When do you refer a patient with difficult-to-treat depression for esketamine nasal spray versus IV ketamine treatment?

For treatment-resistant depression (TRD), intravenous ketamine is slightly more efficacious than intranasal esketamine (Spravato), probably due to more controlled bioavailability (all the substance administered is absorbed) and better personalization of doses. However, IV ketamine is usually not cov...

There are several considerations here worth discussing. First of all, only esketamine is FDA-approved and covered by insurance - only for severe MDD. IV ketamine is usually out of pocket but it offers more versatility, being less tightly regulated compared to esketamine. It can be used for some othe...

Being an addiction psychiatrist, I am quite reluctant to advocate for the use of a medication that has abuse liability. Fortunately, some of my patients have reached out to the ketamine providers in Nashville, a rapidly expanding business among various adventuresome physicians in our town. This has ...

My practice is not set up for ketamine. When a patient has treatment-refractory depression, meaning failure to respond to multiple oral agents, including combinations, I would then entertain other modalities.

Esketamine (Spravato), from what I’ve seen, doesn’t show as much robust response, which makes sense, but in longer-term trials, they end up having around the same endpoint, nothing too significant. But cost is the main thing that comes into the equation, as most insurances will cover Spravato becaus...

The question neglects an important third option: IM ketamine. I use IM ketamine in my office because I can administer it myself during a session with a patient. Ketamine is dirt cheap, so I don't charge more than the usual session fee (I don't take insurance), and it works. Biggest side effect: naus...