Matthew
@drwestling15.bsky.social
Board certified psychiatric pharmacist 🧠💊 | MPA 🏛 | Advocate ✊ | Houseplant enthusiast 🌵| Tea connoisseur ☕️ | Bicon 🏳️🌈| He/Him | Views are my own
VA/DoD Clinical Practice Guidelines recommendations:
There is insufficient evidence to recommend for or against ketamine infusions or esketamine to reduce the risk of suicide or suicide attempts. (Neither for nor against)
There is insufficient evidence to recommend for or against ketamine infusions or esketamine to reduce the risk of suicide or suicide attempts. (Neither for nor against)
April 27, 2025 at 8:49 PM
VA/DoD Clinical Practice Guidelines recommendations:
There is insufficient evidence to recommend for or against ketamine infusions or esketamine to reduce the risk of suicide or suicide attempts. (Neither for nor against)
There is insufficient evidence to recommend for or against ketamine infusions or esketamine to reduce the risk of suicide or suicide attempts. (Neither for nor against)
VA/DoD Clinical Practice Guidelines recommendations:
We suggest offering ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation in patients with the presence of suicidal ideation and major depressive disorder. (Weak for)
We suggest offering ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation in patients with the presence of suicidal ideation and major depressive disorder. (Weak for)
April 27, 2025 at 8:49 PM
VA/DoD Clinical Practice Guidelines recommendations:
We suggest offering ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation in patients with the presence of suicidal ideation and major depressive disorder. (Weak for)
We suggest offering ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation in patients with the presence of suicidal ideation and major depressive disorder. (Weak for)
VA/DoD Clinical Practice Guidelines recommendations:
For patients with MDD who have not responded to several adequate pharmacologic trials, we suggest ketamine or esketamine as an option for augmentation. (Weak for)
For patients with MDD who have not responded to several adequate pharmacologic trials, we suggest ketamine or esketamine as an option for augmentation. (Weak for)
April 27, 2025 at 8:49 PM
VA/DoD Clinical Practice Guidelines recommendations:
For patients with MDD who have not responded to several adequate pharmacologic trials, we suggest ketamine or esketamine as an option for augmentation. (Weak for)
For patients with MDD who have not responded to several adequate pharmacologic trials, we suggest ketamine or esketamine as an option for augmentation. (Weak for)
Systematic review of available literature found intravenous, intranasal, oral, and possibly intramuscular and subcutaneous maintenance ketamine treatment to be effective in sustaining antidepressant effect in treatment resistant depression
Serious renal and urinary problems seem uncommon
Serious renal and urinary problems seem uncommon
April 27, 2025 at 8:49 PM
Systematic review of available literature found intravenous, intranasal, oral, and possibly intramuscular and subcutaneous maintenance ketamine treatment to be effective in sustaining antidepressant effect in treatment resistant depression
Serious renal and urinary problems seem uncommon
Serious renal and urinary problems seem uncommon
Despite low response rate and considerable out-of-pocket costs, almost half of real-world outpatients with TRD decided to continue with maintenance ketamine treatment due to perceived significant improvement
More than one third of patients displayed reduction in suicidality
More than one third of patients displayed reduction in suicidality
April 27, 2025 at 8:49 PM
Despite low response rate and considerable out-of-pocket costs, almost half of real-world outpatients with TRD decided to continue with maintenance ketamine treatment due to perceived significant improvement
More than one third of patients displayed reduction in suicidality
More than one third of patients displayed reduction in suicidality
Key risks of ketamine and esketamine:
Dry mouth, tachycardia, increased BP, and feelings of disassociation
Ketamine ulcerative cystitis
Risk of addiction?
Inconsistent evidence on long-term risks with ketamine infusion; Esketamine appears safe and effective for maintenance use up to one year
Dry mouth, tachycardia, increased BP, and feelings of disassociation
Ketamine ulcerative cystitis
Risk of addiction?
Inconsistent evidence on long-term risks with ketamine infusion; Esketamine appears safe and effective for maintenance use up to one year
April 27, 2025 at 8:49 PM
Key risks of ketamine and esketamine:
Dry mouth, tachycardia, increased BP, and feelings of disassociation
Ketamine ulcerative cystitis
Risk of addiction?
Inconsistent evidence on long-term risks with ketamine infusion; Esketamine appears safe and effective for maintenance use up to one year
Dry mouth, tachycardia, increased BP, and feelings of disassociation
Ketamine ulcerative cystitis
Risk of addiction?
