Esketamine recently underwent an expedited trial to see if it could be of benefit for people with depression. In March, the FDA granted a controversial fast-track approval to the drug (which is sold under the brand name Spravato) for use in severe depression. Only one of three clinical trials showed any benefit. The drug was not shown to decrease suicide: three patients who were taking the drug died by suicide during the clinical trials, compared with none who weren’t.
The FDA ultimately voted to approve the drug, but only for use in conjunction with an oral antidepressant medication, and only for the treatment of severe cases of depression where other approaches haven’t helped. Given the many potential adverse effects, the drug has to be administered by a physician. The patient then has to be overseen for two subsequent hours. Effectively, esketamine was deemed safe enough for doctors to consider prescribing when everything else has failed and a person is still suffering.
This is a far cry from the promises the president made to veterans. “Hopefully we are getting it at a very good cost,” Trump said. “I guess it’s a form of a stimulant where if somebody is really in trouble from the standpoint of suicide, it can do something.” The drug is, in fact, a sedative; ketamine has long been used as an anesthetic. And its daily cost is $737.50.
Speaking to veterans later that day in Kentucky, Trump reiterated the promise: “I’ve instructed the top officials to go out and get as much of it as you can from Johnson & Johnson.”
Despite Trump’s remarks, the VA spokesperson, Susan Carter, told me that the agency has no immediate plans to change its policy: “VA will closely monitor the use of esketamine in veterans to more fully understand its relative safety and effectiveness as compared to other available treatments. Based on this information, VA may revise its clinical guidance and formulary status if warranted.”
Even if the drug does prove safe and effective enough for the VA to adopt it widely, by no measure would it constitute a comprehensive approach to preventing suicide. Antidepressant medications of all sorts have only ever constituted part of an effective treatment plan.
Preventing the onset and escalation of depression in high-risk groups is more difficult still. It involves building community and connection—creating and maintaining healthy avenues for veterans to process trauma, reintegrate into the often directionless maw of civilian life, and recalibrate a sense of purpose and belonging. Putting great hope in a nasal spray—as anything more than an emergency last resort in extreme cases—is to overlook the fundamental complexity of depression, and to miss the root causes of the disease.
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