’s rest.

Why do patients have to be monitored x 2 hours?

This is to monitor for anticipated side effects including increase in blood pressure and dissasociation.

Some patients at 40 min have an increase in blood pressure, staff will measure it at this time. After 2 hours the blood pressure will usually recover. Often people don’t have blood pressure concerns, but still should be monitored for it.

Dissociation occurs and can be experienced differently varying on the person. It is often a pleasant and relaxing experience, but some people have inc anxiety, and rarely have spontaneous high anxiety. Monitoring for these symptoms and intervening when disassociation or anxiety is too intense is important to do for the first 2 hours.

Also administering the medication in office prevents diversion (or sharing of med) since esketamine is a controlled III substance.

Will my insurance cover Esketamine?

Different insurances can vary as to how well they cover this treatment, and by calling the office 509-415-3507 we can answer these questions. You can also complete the spravato screener to get an idea of what criteria you need to meet for your insurance to cover treatment.

Can I pay cash for Esketamine?

Because esketamine is brand name and new, it is very expensive but our office can quote cash price by calling 509-415-3507.

Is intranasal esketamine treatment right for me?

See below for eligibility requirements and insurance pre-requisites (intranasal esketamine/spravato only):

1. Are you currently diagnosed with Major Depressive Disorder (not Bipolar Disorder)?

Sometimes people have been diagnosed with both so it can be confusing. For this medication, we use a strict definition of Bipolars criteria from the DSM-5 which requires 3 + days of Mania. If you are unsure about this, we can still see you to determine if this will be a barrier
Some insurances require a certain score on a depression screening tool. We use PHQ-9.

2. Have you tried and failed several medications, being determined as “treatment resistant”?

Most insurances require at least FOUR medications have either been tried and found not effective—or not tolerated. If not effective, the med should have been used for 6-8 weeks or more at therapeutic dosing
One of these medications should be something different than a typical antidepressant (like Abilify, Seroquel, or lithium, see “Alternative Medication” below for a full list)

3. Have you checked the contraindications (see below) to make sure you don’t have any?

4. Would you be able to commit to 2-hour appointments twice a week for four weeks, and possibly weekly thereafter?

5. Would you be able to get a ride home afterward, and commit to not driving a vehicle for the rest of the day?

Insurances:

Review what insurance we are accepting at this time.

We are currently accepting most insurances including: Blue cross/blue Shield, Premera, United, Ambetter, Asuris, Molina Medicaid (non-BHSO), Amerigroup medicaid (non BHSO), and medicare, amongst others

We are not taking new clients with the following insurance: Kaiser, CHPW (medicaid), Coordinated care (medicaid), or BHSO (behavioral health services only)—with any of the medicaid plans

We are not in-network with Kaiser.

With CHPW, Coordinated Care, and BHSO we are ‘in-network’ but are still figuring out how to offer esketamine to these clients, in regards to difficulty with medication approvals, and claim reimbursement.

Alternative medication:

To get esketamine approved, insurances usually want to see 4 meds tried. Sometimes they have more complicated requirements as far as what combinations they want to see.

Traditional antidepressants: like SSRI’s and SNRI’s. Sertraline, fluoxetine, citalopram, escitalopram, paroxetine, fluvoxamine, venlafaxine, desvenlafaxine, or duloxetine
Other antidepressants: like bupropion and mirtazapine
Adjunctive medication: buspirone
Alternative adjunctive medication: aripiprazole, quetiapine, rexulti, vraylar, latuda, lithium, thyroid hormone
Non-medication alternatives: ECT or TMS

The more combinations in different categories the more likely the med will get approved.

We see the most effective combination being combining meds in groups 1 & 2 with at least one option from group 4 & 5. Sometimes buspirone will count as the fourth alternative.

Contraindications

Hypersensitivity to esketamine or ketamine, aneurysmal vascular disease, arteriovenous malformation, history of intracerebral hemorrhage, severe hepatic impairment, or pregnancy/breastfeeding.

These are absolute contraindications and any candidates with these clinical features would not be able to receive esketamine.

Other medical considerations:

The following are not contraindications but are possible complications that will require your primary care or specialist to sign off and collaborate:

Untreated hypertension or blood pressure that is regularly high or above 140/90 will require treatment first
Moderate hepatic impairment, cardiovascular disease, cerebrovascular disease, history of hypertensive encephalopathy, history of psychosis
Actively using illicit substances—we will require a clean urine or buccal swab drug test (depending on insurance requirement) and you will have to agree to random drug testing during treatment
Willingness to stop using Marijuana while receiving esketamine treatment, which would be confirmed by a drug test (not necessarily before starting)
Not misusing alcohol. And ideally limiting alcohol.