Inconsistent evidence on long-term risks with ketamine infusion; Esketamine appears safe and effective for maintenance use up to one year
Both esketamine and ketamine require in office administration and require transportation to and from the appointment
April 27, 2025 at 8:49 PM
Both esketamine and ketamine require in office administration and require transportation to and from the appointment
#Ketamine and #Esketamine are both relatively effective for TRD but only Esketamine is #FDA approved for depression and suicidality
Ketamine is administered IV and cheaper but has less evidence for use
Esketamine is administered intranasally and is more expensive
Ketamine is administered IV and cheaper but has less evidence for use
Esketamine is administered intranasally and is more expensive
April 27, 2025 at 8:49 PM
#Ketamine and #Esketamine are both relatively effective for TRD but only Esketamine is #FDA approved for depression and suicidality
Ketamine is administered IV and cheaper but has less evidence for use
Esketamine is administered intranasally and is more expensive
Ketamine is administered IV and cheaper but has less evidence for use
Esketamine is administered intranasally and is more expensive
rTMS is #FDA indicated for the treatment of major #depresison
Patients with TRD were three times as likely to achieve a response versus sham and were five times as likely to achieve remission
#Placebo effect plays a large role
Risks include irritation to stimulation site and headaches
Patients with TRD were three times as likely to achieve a response versus sham and were five times as likely to achieve remission
#Placebo effect plays a large role
Risks include irritation to stimulation site and headaches
April 27, 2025 at 8:49 PM
rTMS is #FDA indicated for the treatment of major #depresison
Patients with TRD were three times as likely to achieve a response versus sham and were five times as likely to achieve remission
#Placebo effect plays a large role
Risks include irritation to stimulation site and headaches
Patients with TRD were three times as likely to achieve a response versus sham and were five times as likely to achieve remission
#Placebo effect plays a large role
Risks include irritation to stimulation site and headaches
Key risks to consider with #ECT:
- Short term memory loss
- General anesthesia risks
Symptom improvement is short-term and should be followed by maintenance treatment with antidepressants or repeated ECT treatments if antidepressants are not tolerated
- Short term memory loss
- General anesthesia risks
Symptom improvement is short-term and should be followed by maintenance treatment with antidepressants or repeated ECT treatments if antidepressants are not tolerated
April 27, 2025 at 8:49 PM
Key risks to consider with #ECT:
- Short term memory loss
- General anesthesia risks
Symptom improvement is short-term and should be followed by maintenance treatment with antidepressants or repeated ECT treatments if antidepressants are not tolerated
- Short term memory loss
- General anesthesia risks
Symptom improvement is short-term and should be followed by maintenance treatment with antidepressants or repeated ECT treatments if antidepressants are not tolerated
Other considerations for ECT:
Catatonia
Psychotic depression
Severe suicidality
Hx of a good response to ECT
Need for rapid treatment response
The risks associated with other treatments are greater
Hx of a poor response to multiple antidepressants
Patient preference
Catatonia
Psychotic depression
Severe suicidality
Hx of a good response to ECT
Need for rapid treatment response
The risks associated with other treatments are greater
Hx of a poor response to multiple antidepressants
Patient preference
April 27, 2025 at 8:49 PM
Other considerations for ECT:
Catatonia
Psychotic depression
Severe suicidality
Hx of a good response to ECT
Need for rapid treatment response
The risks associated with other treatments are greater
Hx of a poor response to multiple antidepressants
Patient preference
Catatonia
Psychotic depression
Severe suicidality
Hx of a good response to ECT
Need for rapid treatment response
The risks associated with other treatments are greater
Hx of a poor response to multiple antidepressants
Patient preference
When would you consider ECT?
Only “strong for” recommendation – even though evidence of low quality, meets GRADE 15 criteria as an intervention for treatment in a life-threatening situation in certain subpopulations
#ECT is more efficacious than sham ECT or pharmacotherapy but comes with risks
Only “strong for” recommendation – even though evidence of low quality, meets GRADE 15 criteria as an intervention for treatment in a life-threatening situation in certain subpopulations
#ECT is more efficacious than sham ECT or pharmacotherapy but comes with risks
April 27, 2025 at 8:49 PM
When would you consider ECT?
Only “strong for” recommendation – even though evidence of low quality, meets GRADE 15 criteria as an intervention for treatment in a life-threatening situation in certain subpopulations
#ECT is more efficacious than sham ECT or pharmacotherapy but comes with risks
Only “strong for” recommendation – even though evidence of low quality, meets GRADE 15 criteria as an intervention for treatment in a life-threatening situation in certain subpopulations
#ECT is more efficacious than sham ECT or pharmacotherapy but comes with risks
What options are there to treat DtD?
