Esketamine nasal spray plus an oral antidepressant costs less per patient who achieves remission than quetiapine extended release plus an oral antidepressant for adults with treatment-resistant depression. Over 32 weeks, 50% of those taking esketamine plus an antidepressant achieved remission, compared with 33% taking quetiapine plus an antidepressant. The cost-per-remitter was $3,102 lower for esketamine in a commercial insurance setting and $456 lower in a Medicaid setting. In a scenario where non-responders switched to repetitive transcranial magnetic stimulation, the cost savings were larger: $15,134 lower commercially and $12,488 lower for Medicaid. The authors suggest esketamine plus an antidepressant is a cost-effective option.
Expanding access to intravenous ketamine for US patients with nonpsychotic treatment-resistant depression (TRD) and moderate-to-severe depression, compared to electroconvulsive therapy (ECT), could yield net societal savings of $828.2 million annually over five years, including $95.3 million in patient savings and $743.7 million in payer savings, while imposing an additional $10.8 million burden on caregiver time. A population-level Markov simulation model, parameterized with data from a randomized trial, projected that expanded ketamine access would increase the number of treated patients by 75,000 in the first year and 4,292 annually thereafter. Ketamine may be a noninferior treatment relative to ECT for improving depression symptoms.