Ketamine Has a New Indication – This Time for Major Depression with Suicidal Thoughts

What’s happening – The party drug ketamine is back in the spotlight thanks to its related compound esketamine, in the form of the nasal spray Spravato, now approved to treat adults with major depressive disorder and acute suicidal ideation or behavior. The nasal spray was first approved in March of 2019 for treatment-resistant depression (TRD) in conjunction with an oral antidepressant.

The hope is that Spravato can help ease acute suicidal and depressive symptoms until other longer-term treatments take effect. The stresses of the pandemic are putting more pressure on depressed people, so Spravato could fill an urgent need. FDA’s new indication is based on two Phase III studies that showed reduction of depressive symptoms with when taken with standard-of-care treatments such as hospitalization and oral antidepressants. Of note, the drug has restricted distribution; a REMS program highlights potential adverse outcomes related to sedation and dissociation effects.

The details Read J&J’s Janssen Pharmaceutical Companies announcement on the new Spravato indication.

The perspectives –

Why it’s complicated – The latest Spravato studies are considered  innovative because suicidal patients are often left out of research due to the risks involved. Further, the drug is not universally recognized as an effective treatment for TRD or major depressive disorder (MDD) with suicidal ideation. The EMA approved the medicine in December 2019 for TRD, and in January 2020 J&J applied for Spravato to be used to treat MDD and suicidal ideation and intent in the EU. In the UK, Spravato was rejected in January 2020 and again in September by the country’s National Health Service, the publicly funded healthcare system,  because of concerns over efficacy and cost. But in Scotland, the drug was approved in September by the Scottish Medicines Consortium for people with TRD who have not responded to two or more other antidepressants.

On Canada’s CTV, Dr. Sameh Hassan discussed major depressive disorder and treatment-resistant depression in the context of the pandemic, including how Spravato may be a treatment option for those under added stress.

The conversation – 

  • @Psych_Fin (Psychedelic Finance) called the approval “more medical validation for the psychedelic movement.”
  • @Novamind (Novamind_Inc) and its Chief Medical Officer, @reidrobison, discussed Spravato and ketamine as treatments for depression with KSLTV on be/pTCR-ryRARk
  • @pharmaphorum (pharmaphorum) discusses Spravato’s status in the UK, tweeting: “More medicine access discrepancies in UK as Scotland’s SMC backs @JanssenEMEA’s Spravato and @Sanofi’s Cablivi after NICE rejections” and linking to this story.

In practice – see clinicians’ take on psychopharmacologic and behavioral suicide prevention approaches in this Psych Congress 2020 meeting highlight.


Our Crisis Culture & Mental Health: Training and a Pending 9-8-8 Hotline

What’s happening – With all elements of police work in the news, it is worth looking at what’s happening in interactions between police and those with mental disorders. Specialized training for police officers can help them to recognize mental illness, de-escalate situations, and improve safety for themselves and the public.

The details – Articles like this example of a co-responder program in St. Cloud, MN, or this proposal for policy changes in Philadelphia, highlight the progress that police departments around the country are making in training officers to handle situations in which a person might be in crisis.

The perspectives – Crisis Intervention Team (CIT) training is increasingly becoming a part of police training. The program is more than 30 years old, and it aims to create relationships between police, mental health providers, hospital emergency services, and patients and their families. The community-based program trains police officers to recognize mentally ill people or someone in crisis and identify how to give them the services they need rather than sending them to jail. Not only is it better for patients, but it also saves police departments time that would be been spent booking someone and money had that person gone to jail. Read details of what the officers experience in their CIT training in our sister site’s look at a police department in New Jersey.

The One Mind Campaign, founded in 2016 by the International Association of Chiefs of Police, challenges police departments to implement policies to improve interactions between police and people with mental illness. Taking the pledge means promising to include training such as mental health first aid, CIT training, and forming relationships with community mental health organizations, all within 12-36 months. Police departments that recently completed the pledge include Irving, TX; Braintree, MA; Ipswich, MA; and Michigan State University PD.

An effort is underway to replace the National Suicide Prevention Hotline with a simple 3-digit call to 9-8-8. The National Alliance on Mental Illness supports this new nationwide number.

Why it’s complicated –  In 2017, research focused on mental health-related calls handled by the Chicago Police showed the complex nature of responding to mental health issues. Police preferred hospital psychiatric assessments over arrests, and there was an emphasis on de-escalation and building trust to gain compliance. The researchers noted the need to further develop community mental health resources and programs.

Another 2017 study examined the implementation of a countywide CIT program and found an increase in officers bringing patients to a mental health crisis center after receiving CIT training, as well as a change in police officers’ perceptions of people with mental illness.

A more recent 2019 report looked at the effectiveness of CIT programs. However, because studies in the mental health and criminal justice disciplines focus on different aspects – and use different terminology – the team noted it can be difficult to draw conclusions or reach consensus.

The conversation –  

  • @DEAHQ (the official Drug Enforcement Administration) highlighted campus police as a link between mental health and substance abuse resources for students in need of help in on-campus or off-campus settings
  • @RoyBlunt (Senator Roy Blunt) tweeted: “Crisis intervention officers play a critical role in helping someone struggling with a mental health issue get the help they need. Great to see more police departments, like the Battlefield Police Department, bringing this specialized role into their teams” and linked to a Ky3 article
  • @IrvingPD (Irving Police Department) tweeted: “The Irving PD is the 1st PD in TX to complete the @TheIACP One Mind Campaign Pledge. We are committed to ensure successful interactions between our officers & persons affected by mental illness. We invite the rest of the departments in TX to take the pledge.”
  • @OxfordPolice (the Oxford, MS, Police Department) announced it has taken One Mind Pledge through the @TheIACP

In practice – helping patients with mental breakdowns during COVID.