Electroconvulsive Therapy (ECT)
Repetitive transcranial magnetic stimulation (rTMS)
#Ketamine or #Esketamine
Electroconvulsive Therapy (ECT)
Repetitive transcranial magnetic stimulation (rTMS)
#Ketamine or #Esketamine
April 27, 2025 at 8:49 PM
What options are there to treat DtD?
Electroconvulsive Therapy (ECT)
Repetitive transcranial magnetic stimulation (rTMS)
#Ketamine or #Esketamine
Electroconvulsive Therapy (ECT)
Repetitive transcranial magnetic stimulation (rTMS)
#Ketamine or #Esketamine
What are the goals and principals for managing DtD?
• Strive for optimal symptom control
• Reduce risks and impact of relapse
• Optimize psychosocial functioning
• Strive for optimal symptom control
• Reduce risks and impact of relapse
• Optimize psychosocial functioning
April 27, 2025 at 8:49 PM
What are the goals and principals for managing DtD?
• Strive for optimal symptom control
• Reduce risks and impact of relapse
• Optimize psychosocial functioning
• Strive for optimal symptom control
• Reduce risks and impact of relapse
• Optimize psychosocial functioning
Treatment can be any modality and should normally be considered after at least two treatment trials
"Adequate" treatment includes evidence based #psychotherapy (EBP) and #pharmacotherapy
For pharmacotherapy, it means an adequate duration (4-6 weeks) and dose (half maximum dose or more)
"Adequate" treatment includes evidence based #psychotherapy (EBP) and #pharmacotherapy
For pharmacotherapy, it means an adequate duration (4-6 weeks) and dose (half maximum dose or more)
April 27, 2025 at 8:49 PM
Treatment can be any modality and should normally be considered after at least two treatment trials
"Adequate" treatment includes evidence based #psychotherapy (EBP) and #pharmacotherapy
For pharmacotherapy, it means an adequate duration (4-6 weeks) and dose (half maximum dose or more)
"Adequate" treatment includes evidence based #psychotherapy (EBP) and #pharmacotherapy
For pharmacotherapy, it means an adequate duration (4-6 weeks) and dose (half maximum dose or more)
Difficult to Treat Depression = #depression that continues to cause significant burden despite usual treatment efforts
This terminology is intended to be used in a clinical setting vs #research or regulatory settings
This terminology is more empathic and fosters a collaborative approach
This terminology is intended to be used in a clinical setting vs #research or regulatory settings
This terminology is more empathic and fosters a collaborative approach
April 27, 2025 at 8:49 PM
Difficult to Treat Depression = #depression that continues to cause significant burden despite usual treatment efforts
This terminology is intended to be used in a clinical setting vs #research or regulatory settings
This terminology is more empathic and fosters a collaborative approach
This terminology is intended to be used in a clinical setting vs #research or regulatory settings
This terminology is more empathic and fosters a collaborative approach
De Novo = Provides a pathway to classify novel #medical devices for which there is no legally marketed predicate device
The verbiage for DTx is different compared to Drugs. DTx is "Authorized" where as drugs are "Approved"
The verbiage for DTx is different compared to Drugs. DTx is "Authorized" where as drugs are "Approved"
April 27, 2025 at 8:20 PM
De Novo = Provides a pathway to classify novel #medical devices for which there is no legally marketed predicate device
The verbiage for DTx is different compared to Drugs. DTx is "Authorized" where as drugs are "Approved"
The verbiage for DTx is different compared to Drugs. DTx is "Authorized" where as drugs are "Approved"
How is DTx created?
1. Preclinical phase
2. Trial version - create a dry run trial for the software to work out kinks in patients
3. Pilot clinical study - test in a small group under controlled conditions
4. Full development - if successful, move into technical and commercial expansion
1. Preclinical phase
2. Trial version - create a dry run trial for the software to work out kinks in patients
3. Pilot clinical study - test in a small group under controlled conditions
4. Full development - if successful, move into technical and commercial expansion
April 27, 2025 at 8:20 PM
How is DTx created?
1. Preclinical phase
2. Trial version - create a dry run trial for the software to work out kinks in patients
3. Pilot clinical study - test in a small group under controlled conditions
4. Full development - if successful, move into technical and commercial expansion
1. Preclinical phase
2. Trial version - create a dry run trial for the software to work out kinks in patients
3. Pilot clinical study - test in a small group under controlled conditions
4. Full development - if successful, move into technical and commercial expansion