Today's post is about esketamine, and its lack of equivalence to ECT. The below letter, "Approval of esketamine for treatment-resistant depression," by Singh et al. just came out in Lancet Psychiatry.
Here is the url for the pdf:
https://drive.google.com/file/d/16Rlxt6goVF5Gwsp1udl5wX7GuQS12Dbo/view?usp=sharing
This letter (accompanied by another rebuttal) is in response to two editorials in Lancet Psychiatry several months ago that were critical of ketamine for depression.
This was brought to my attention today by a piece in the online site MedPage Today, entitled "Spravato Debate Still rages."
Several things to point out, including that Singh and co-authors are all employees of Janssen.
Whether ketamine in its various forms will be the panacea claimed by its discoverers remains to be seen.
What is clear is that the evidence base for ketamine in depression remains thin compared to a vast evidence base for ECT.
Also, the concept of treatment-resistant depression is fraught (please see 'Treatment resistance' in electroconvulsive therapy (ECT) patients: time to move on'). Some patients are likely "treatment-resistant"because they have a complex psychiatric presentation with several comorbidities. This is distinct from the classic ECT patient who presents with severe, episodic, inherited mood disorder (or a psychotic disorder, without the episodicity).
It is unclear if ketamine and ECT should be considered for the same population. The idea that ketamine is a substitute for ECT, possibly intentionally promulgated by its developers, is risky for many seriously and urgently ill patients. It is common nowadays for patients who present for ECT consultation to have failed ketamine and rTMS, along with multiple medication trials. As I have discussed previously (see blog post of Feb.15), there is already too much delay in the prescription of ECT for urgently ill patients.
We all hope ketamine proves to be a useful treatment for some of our patients. Until the proof is substantial, and we know more about the clinical profile of who is likely to respond to ketamine, it is prudent not to assume equivalent efficacy to ECT.
Here is the url for the pdf:
https://drive.google.com/file/d/16Rlxt6goVF5Gwsp1udl5wX7GuQS12Dbo/view?usp=sharing
This letter (accompanied by another rebuttal) is in response to two editorials in Lancet Psychiatry several months ago that were critical of ketamine for depression.
This was brought to my attention today by a piece in the online site MedPage Today, entitled "Spravato Debate Still rages."
Several things to point out, including that Singh and co-authors are all employees of Janssen.
Whether ketamine in its various forms will be the panacea claimed by its discoverers remains to be seen.
What is clear is that the evidence base for ketamine in depression remains thin compared to a vast evidence base for ECT.
Also, the concept of treatment-resistant depression is fraught (please see 'Treatment resistance' in electroconvulsive therapy (ECT) patients: time to move on'). Some patients are likely "treatment-resistant"because they have a complex psychiatric presentation with several comorbidities. This is distinct from the classic ECT patient who presents with severe, episodic, inherited mood disorder (or a psychotic disorder, without the episodicity).
It is unclear if ketamine and ECT should be considered for the same population. The idea that ketamine is a substitute for ECT, possibly intentionally promulgated by its developers, is risky for many seriously and urgently ill patients. It is common nowadays for patients who present for ECT consultation to have failed ketamine and rTMS, along with multiple medication trials. As I have discussed previously (see blog post of Feb.15), there is already too much delay in the prescription of ECT for urgently ill patients.
We all hope ketamine proves to be a useful treatment for some of our patients. Until the proof is substantial, and we know more about the clinical profile of who is likely to respond to ketamine, it is prudent not to assume equivalent efficacy to ECT.
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