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    Has all of the relevant evidence been taken into account?
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    Are the summaries of clinical and cost effectiveness reasonable interpretations of the evidence?
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    Are the recommendations sound and a suitable basis for guidance to the NHS?
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    Are there any aspects of the recommendations that need particular consideration to ensure we avoid unlawful discrimination against any group of people on the grounds of race, gender, disability, religion or belief, sexual orientation, age, gender reassignment, pregnancy and maternity?
The content on this page is not current guidance and is only for the purposes of the consultation process.

1 Recommendations

1.1 Esketamine with a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) is not recommended, within its marketing authorisation, for treating treatment-resistant depression that has not responded to at least 2 different antidepressants in the current moderate to severe depressive episode in adults.

1.2 This recommendation is not intended to affect treatment with esketamine that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.

Why the committee made these recommendations

Treatment-resistant depression is managed with oral antidepressants, then a second drug if symptoms do not improve. Electroconvulsive therapy can be used if oral treatments do not work. Drug treatment can also be combined with psychological therapy. Esketamine is a drug treatment taken by nasal spray, supervised by a healthcare professional in a clinic.

Clinical trials suggest that esketamine with an oral antidepressant may be more effective at relieving the symptoms of depression than placebo and an oral antidepressant. But how much benefit it provides over other oral antidepressants with adjunctive therapy or electroconvulsive therapy is unclear because these treatments have not been compared directly. Also, the available evidence did not include psychological therapies.

There is uncertainty about the effect of stopping esketamine treatment. It is unclear if any improvements in symptoms will be maintained after a course of treatment and whether this will improve someone's quality of life. The costs of repeated courses of treatment with esketamine are unknown, as are the costs of providing the clinic service for esketamine.

The cost-effectiveness estimates for esketamine are likely to be much higher than what NICE usually considers to be a cost-effective use of NHS resources. So it cannot be recommended.