Written and transcribed by Chay Tanchanco, LMFT
Interview of Dr. Jerry Gelbart, Medical Director at Foresight
Dr. Gelbart is a Board-Certified psychiatrist and Fellow in the American Psychiatric Association. He earned a Bachelor of Science in Psychology at the University of Michigan, Medical Degree from Ohio State University, and completed a psychiatry residency at UCLA in 1989. He has extensive experience in both areas of psychopharmacology and psychotherapy. His integrative approach is biological, psychological, social, and spiritual. He is one of the first clinicians in the Bay Area to apply Mindfulness and, more recently, genetic testing into their practice. During his 29 years of clinical work he has lectured on a wide range of topics, supervised psychology students at Stanford, and is currently training family practice residents from UCSF.
What is Spravato, and how does the research say that it can help?
In 1956 phencyclidine, or “PCP” was synthesized. It seemed to be a useful anesthetic, however it caused very intense confusion in humans, so it was undesirable. The search was on for something similar without the side effects. In 1962, ketamine was developed. It had 1/10 the potency of PCP, and subsequent human trials proved it was safe for anesthesia. Spravato is a form of ketamine.
I did a few years of surgery residency in the early 80’s and understood ketamine to be a “dissociative.” While it does have anti-pain effects and some sedation, it primarily acts by causing a mental “dissociation” from what’s going on, and that’s useful in surgery. During the dissociative state, patients might appear awake but are unable to respond to sensory input.
Over time, patients and clinicians also saw it improve depressive symptoms. We also saw how it could be abused.
Some anesthesiologists and then psychiatrists started administering ketamine intravenously (IV), even though it wasn’t approved for depression. More and more people became convinced that it helped depression, and also that it was a very different medication for depression than others we were using, both because of novel mechanisms of action and also that a single treatment could have lasting effects.
Last year the FDA approved Spravato for depression. Ketamine (usually given IV) has the “S” and “R” mixture of ketamine, (like your 2 hands that are mirror images of each other). Spravato is just the “S” form so its also known as “esketamine,” and is given through nasal inhalation. Due to risks of abuse and diversion, it must be administered in a doctor’s office under medical supervision. Also, blood pressures must be monitored.
We have a lot of models, theories, and assumptions about how antidepressants work. There are the serotonin theories, but we know that other neurotransmitters are also involved. Ketamine seems to work on multiple receptors, including opioid receptors (which helps pain relief and probably depression), and NMDA and AMPA receptors, both of which effect glutamate.
Several studies indicate a “re-wiring” of the brain going on during ketamine treatments. It appears that it stimulates neuronal and possibly vascular growth in the brain and increasing connectivity between brain circuits. That’s really exciting to me as a psychiatrist!
Image from drugabuse.gov
Note: "Receptors" refer to the gateways of your neurons, aka your brain cells. Substances like ketamine affect how those gates take in neurotransmitters--think of those as chemical 'messages' that your brain cells send back and forth.
What diagnoses can Spravato treat?
It's currently authorized through some insurances to be used for "treatment-resistant depression". Technically that means the person has had a minimum of 2 “real” antidepressant trials. That means adequate dose for an adequate period of time. Example is the therapeutic range of Zoloft is 50-200 mg, and for at least 3 weeks. So if someone tried 50 mg of Zoloft for a couple weeks and gave up, that’s not an adequate trial. When applying for approval, adequate trials must be described.
It can depend on the insurance company which depressive diagnoses can qualify, but we have seen some success. I believe it can be used for other diagnoses in the future.
How is Spravato administered?
We use a nasal spray, starting with one dose and increasing if more is needed. The effects usually set in within 5 minutes, and they last for about an hour at most. The person is asked to bring comfortable clothing and we have a recliner or couch set up in the clinics where we administer it.
A trained psychiatrist or nurse practitioner will sit with them and monitor them, doing psychotherapy if the client is open and willing to do so. It is especially important to monitor their blood pressure, as there is a risk that Spravato will increase it. There is a very strict protocol for using Spravato. The protocol requires that the client makes plans for someone else to pick them up from the clinic; they are not allowed to drive themselves home. I know that has been tricky for some people to coordinate, especially during COVID, but it is for their safety.
Some people may experience nausea or slight discomfort. People we have worked with have seen relief from these symptoms if they take an anti-nausea medication beforehand, such as Zofran.
How often do you go into appointments, and what is a typical duration?
Twice a week for a month, then once a week for another month. After that, we usually see appointments go to every other week and then even once a month. We are still gathering data on typical duration.
Does it interact with other medications or substances?
Yes, we have to be careful with any benzodiazepenes, alcohol, MAOIs, and opioid-type substances. Tranquilizers and pain medications may also suppress respiratory system, which is also affected so it is important to be thorough in your medication and/or substance history with your doctor should you opt to start Spravato treatments.
I highly recommend getting genetic testing before a person considers Spravato. Genetic testing is the main recommended intervention treatment-resistant depression because it can give a wealth of information about the medications that each person's body responds to well and poorly. I want to dispel the myth that Spravato is the only way to move forward if a person is frustrated with their prior medications or psychotherapy.
What is the risk for abuse or addiction?
Because there are no withdrawal symptoms with Spravato, there is not so much risk for addiction. However, a substance does not need to be addictive to be abused, and I do see the risk for abuse. Spravato activates the opioid receptors. The opioid crisis in this country cannot be denied, so it is possible for people to use it excessively and outside of healing.
Is it covered by insurance, and if not, could I pay out of pocket?
Yes, under some insurance plans Spravato is covered. Foresight can assist you with the process if you are recommended by your psychiatrist to begin treatment. Currently Foresight does not have a policy for paying out of pocket. Paying out of pocket could be financially prohibitive due to the cost of the medication and the extensive in-office time. Contact a staff member if you would like to discuss a quote.
How would I get an appointment?
Start by meeting with your psychiatrist and ask them about it. There is a list of qualifications that need to be met before you start Spravato. We are still doing a few Spravato appointments during COVID in the Bay Area.
There are Foresight providers who have been trained to administer this treatment, and so far we have seen promising results from our members. If you or someone you care about is experiencing treatment-resistant depression, inquire about an appointment with a psychiatrist or nurse practitioner at one of our clinics.
And I'd just like to also offer a special thank you to Dr. Gelbart for taking the time to answer these questions and provide a promising look into the future of mental health!