What is included in long-term care of depression?

Updated: Sep 02, 2020
  • Author: Louise B Andrew, MD, JD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Answer

Patients may require additional interventions that can be instituted immediately on transfer from the emergency department, but never actually in the emergency department. Electroconvulsive therapy (ECT) is safe and can be quickly effective. It is usually reserved for refractory cases, cases of pharmacologic resistance or adverse effects, and cases in which rapid reversal is indicated. Newer treatment modalities for refractory depression, including electromagnetic transcranial stimulation and repetitive vagal stimulation, are becoming more widely available. For individuals who have previously been given a diagnosis and who have been successfully treated with these modalities, rapid reinstitution can be lifesaving. 

The N-methyl-D-aspartate (NMDA) receptor antagonist esketamine intranasal (Spravato) was approved in 2019 for treatment-resistant depression in conjunction with an oral antidepressant. [32, 33]  The precise mechanism by which esketamine elicits its antidepressant effect is not fully understood. NMDA is an ionotropic glutamate receptor. 

In August 2020, esketamine intranasal gained approval for treatment of depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior in conjunction with an oral antidepressant. Approval was based on the ASPIRE I and II trials in which esketamine intranasal plus comprehensive standard of care demonstrated a significant, rapid reduction of depressive symptoms within 24 hours, with some patients starting to respond as early as 4 hours. Esketamine intranasal led to a 15.9- and 16.0-point decrease on the Montgomery-Åsberg Depression Rating Scale (MADRS) in each trial at 24 hours after the first dose of study medication. This compared to a reduction of 12.0 and 12.2 points in the placebo plus comprehensive standard of care group. [34, 35]  


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