Ketamine Nasal Spray

The University of Kansas Health System offers ketamine nasal spray outpatient therapy to help more patients achieve and retain remission from depression.

Our comprehensive depression assessment and treatment program includes multidisciplinary care across pharmacy, psychology and psychiatry to provide the most up-to-date, evidence-based treatment for improved outcomes and quality of life.

Ketamine nasal spray, sometimes referred to as intranasal esketamine, is used as a nasal spray to treat patients with treatment-resistant depression (TRD) and major depressive disorder (MDD). The main type of ketamine used is SPRAVATO® (esketamine) CIII nasal spray, which is administered in combination with an oral antidepressant.

Ketamine nasal spray is used to treat patients with treatment-resistant depression (TRD) and major depressive disorder (MDD) who have chronic suicidal ideation and:

• A defined depression diagnosis
• Have not found relief from at least 3 initial treatment therapies
• Are seeking an alternative to electroconvulsive therapy (ECT)
• Have well-controlled blood pressure
• Can commit to biweekly visits with a support person for transportation
• Have an established provider managing their care
• Additional screening criteria

While no formalized definition of treatment-resistant depression currently exists, TRD is commonly defined as failure of depressive symptoms to respond to both psychological and psychopharmacological interventions such as therapy or antidepressants. TRD represents the highest direct and indirect medical costs among those with MDD. Individuals with TRD are twice as likely to be hospitalized among those with MDD and have an almost 14% lifetime risk of suicidal behavior compared to 10% for those with MDD.

Those who would not benefit from ketamine as a form of outpatient therapy and would instead be recommended for alternative nonketamine therapies include:

• Patients who have depression due to bipolar disorder, schizophrenia or other psychotic disorders
• Patients with active substance abuse (alcohol or drugs)
• Patients with ketamine allergies or insensitivities
• Patients with uncontrolled hypertension due to ketamine’s blood pressure raising effects
• Patients with a known history of an aneurysmal vascular disease, arteriovenous malformations or intracranial hemorrhages

The full spectrum of ketamine's antidepressant and antisuicidal effects have not been fully explained. However, we do know that this novel approach to therapy works with the brain's NMDA receptors, which play a role in several neurological functions like memory, learning, movement and more. This is an alternative to SSRIs (Prozac, Paxil, Zoloft), which work with serotonin receptors.

We also know that ketamine affects other receptors and pathways in the brain, which creates a combination of positive effects that help combat depression.

Over the last 2 decades, several studies have shown that ketamine produces antidepressant and anti-suicidal effects.

Risks for patients eligible for ketamine therapy are generally minor. Patients are monitored immediately after administration of the spray to check for side effects such as:

• Allergic reaction
• Anxiety or panic
• Blood pressure elevation
• Burning/discomfort
• Dissociation, including out-of-body experience
• Drowsiness/grogginess
• Nausea and vomiting (uncommon)

Most of these side effects wear off quickly and patients usually experience them less frequently as they progress with treatment. Patients are kept under close observation for up to 2 hours after the administration of ketamine nasal spray to ensure safety.

Doctors will begin by assessing the patient, including vital signs, mood and response to previous treatment (if any). Patients will have their blood pressure checked to ensure a proper level since patients with high blood pressure are not eligible for ketamine therapy.

Patients will likely be asked to blow their nose and will then be reclined at a 45-degree angle. The patient is given the nasal spray and self-administers the drug by inhaling the spray in each nostril. After 5 minutes, a second dose will be administered, and then after another 5 minutes an optional third dose will be administered.

After the last dose is inhaled, the patient will be monitored and then periodically assessed for depression, suicidality, hallucinations, dissociation and physical symptoms. The doctor will also keep tabs on the patient's blood pressure. After the 2-hour mark, the patient will be able to go home with the assistance of a driver if the doctor deems it safe.

For the first 8 weeks of treatment, there are 12 total sessions – twice weekly for the first 4 weeks, and then once weekly for the next 4 weeks. After the initial 8 weeks patients can receive treatment as often as once per week or as infrequently as once per month.

Psychiatry and behavioral sciences at The University of Kansas Health System has provided leading-edge psychiatry services for the state of Kansas and beyond since 1905. We are 1 of only a few hospitals in Kansas and the Kansas City area that offers ketamine nasal spray therapy, and we have a unique program designed specifically for patients with treatment-resistant depression.

Rapid access is available for treatment with ongoing care under the direction of your referring provider. Services are available at the Medical Pavilion on our main campus. Call 913-588-5862 to refer a patient.