Cost-effectiveness of esketamine nasal spray compared to intravenous ketamine for patients with treatment-resistant depression in the US utilizing clinical trial efficacy and real-world effectiveness estimates

Brendle, Madeline; Robison, Reid; Malone, Daniel C.

doi:10.1016/j.jad.2022.09.083

Cited by 9 publications

(5 citation statements)

References 19 publications

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“…Is their decision not to cover this treatment truly in the service of protecting their patients or driven by a desire to reduce expenditures by limiting customer access to maximize profits? Given that ketamine seems to be more cost-effective than esketamine from a health care sector perspective 10 and possibly has greater efficacy for depression, 14 are insurers being good stewards of health care dollars by preferentially reimbursing the use of esketamine? This situation also calls into question the manner in which the FDA handles the approval of new indications for medications already on the market.…”

Section: Discussionmentioning

confidence: 99%

“…The pharmaceutical industry did not fail to take notice of mounting evidence for ketamine's antidepressant potential, which ultimately led to the development and FDA approval of Janssen's intranasal esketamine (an enantiomer of ketamine) for TRD in 2019, 8 and for major depressive disorder with acute suicidal ideation or behavior in 2020. 9 Evidence suggests that intravenous ketamine is considerably more cost-effective than intranasal esketamine from a health care sector perspective, 10 with the cost of esketamine to Medicare ranging from $951 to $1353 depending on dosage compared with $187 per treatment for intravenous ketamine. 11 While clinical staff can monitor more patients receiving intranasal esketamine than intravenous ketamine, since esketamine does not require the additional complexities of securing and maintaining intravenous access, the reduced staffing expenses are significantly outweighed by higher drug cost for esketamine.…”

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confidence: 99%

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Formulary Coverage of Esketamine and Ketamine for Depression in Ohio Health Insurance Marketplace and Medicaid Plans

Barnett

2024

Journal of Psychiatric Practice

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For more than 2 decades, intravenous ketamine has been demonstrated to have rapid antidepressant effects. However, access to this generic drug is limited due to insurers claiming it is “experimental” because ketamine does not have a Food and Drug Administration indication for depression. In contrast, intranasal esketamine, an enantiomer of ketamine, is approved by the Food and Drug Administration for depression and is still under patent. The goal of this column is to provide a clearer understanding of formulary coverage of these similar medications by insurers. Formularies of all 2023 Ohio Health Insurance Marketplace and Medicaid plans were reviewed to determine the inclusion status of intravenous ketamine and intranasal esketamine for depression. This review found that intravenous ketamine was not covered by any Marketplace or Medicaid plan for depression, while intranasal esketamine was on 72.7% and 100% of formularies, respectively. Thus, members of the analyzed insurance plans can more easily access intranasal esketamine than intravenous ketamine for depression, despite the latter being more cost-effective and possibly more efficacious.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Formulary Coverage of Esketamine and Ketamine for Depression in Ohio Health Insurance Marketplace and Medicaid Plans

Barnett

2024

Journal of Psychiatric Practice

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“…These same limitations also apply to some extent to the current evidence-base for racemic ketamine, with the notable difference that its drug costs are significantly lower—an advantage that is somewhat offset by the greater costs associated with IV administration ( 68 ). Nevertheless, the tremendous need for novel treatments of TRD in conjunction with meta-analytic evidence of antidepressant effects for both IV racemic ketamine and intranasal esketamine have resulted in both finding active use in a variety of models of care ( 25 , 69 ).…”

Section: Methodsmentioning

confidence: 99%

The Montreal model: an integrative biomedical-psychedelic approach to ketamine for severe treatment-resistant depression

