I've linked the summary document. If you want the technical details they are here: https://www.nice.org.uk/guidance/gid-ta10371/documents/129 We hear a lot about novel treatments for depression...
We hear a lot about novel treatments for depression such as ketamine or psychedelics, so some people may be surprised by the NICE decision to not recommend esketamine.
I'm pretty confident that esketamine will be approved by NICE in the future, once the costs have dropped and when we have better quality research showing the effectiveness.
Depression is an umbrella term that covers a wide range of different illness.
Some people with depression are going to have spontaneous remission -- they'll get better even if we don't provide any treatment. Some people have reactive depression and they'll get better if we change the situation they're in.
We know that short form talking therapy like cognitive behaviour therapy is effective for about 50% to 60% of the people who try it. We know that medication has similar effectiveness. We know that some people get most benefit from a combination of meds and therapy.
But there are people who have chronic, severe, treatment resistant depression.
For some people with long-lasting, treatment-resistant, severe depression where they are at risk of death by suicide we've used electro-convulsive therapy. Some people think ECT was the best thing that happened to them, but others tell us that it caused them harm.
For this small group of people ketamine is probably going to be useful.
So, why did NICE chose not to approve esketamine nasal spray?
It wasn't being looked at for just this narrow group of people, but for a more general group. The definition of "treatment resistant" being used in the trials was "hasn't responded to two or more anti-depressant medications". The trials had an unusually large response from the placebo group -- people with supposedly treatment resistant depression were getting better after a placebo treatment. The trials also haven't compared esketamine nasal spray with talking therapies -- this is a large gap in the research.
It costs £10,000 per course of treatment. That's a lot more than antidepressants or talking therapies and so it would need to show clear unambiguous benefits over those, which at the moment it cannot do.
And there's uncertainty about side-effects and what happens when people stop treatment. This is a valid concern, but it has been perhaps manipulated a bit by anti-medication campaign groups. Discontinuation effects are unpleasant and they've only recently been taken seriously.
Based on my reading (and experience with various antidepressant and therapy regimens), this is a sensible decision. I'd like to see some studies on ketamine/esketamine as a quick induction,...
Based on my reading (and experience with various antidepressant and therapy regimens), this is a sensible decision.
I'd like to see some studies on ketamine/esketamine as a quick induction, short-term treatment for acute suicidality, because that's likely to have the biggest advantage over conventional SSRI/SNRI drugs + therapy, and highest QALY impact. Otherwise, it's going to require some substantial cost improvements and extended studies on efficacy/safety/addiction potential for longer use.
I've linked the summary document. If you want the technical details they are here: https://www.nice.org.uk/guidance/gid-ta10371/documents/129
We hear a lot about novel treatments for depression such as ketamine or psychedelics, so some people may be surprised by the NICE decision to not recommend esketamine.
I'm pretty confident that esketamine will be approved by NICE in the future, once the costs have dropped and when we have better quality research showing the effectiveness.
Depression is an umbrella term that covers a wide range of different illness.
Some people with depression are going to have spontaneous remission -- they'll get better even if we don't provide any treatment. Some people have reactive depression and they'll get better if we change the situation they're in.
We know that short form talking therapy like cognitive behaviour therapy is effective for about 50% to 60% of the people who try it. We know that medication has similar effectiveness. We know that some people get most benefit from a combination of meds and therapy.
But there are people who have chronic, severe, treatment resistant depression.
For some people with long-lasting, treatment-resistant, severe depression where they are at risk of death by suicide we've used electro-convulsive therapy. Some people think ECT was the best thing that happened to them, but others tell us that it caused them harm.
For this small group of people ketamine is probably going to be useful.
So, why did NICE chose not to approve esketamine nasal spray?
It wasn't being looked at for just this narrow group of people, but for a more general group. The definition of "treatment resistant" being used in the trials was "hasn't responded to two or more anti-depressant medications". The trials had an unusually large response from the placebo group -- people with supposedly treatment resistant depression were getting better after a placebo treatment. The trials also haven't compared esketamine nasal spray with talking therapies -- this is a large gap in the research.
It costs £10,000 per course of treatment. That's a lot more than antidepressants or talking therapies and so it would need to show clear unambiguous benefits over those, which at the moment it cannot do.
And there's uncertainty about side-effects and what happens when people stop treatment. This is a valid concern, but it has been perhaps manipulated a bit by anti-medication campaign groups. Discontinuation effects are unpleasant and they've only recently been taken seriously.
Based on my reading (and experience with various antidepressant and therapy regimens), this is a sensible decision.
I'd like to see some studies on ketamine/esketamine as a quick induction, short-term treatment for acute suicidality, because that's likely to have the biggest advantage over conventional SSRI/SNRI drugs + therapy, and highest QALY impact. Otherwise, it's going to require some substantial cost improvements and extended studies on efficacy/safety/addiction potential for longer use.