The narcotic-classified drug ketamine has been used for a long time in healthcare in connection with operations. It has also shown a rapid and powerful antidepressant effect in studies, but is not an approved treatment for depression.
A survey from TT, which 20 regions have responded to, shows that the treatment has still made its way into psychiatry. 13 regions respond that they use or have used ketamine drops, compared to seven in a 2017 survey from the National Board for Health and Welfare.
The drug is only prescribed to patients who have not improved with any other antidepressant treatment, which is around 30 percent of those with a depression diagnosis. Since ketamine is not approved, it is prescribed off-label, i.e., when a drug is prescribed for use in another purpose than it is intended for.
What may have paved the way for increased use is the ketamine-based nasal spray Spravato, which has been approved since 2019 for the same patients. But Spravato is expensive, with a year's treatment costing around 200,000 kronor. Ketamine drops are about 50 times cheaper, according to calculations from Region Stockholm.
Divided opinions
The 13 regions offer both Spravato and ketamine, and several state that they prefer ketamine. The effect of the drops, which go directly into the bloodstream, is considered safer than a nasal spray, but the price also plays a role.
Others start with Spravato, citing that it is approved, and turn to ketamine drops as a last resort.
When Mikael Tiger, chief physician and associate professor of psychiatry at the Karolinska Institute, hears about the result, he points out the lack of guidance regarding ketamine drops and the fact that there are several recommendations for how Spravato should be used.
The differences reflect that ketamine is seeking its place in treatment since it lacks its own recommendation in Sweden, and with Spravato, the authorities say different things.
He also notes that the drugs are not interchangeable since they differ in effect. The effect of ketamine drops can be seen within a few hours, while it can take weeks before the nasal spray has a clear effect.
Authority opens the door
According to the Medical Products Agency, the approved Spravato is the first choice. But Mats Persson, psychiatrist and investigator at the agency, notes that new national treatment guidelines for depression are on the way.
Considering that off-label prescribing of ketamine drops occurs, it may well be that the guidelines will address this, he says.
20 of 21 regions participated in TT's survey and responded to whether they offer Spravato or ketamine, or both. They also responded to how many medication options had been tried before, indicated in parentheses. Not all responded to that question.
Blekinge: Spravato
Dalarna: None
Gotland: Ketamine
Gävleborg: Spravato
Halland: Spravato
Jämtland/Härjedalen: None
Jönköping: Spravato/ketamine
Kalmar län: Spravato/ketamine
Kronoberg: Spravato/ketamine (individual assessment)
Norrbotten: No response
Skåne: Spravato/ketamine (4)
Stockholm: Spravato/ketamine (2)
Sörmland: None
Uppsala: Spravato/ketamine (4)
Värmland: Spravato/ketamine
Västerbotten: Spravato
Västernorrland: Spravato/ketamine (4)
Västmanland: Spravato/ketamine
Örebro: Spravato/ketamine
Östergötland: Spravato/ketamine (4)
Västra Götalandsregionen: Spravato/ketamine (2)
Ketamine is a mixture of two narcotic-classified substances, esketamine and racemic ketamine. It has been used as an anesthetic since the 1960s and is a well-known drug in healthcare. In depression, lower doses are given than in anesthesia.
Ketamine is given as drops at the clinic under supervision. It is addictive and can cause side effects in the urinary tract.
Spravato is a nasal spray based on esketamine alone, which has been an approved treatment for depression since 2019. The spray is given under supervision at the clinic. It is only the pharmaceutical company Jansen that has the right to manufacture Spravato, which is why the treatment is expensive since they set the price.
Source: Fass, The Council for New Therapies (NT Council)
