Ketamine for Depression in Cancer: Separating Real Promise From Hype

In this episode of Oncology On the Go, Daniel C. McFarland, DO, spoke with Erik Bengtsen, MD, a psychiatrist at Memorial Sloan Kettering Cancer Center (MSK), about interventional psychiatry and what emerging treatments such as ketamine, esketamine, and psilocybin may mean for patients with cancer.

Interventional psychiatry differs from talk therapy or take-home medication because patients come into the office for a monitored procedure, whether neuromodulation such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) or interventional pharmacology. Bengtsen described how Memorial Sloan Kettering launched an intranasal esketamine program in a small wing of a chemotherapy infusion suite, treating up to 4 patients at a time and completing approximately 70 visits in its first year. The FDA-approved agent's REMS program, which includes strict monitoring and required nursing education, helped secure institutional buy-in.

Patients who have benefited so far fall into 2 groups: those with severe depression, sometimes with passive suicidality, at diagnosis who urgently need to proceed with cancer treatment, and survivors with no evidence of disease whose depression has not responded to optimized antidepressant therapy. The experts explain the putative mechanism, NMDA receptor antagonism with downstream effects on brain-derived neurotrophic factor and neuroplasticity, and note that response is far faster than with standard antidepressants, often apparent after 3 sessions. Bengtsen also shared how his team pairs treatment with meaning-centered psychotherapy and how esketamine may help when conventional agents are contraindicated, such as in patients with severely low platelets after bone marrow transplant.

The conversation turned to psilocybin, which remains investigational but has shown promise for existential distress and fear of recurrence. Both experts stress the importance of safety, adherence to psychiatric standards of care, and treatment in monitored academic settings that know a patient's full oncology history, while noting that ECT continues to play a well-established role.

McFarland is the director of the Psycho-Oncology Program at Wilmot Cancer Institute and a medical oncologist who specializes in head and neck cancer and lung cancer, in addition to being a psycho-oncology editorial advisory board member for the journal ONCOLOGY®. Bengtsen, is an assistant attending psychiatrist and assistant director of the Consultation-Liaison Psychiatry Training Program at Memorial Sloan Kettering Cancer Center.