Spravato, which received Food and Drug Administration (FDA) approval in March, has raised hopes for preventing suicides and relieving depression after other treatments have failed. But there are concerns about possible side effects, including drug abuse, elevated blood pressure and heart rate, sedation, and hypersensitivity to surroundings.

The nasal spray is prescribed for treatment-resistant depression after at least two other antidepressants haven’t worked and is given with an oral antidepressant. It is only administered in restrictive clinical settings to reduce potential for abuse and side effects.

Nationally, of the 17.3 million adults with depression, one-third are treatment-resistant, increasing their risk of suicide.

Yale New Haven Hospital, the Institute of Living, UConn Health John Dempsey Hospital, Wheeler Clinic, VA Connecticut Healthcare, and Dr. Lori Calabrese in South Windsor report that they have either started or are planning to offer the fast-acting medication whose chemical name is esketamine. It is designed to show results in hours and days compared to the weeks and months it takes for traditional antidepressants to work.

Dr. Jayesh Kamath, director of the mood and anxiety disorders program at UConn Health, has conducted esketamine studies for Janssen, its manufacturer. “I want to make sure people hear the positives and the negatives of this medication,” he said.

Spravato, a nasal spray, is prescribed for treatment-resistant depression.

While he said that “it is changing how we treat depression” and shows promise for enabling severely depressed people to function, he added that “the results are concerning about side effects.”

Janssen, a Johnson & Johnson subsidiary, is charging $590 to $885 for the medicine, depending on dosage. This does not include costs charged by providers for administering it. Veterans who receive it at the VA will not be charged. Medicaid and Husky will cover it, according to the state Department of Social Services.

A Janssen spokesperson said insurance companies are starting to cover it and Janssen is providing help, such as co-pay coupons.

Janssen refused to provide a list of Spravato-certified treatment centers and applicants in Connecticut but said that nationally about 1,600 sites have been certified. Restrictions imposed on Spravato sites include: prohibiting it from being sent home with patients; requiring patients to remain at the site for at least two hours and not drive for another day; and specifications for dosages, screening and monitoring patients, and labeling and handling of the medication.

Dr. Michael Twist, Wheeler Clinic’s medical director, said Spravato can be a replacement for electric convulsive therapy. “This is going to be a way of getting someone much better much quicker,” he said. “It’s huge.”

Esketamine: A Derivative Of Ketamine

Yale School of Medicine Photo.

Dr. John Krystal, psychiatry chair, Yale School of Medicine.

Esketamine is a derivative of ketamine, an anesthetic that has been abused as a party drug called Special K. Yale School of Medicine pioneered research on ketamine for depression starting in 1995. It has not been approved by the FDA to treat depression because as a generic drug, it doesn’t have the profit-making potential to attract research funding, several doctors said.

Ketamine is FDA-approved as an anesthetic administered intravenously or by intramuscular injections. The chemical difference between the two drugs is that ketamine is comprised of two mirror-image molecules and esketamine (Spravato) is comprised of one of those molecules.

Some doctors, including Calabrese, provide it intravenously “off label” for depression treatment, a legal use of a non-approved medication that is usually not covered by insurance.

Calabrese, a psychiatrist, said she will continue to offer intravenous ketamine in addition to Spravato. She said an analysis of 144 of her suicidal patients showed 68 percent no longer had suicidal thoughts after ketamine treatment and 82 percent had diminished suicidal thoughts. She said there were no suicide attempts, emergency room visits, or hospitalizations from the time of treatment through follow-up four weeks later. She charges patients $502 for ketamine.

Dr. Vincent Carlesi, an anesthesiologist and pain management specialist in Stamford and Ridgefield, is among other physicians who offer intravenous ketamine. Patients with depression are referred by psychiatrists, said Robin Asken, the practice’s manager. She wouldn’t provide numbers, but reported seeing “a marked improvement in quite a few of the patients.” The charge is $850 per infusion, which is typically not reimbursed by insurance, Asken said.