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What Your Patients’ Cells Can Reveal about Anxiety and Depression

What’s happening – We’re talking about mitochondria here, not cell-phones. These endogenous powerhouses are increasingly being studied in the mental health arena, specifically with regard to anxiety and depression. In addition to providing cells with energy, we know mitochondria play a role in producing the stress hormone cortisol. Think back to 1975, when the first evidence of mitochondrial inheritance in human cells was discovered, and to the 1990s, when more connections between mitochondrial DNA and genetic disorders were revealed. Since then, researchers have investigated the relationship between mitochondrial DNA and mental health and they are now digging into the relationship between low levels of reelin and stress and inflammation. Dysfunction within these systems and the effect on mental health may lead to newer intervention targets. How much of this will come to fruition?

The details – An article published in Quanta gives a background on the recent research on mitochondria and mental health.

The perspectives – A January 2020 Nature article reviewed the use of reelin infusions in rats under stress and observed an antidepressant-like effect. The same team of researchers looked at the role of mitochondrial dysfunction in depression in 2018. This year, studies have been published on reelin and its potential relationship with other health issues such as children with autism (in March), traumatic brain injury (in June), and multiple sclerosis (in August.)

Where this research could lead –  In terms of developing interventions, there are a few groups studying this topic that could reveal the diversity of mitochondria, the role of mitochondria in early-life stress, and the role of mitochondrial function in anxiety and low social rank.

The conversation – 

  • @jjb930 (Justin Botterill) is one of the authors of the antidepressant-like effect of reelin study. He tweeted: “I was lucky to be a part of this paper on the fast-acting antidepressant effects of reelin. We infused recombinant reelin into the hippocampus of rats given daily cort injections…”
  • @matthewhirschey (Matthew Hirschey) who was quoted in Quanta noted: “Stress is too complicated a phenomenon to be reduced to a single cause or a simple pathway.”

In practice – more on GAD from Psych Congress 2020.


Teletherapy During COVID is, in a Word, Complicated

What’s happening – We know that telepsychiatry is often no substitute to in-person sessions but what’s the true impact? Given the increase in this form of care since the beginning of the COVID pandemic, several clinicians have investigated the shortcomings of teletherapy for patients with serious mental illness (including depression, bipolar disorder, and schizophrenia). Core challenges include patients not having access to a cellphone or computer (such as in the case of elderly or homeless), non-English-speaking immigrants, or severely ill patients. Psychiatrists cannot pick up on subtle signs of a person’s health, such as if they are keeping up with personal hygiene (often a concern in patients with schizophrenia).

The details – Heeding Hamilton’s “The Room Where it Happens,” a recent Slate article highlighted the need for psychiatrists to be in the room with their seriously mentally ill patients and discussed how some patients are being left behind in the pandemic restrictions and lockdowns.

The perspectives – A spring 2020 article from Schizophrenia Research talked about the urgent need for teletherapists to help patients with serious mental illness and proposed that smartphone apps be further developed to meet this need. Several existing apps are mentioned for their strengths. Also recommended were the standardization of privacy policies and increased training for clinicians on the use of mental health apps.

A July 2020 study looked at the possibility of using “mobile interventionists” as part of the care of people with serious mental illness. Team members were trained to engage with patients through texts as part of their treatment plan and the results were promising.

The bigger picture of how COVID has affected those with serious mental illness pointed out that “virtual care cannot completely replace in-person care for schizophrenia.”

Why it’s complicated –  The authors of this letter to the editor of the Australian & New Zealand Journal of Psychiatry, published in June 2020, asked whether telepsychiatry is a “realistic option” for people with severe mental health problems during the pandemic. They also discuss barriers faced by these patients to telemedicine.

And the authors of a May 2020 protocol paper outlined a plan to evaluate the effects of the COVID pandemic on the mental health of people with serious mental illness as well as measures taken to prevent infection in this group. Using two rounds of phone surveys in March-April and June-August, the authors aimed to better understand the challenges that the pandemic presents to this already vulnerable group.

This early 2020 systematic review in General Hospital Psychiatry looked at the role of telemedicine in medication adherence in people with depression, bipolar disorder, or schizophrenia. The takeaway: it may worth asking patients for their technology preference to improve adherence.

The conversation – 

  • @NMD_online (Journal of Nervous & Mental Disease) shared a recently published paper on texting and people with schizophrenia in May 2020: “Current Issue: Developing Texting for Relapse Prevention: A Scalable mHealth Program for People With Schizophrenia and Schizoaffective Disorder”
  • @UCSF (University of California San Francisco) studied people with serious mental illness and poverty and their use of telehealth in the summer of 2020. @UCSF tweeted: “Until the pandemic, we rarely thought of telehealth as a possibility.”
  • @APAPubJournals (Journals of the American Psychiatric Association) shared a report about a clinic that used video-supported telehealth to provide recovery-oriented behavioral health services to patients with serious mental illnesses during the pandemic.

In practice – Dr. Paula A. Madrid on teletherapy cues during COVID and Dr. Cosio on teletherapy to-do’s and not-to-do’s. Plus, the prevalence of overlapping schizophrenia and PTSD.


This week’s Psy-Q: Test your teletherapy knowledge


This Week’s Practice Essential: How I Avoid Burnout


Last Updated: Jun 16, 2021