Navigating the Cost, Challenges, and Complexities of Ketamine for Depression Treatment

Andrew Penn, MS, PMHNP, explores ketamine as a rapidly acting antidepressant, unraveling its effectiveness and limitations. Penn discusses the evolving questions around redosing, financial implications, and pragmatic considerations for clinicians in managing patients with these treatments.

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Andrew Penn, MS, PMHNP, has practiced as a psychiatric/mental health nurse practitioner, treating veterans and training residents at the San Francisco Veterans Administration Hospital. As a researcher, he collaborates on psychedelics studies of psilocybin and MDMA in the Translational Psychedelics Research (TrPR) lab at UCSF, serving as Co-PI on a phase 2 study of psilocybin for depression and is currently working on a study using psilocybin to treat depression in patients with Parkinson's disease. He is a cofounder of the Organization of Psychedelic and Entheogenic Nurses, he has published on psychedelics in the American Journal of Nursing, Frontiers in Psychiatry, and The Journal of Humanistic Psychotherapy. Penn has also lectured at SXSW, Aspen Health Ideas Festival, the Singapore Ministry of Health, TEDx, and Oxford University.

Read the transcript:

Hi, I'm Andrew Penn, I'm a psychiatric nurse practitioner and a clinical professor at the University of California San Francisco School of Nursing.

Ketamine, as we know, can be a very effective, rapidly-acting antidepressant drug. There are a couple downsides to ketamine. One is that it can be expensive and the other is that it doesn't have a real long duration of effect.

Now, that duration of effect can vary from patient to patient. For some people, it may last only a week. Other people may be able to go several weeks between treatments with ketamine, and how often they need to be re-dosed is really something that has to be sort of explored with each individual patient. This really begs the question: are we going to treat patients indefinitely with ketamine, given that it does have this short-acting effect? I think this is an answer that's still being sorted out.

One of the challenges with racemic ketamine is that it doesn't have FDA approval. It's being used in an off-label fashion for depression. As such, a lot of insurance companies won't cover it, and that creates a significant financial burden for patients who often will pay hundreds of dollars per infusion. If that's something that has to be done several times a month, it's easy to see the financial impact that that might have.

Esketamine, which has an FDA approval for depression, does not have an endpoint in when it has to be stopped. So, that could conceivably be used for the indefinite future. Now that it's been out for several years, we certainly have patients that have been taking tha—it has to be given in a monitored setting—on a regular basis. And that is something that is on many commercial formularies for insurance.

So, these are evolving questions in the rapidly acting antidepressant space: How often are we going to need to redose? What are the financial implications of that? What are the pragmatic aspects of that for clinicians who may need to structure their practices in such a way that they can see patients repeatedly for these treatments?

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