Dr. John Krystal, psychiatry chair of the Yale School of Medicine, said that “it is very moving to hear the stories of people who have been depressed for many years, who have tried multiple treatments without success, and then to hear how they had their first good clinical response to ketamine, often within 24 hours of their first doses.”

He said people have told him it saved their lives.

Yale medical school’s first ketamine study was at a clinic it ran at the Connecticut VA in 1995 and 1996. Five years ago, it established a ketamine clinic at Yale New Haven Hospital and last year, it opened a new ketamine program at the VA, Krystal said.

“Uncovering Our Kids: Towards a Better Understanding of Teen Mental Health,” will feature a panel of experts in adolescent behavioral health who will lead a discussion about teen mental health screening, intervention and treatment.

Jeff Vanderploeg

The Conn. Health I-Team, in collaboration with ConnectiCare and Hartford Hospital’s Institute of Living, invites the public to come “talk openly about teen mental health, learn from experts, and help Connecticut reduce the stigma of depression and mental illness,” said C-HIT co-founder and editor Lynne DeLucia.

The event will run from 5 to 7:30 p.m. at the Lyceum Conference Center in Hartford. Walk-in registration is welcome.

Dr. Harold Schwartz

Panelists will speak about ways to identify depression in youths and how to intervene if necessary, and will give an overview of Connecticut’s behavioral health landscape. Speakers include: Dr. Harold (Hank) Schwartz, psychiatrist-in-chief at the Institute of Living and vice president of Behavioral Health for Hartford HealthCare; Nancy von Euler, a parent advocate for suicide prevention whose 17-year-old daughter took her own life in 2009; Jeff Vanderploeg, vice president for mental health initiatives at the Child Health & Development Institute and an assistant clinical professor in psychiatry at Yale University School of

Kim Nelson

Medicine; Kim Nelson, vice president of Children’s Outpatient and Community-Based Services at the Wheeler Clinic; and Jill Holmes Brown, a social worker and director of East Hartford’s School-Based Health Center Program. U.S. Sen. Chris Murphy also has been invited to participate.

The panel will be moderated by Christine Stuart, editor-in-chief of the online news organization CTNewsjunkie.com.

Jill Holmes Brown

“ConnectiCare is pleased to co-sponsor this forum so parents, teachers, doctors and others can speak openly about teen mental health issues.  With one in five young people suffering from behavioral health conditions, many families in Connecticut need help identifying disorders and seeking treatment.  We need to work together to increase timely referrals, reduce barriers to treatment and get our young people the resources they need to lead productive lives,” said John Harper, vice president and chief medical officer, ConnectiCare.

Nancy von Euler

The panel begins at 6 p.m. and will be preceded by a social hour with refreshments.

Tickets are $10, with a portion of the proceeds going to the American Foundation for Suicide Prevention, Southern CT Chapter.

The Lyceum is located at 227 Lawrence St., Hartford; on-site parking is available.

For more information on attending the forum or becoming a sponsor, please contact Lynne DeLucia at delucia@c-hit.org.

“They are terrified of gaining the weight back,” said Dr. Sara Niego, medical director of the Eating Disorders Program at Hartford Hospital’s Institute of Living, who has treated patients with anorexia, bulimia and binge eating disorder years after weight loss surgery.

The lack of a national “gold standard” to psychologically assess prospective patients has led Connecticut mental health professionals to call for standardized criteria to identify those who are at risk before and after surgery. They worry some patients with mental health problems may slip through the cracks because each hospital and insurance company has different psychological screening requirements.

“Unfortunately, there is no consensus in the field regarding what constitutes a psychological evaluation or what would prohibit an individual from obtaining surgery from a psychological standpoint,” said Kimberly Daniels, a clinical psychologist with the Center for Weight Loss Surgery at Middlesex Hospital. “There is not, but should be, a standard of care for these evaluations to minimize the psychological risks to clients.”

