Finding Joy – Treating Depression with Dr. Samarth Bhandari
The atmosphere at Sanford West Behavioral Health Campus is welcoming and non-institutional. We designed it that way on purpose. The hallmarks of Sanford, such as original artwork, custom furniture, and an abundance of light, are apparent at Sanford West. Although it is a big, sprawling campus, program areas are strategically divided into more intimate spaces. By doing this, we have the flexibility and can create a sense of community that most large, institutionalized centers cannot.
Our approach is non-bureaucratic; however, our programs are evidence-based and led by a psychiatrist and a collaborative care team. We provide treatment for various mental health diagnoses across multiple levels of care, all in one location. According to the National Alliance on Mental Illness (NAMI), over 20% of American adults experience some form of mental illness each year. Many of our clients at Sanford experience more than one mental health disorder simultaneously. To meet this challenge, Sanford Behavioral Health is equipped with innovative, cost-effective, and proactive programs.
Finding Joy – Treating Depression with Dr. Samarth Bhandari
Dr. Samarth Bhandari
We sat down with Sanford Psychiatrist, Dr. Samarth Bhandari, to talk about recent innovations in treating depression and how the Sanford SPRAVATO (esketamine) Clinic enhances treatment for those with addiction, eating disorders, and mental health conditions.
SBH: What is SPRAVATO (esketamine) for treating depression?
Dr. Bhandari: SPRAVATO is a nasal spray of esketamine (one part of ketamine). Ketamine is a racemic mixture of two mirror-image molecules – esketamine and arketamine. SPRAVATO is a solution containing only esketamine. It’s a new way to treat depression, in that it addresses a neurotransmitter system that we did not previously put so much emphasis on. A lot of the focus in treating depression in the past has been on serotonin, but SPRAVATO acts as a blockade of the NMDA receptors. It’s a paradigm shift from what we’ve been used to focusing on when treating depression.
SBH: Who is SPRAVATO suited for?
Dr. Bhandari: SPRAVATO is for individuals who have treatment-resistant depression and have failed two or more trials of antidepressants in the past. In other words, they have had no response to at least two adequate antidepressant trials. It is estimated that 1/3 of individuals with depression (who have lost hope) would qualify. We treat new patients seeking innovative care, those referred by an outpatient psychiatrist or their primary care provider, and current Sanford patients at the on-site SPRAVATO Clinic at Sanford West.
SBH: What is depression?
Dr. Bhandari: I would say (per the Diagnostic Statistical Manual used to diagnose mental illness), one of the necessary criteria to meet the diagnosis is the inability to find joy. So, a required criterion is that activities and things that once used to bring people joy no longer do. Individuals can have different clusters of symptoms, but anhedonia is always there. Anhedonia is the diminished capacity and lack of motivation to feel pleasure from what would be considered pleasurable activities. Other things, like impaired sleep, affected appetite, feelings of guilt, decreased energy during the daytime, and suicidal ideation, are also symptoms.
SBH: How do you define joy?
Dr. Bhandari: Obviously, joy is not a baseline state. Nobody can be joyful and happy 24/7. However, joy is a positive emotional reaction to situations that should bring happiness, such as a cake on your birthday, petting a puppy, holding a baby, viewing a beautiful sunrise, or getting a promotion at work. It is all within the human experience of “normalcy.”
SBH: How does an individual get authorization to begin SPRAVATO treatment?
Dr. Bhandari: They must submit paperwork that describes past medication trials, including the length of treatment for those medications. I would agree that it is likely 1/3 of our patients would qualify for SPRAVATO. Interestingly, having a comorbid substance use condition does not exclude a person from receiving esketamine treatment. There’s actually some research that shows that ketamine helps with maintaining abstinence from illicit substances.
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What is SPRAVATO (esketamine) for Treatment-Resistant Depression?
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SBH: Can you talk a bit about the NMDA receptors?
Dr. Bhandari: They’re excitatory receptors in the central nervous system activated by the neurotransmitter glutamate that play a key role in learning, memory, and neuroplasticity. Abnormal activity in these receptors has also been implicated in epilepsy, schizophrenia, and Alzheimer’s disease.
SBH: Where does depression come from, and why is it so prevalent? Are there different degrees of depression?
Dr. Bhandari: So, there are different ways to think about depression. One of the models that I consider is the stress-diathesis model, where individuals have a predisposition based on their genetic makeup and biological factors. Their organic makeup gives them a predisposition, and then some sort of inciting stressor in their life triggers depression. The extent of that depression, the level of impairment and distress, varies among different individuals, too. That is why depression can be categorized as mild, moderate, or severe.
Some individuals can’t function. They cannot leave the house, as their daily living activities are severely impacted. Bathing, cooking, and the basics become untenable. There is also functional depression, where people are able to go about their day, they’re seemingly fine to everyone around them, but inside, they’re not getting the joy out of their life.
SBH: What category of depression would be appropriate for SPRAVATO treatment?
Dr. Bhandari: It is more for the moderate or severe categories. Also, SPRAVATO (eketamine) is indicated for suicidal ideation and suicidal thoughts, so as soon as that comes into the picture, we consider SPRAVATO. We have a mental health intensive outpatient program for those who are looking for therapy or who do not qualify for SPRAVATO. A number of those enrolled patients would be eligible based on past medication trials and how stable they are.
SBH: How do individuals respond to SPRAVATO treatment?
Dr. Bhandari: Each person’s clinical response after the treatment, the few weeks after, will tell us more about whether we can taper that to once a week, once every two weeks, or once a month. Every person will respond differently. I think the evidence is very promising. There are a lot of benefits to it, and SPRAVATO is very rapid-acting. Most patients see the results within the first week. The side effect profile is very benign in that the acute side effects are only present for the first few hours after receiving the dose (potential dissociation, feeling dizzy). We require a 2-hour monitoring period after treatment, and we require patients to have a ride home.
SPRAVATO has a favorable safety profile in that it does not have significant interactions with other medications besides sedatives and stimulants. There are very few contraindications, so most patients are potential candidates. The FDA has approved SPRAVATO for those with major depressive disorder who have two failed trials of antidepressants of two different classes. You can receive SPRAVATO treatment while already taking a prescribed antidepressant.
SBH: Anything else you’d like to say about treating depression, Dr. Bhandari?
Dr. Bhandari: Yes. Depression takes a massive toll on individuals and their families. Treating depression has a ripple effect in our community. The more tools in our tool belt to treat depression, the better. As I said, given the wide breadth of potential applications and the favorable safety profile, there are a lot of benefits with very, very few risks with SPRAVATO (esketamine).
SBH: Does the prospect make you joyful?
Dr. Bhandari: [Smiles] Yes, it makes me joyful.
Thank you, Dr. Bhandari
