Listing on the PBS will make the drug more affordable, but that’s only half the story.
After several attempts, pharmaceutical company Janssen-Cilag has succeeded in having its esketamine nasal spray, sold as Spravato, recommended for subsidy by the Pharmaceutical Benefits Advisory Committee.
The move has been described as “a good step” by Professor Colleen Loo, professor of psychiatry at UNSW and the Black Dog Institute.
A PBS listing will not go the whole way to making ketamine treatment affordable, because it’s not just a question of picking up a prescription from the chemist; but it does open the door, she told TMR.
Esketamine is a form of ketamine, which was initially developed as an anaesthetic and then found to be effective against depression for some individuals for whom other treatments have failed. Without subsidy, patients were up for around $800 per dose.
However, the drug has to be administered under supervision, in conjunction with other treatment. It requires a number of these sessions, sometimes more than one a week, possibly for 12 months or more.
That aspect of the treatment is not covered by the PBS and costs patients around $300-$400 per session. It’s up to the MBS to help with that, via an application to the Medical Services Advisory Committee.
“We had applied for Medicare to fund the treatment costs, but they couldn’t because they said there was no affordable access to ketamine out there. So now the door is open for Medicare to consider an item number for the funding of ketamine treatment,” said Professor Loo.
Professor Loo is involved with two Sydney clinics – at the Black Dog Institute and Ramsay Clinic Northside – that provide ketamine therapy and a range of other treatments for depression.
With 14 years’ involvement in ketamine research, she said the evidence for the treatment in treatment-resistant major depression was available and not at issue.
Ketamine is not technically a psychedelic, but it has similar effects, she said. A person must be monitored, both during dosing and in the two hours following, as well as in the periods between sessions, for efficacy and safety.
It’s not for everyone
When you only have a hammer, every problem looks like a nail, Professor Loo said.
Some clinics offering only ketamine treatment will provide it on a “tick the box” basis for patients who technically meet the PBS criteria – “treatment-resistant major depression in patients who have failed at least two prior oral anti-depressant drugs” – she said. They will make their money from fees for treatment sessions, which are not covered.
But ketamine is not necessarily the best treatment for everyone, said Professor Loo.
“There will be some commercial treatment clinics that I think will be happy to have you because it’s profit making, but that’s not, I think, in the patient’s best interest,” she said.
“I think this [subsidy] is a good step. It makes the treatment more available. It should still be reserved only for people with treatment-resistant or difficult-to-treat depression, and in terms of whether this ketamine treatment step is the next best thing for the patient, they really should have an independent clinical psychiatrist opinion rather than going straight into the treatment clinic.”
For many patients the treatment is appropriate but unaffordable.
“Every week I see people with difficult to treat depression, where this is the best next treatment for them. But their answer is ‘I can’t afford it’. And that’s even with generic ketamine [which can be prescribed off-label], which costs around $10,” she said.
“This is currently happening all the time in Australia. Australian public patients with difficult-to-treat depression are not having the treatment that is optimal for them because of cost. It is cost that is determining what they have, not clinical judgment. The irony is that the cost to Medicare and private health funds of some of these alternatives is even more expensive than ketamine.”