Garel,

Drury,

Thibault Lévesque

et al. 2023

Front. Psychiatry

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BackgroundSubanesthetic ketamine has accumulated meta-analytic evidence for rapid antidepressant effects in treatment-resistant depression (TRD), resulting in both excitement and debate. Many unanswered questions surround ketamine’s mechanisms of action and its integration into real-world psychiatric care, resulting in diverse utilizations that variously resemble electroconvulsive therapy, conventional antidepressants, or serotonergic psychedelics. There is thus an unmet need for clinical approaches to ketamine that are tailored to its unique therapeutic properties.MethodsThis article presents the Montreal model, a comprehensive biopsychosocial approach to ketamine for severe TRD refined over 6 years in public healthcare settings. To contextualize its development, we review the evidence for ketamine as a biomedical and as a psychedelic treatment of depression, emphasizing each perspectives’ strengths, weaknesses, and distinct methods of utilization. We then describe the key clinical experiences and research findings that shaped the model’s various components, which are presented in detail.ResultsThe Montreal model, as implemented in a recent randomized clinical trial, aims to synergistically pair ketamine infusions with conventional and psychedelic biopsychosocial care. Ketamine is broadly conceptualized as a brief intervention that can produce windows of opportunity for enhanced psychiatric care, as well as powerful occasions for psychological growth. The model combines structured psychiatric care and concomitant psychotherapy with six ketamine infusions, administered with psychedelic-inspired nonpharmacological adjuncts including rolling preparative and integrative psychological support.DiscussionOur integrative model aims to bridge the biomedical-psychedelic divide to offer a feasible, flexible, and standardized approach to ketamine for TRD. Our learnings from developing and implementing this psychedelic-inspired model for severe, real-world patients in two academic hospitals may offer valuable insights for the ongoing roll-out of a range of psychedelic therapies. Further research is needed to assess the Montreal model’s effectiveness and hypothesized psychological mechanisms.

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“…Esketamine is more commonly used than IV ketamine because it is FDAapproved and typically covered by insurance, but it may not be as effec tive. 16 An economic analysis by Brendle et al 17 suggested insurance companies would lower costs if they covered ketamine infu sions vs intranasal esketamine.…”

Section: Ketaminementioning

confidence: 99%

Interventional psychiatry (Part 1)

Arbuck¹

2023

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A dvances in the understanding of neurobiological and neuro psychiatric pathophysiology have opened new avenues of treatment for psychiatric patients. Historically, with a few exceptions, most psychiatric medications have been administered orally. However, many of the newer treatments require some form of special ized administration because they cannot be taken orally due to their chemical property (such as aducanumab); because there is the need to produce stable blood levels of the medication (such as brexanolone); because oral administration greatly diminished efficacy (such as oral vs IV magnesium or scopolamine), or because the treatment is focused on specific brain structures. This need for specialized administration has created a subspecialty called interventional psychiatry.Part 1 of this 2part article provides an overview of 1 type of inter ventional psychiatry: parenterally administered medications, includ ing those administered via IV. We also describe 3 other interventional approaches to treatment: stellate ganglion blocks, glabellar botulinum toxin (BT) injections, and trigger point injections. In Part 2 we will review interventional approaches that involve neuromodulation. Parenteral medications in psychiatryIn general, IV and IM medications can be more potent that oral medica tions due to their overall faster onset of action and higher blood con centrations. These more invasive forms of administration can have significant limitations, such as a risk of infection at the injection site, the need to be administered in a medical setting, additional time, and patient discomfort.

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Cost-effectiveness of esketamine nasal spray compared to intravenous ketamine for patients with treatment-resistant depression in the US utilizing clinical trial efficacy and real-world effectiveness estimates

Cited by 9 publications

References 19 publications

Formulary Coverage of Esketamine and Ketamine for Depression in Ohio Health Insurance Marketplace and Medicaid Plans

Formulary Coverage of Esketamine and Ketamine for Depression in Ohio Health Insurance Marketplace and Medicaid Plans

The Montreal model: an integrative biomedical-psychedelic approach to ketamine for severe treatment-resistant depression

Interventional psychiatry (Part 1)

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