Life-Changing Surgery

Twenty-five percent of Connecticut adults are obese, up from 18.9 percent a decade ago, according to the Robert Wood Johnson Foundation. A combination of genetic, environmental and behavioral factors impacts obesity and morbid obesity. Morbidly obese individuals are 100 pounds over their ideal weight and have a 50 percent to 100 percent increased risk of premature death, studies show.

Many Connecticut hospitals offer, or are affiliated with a network that offers, weight loss surgery (also known as bariatric or metabolic surgery). While the types of bariatric surgery vary, the procedures all involve reducing the size of the stomach. Studies show that bariatric surgery can effectively treat morbid obesity and improve or resolve obesity-related diseases such as Type 2 diabetes, heart disease, sleep apnea and certain cancers.

Typically, patients lose the most weight one to two years after surgery, according to the American Society for Metabolic and Bariatric Surgery.  On average, patients maintain 50 percent of their excess weight loss five years after surgery.

But for some patients, new or old patterns of disordered eating can surface years after surgery, leading to clinically diagnosed eating disorders. Disordered eating patterns are harmful behaviors – restricting food, binging and purging – that can develop into an eating disorder. Eating disorders are serious psychiatric conditions. Anorexia, for example, has the highest mortality rate of any psychiatric illness, reports the National Institute of Mental Health.

“The unhealthy behavior goes away for a while because of the substantial weight loss during the first two years – that’s the honeymoon phase,” said Niego. “Then the weight loss plateaus and some people begin to regain. That’s when the eating disorder or disordered eating resurfaces.”

Experts agree the most common eating disorder associated with obese individuals is “binge eating disorder,” which received its own diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders last year. People with binge eating disorder eat extremely large amounts of food and often report feeling out of control during the binging.

But views on the prevalence of eating disorders following weight loss surgery differ between bariatric surgeons and eating disorder specialists. In Connecticut, eating disorder experts said people who had weight loss surgery represent a new segment of patients seeking treatment at their facilities. Bariatric surgeons say cases of clinically diagnosed eating disorders after surgery are uncommon.

A lack of conclusive research on eating disorders in post-surgery patients clouds the debate.

Niego and colleagues conducted a review of research in 2007 that found an “association between pre-surgical binge eating and post-surgical binge eating.” In one study, 37 percent of people who binge ate before surgery continued feeling out of control when eating up to 15 years after surgery. Another study found 24 percent of patients who reported binge eating before surgery continued after the procedure.

Niego isn’t surprised that some post-bariatric surgery patients seek help for eating disorders.

“You cannot cure a mental disorder through surgery,” she said.

Identifying At-Risk Patients

Although individuals undergo a psychological evaluation before surgery, identifying those at risk poses challenges because people aren’t always up-front about their eating habits, said Rebekah Bardwell Doweyko, program director of Walden Behavioral Care in South Windsor, which treats people with eating disorders.

“How honest do you think people will be on a psychiatric evaluation that determines if they’re eligible for a surgery they perceive is going to save their life?” she said.

Griffin Hospital Photo

Dr. Rishi Ramlogan

Dr. Rishi Ramlogan, medical director of the Bariatric Surgery Program at Griffin Hospital, estimated that 95 percent of people who regain weight after surgery do so because of behavioral reasons.

“Patients need to understand that bariatric surgery is not a quick fix or magic pill,” he said.

“Oftentimes, surgery is the easiest part of the whole process. The real challenge is making the necessary lifestyle changes.”

Post-Surgery Support

Follow-up care for patients includes support groups, education forums, checkups with the surgeon, nutritional counseling and behavioral health consultations and treatment.

“We assume all weight loss surgery patients will struggle to some degree with behavior changes because if it were easy, fewer would require surgery,” said Jennifer Ferrand, a clinical psychologist who works with bariatric patients at the Institute of Living, adding that early intervention “could prevent the development of a full-fledged eating disorder.”

In addition, the state lags behind in providing adequate post-discharge continuing care plans for psychiatric patients, especially teens and the elderly. Connecticut’s 28 inpatient psychiatric units and hospitals developed continuing-care plans for fewer than 70 percent of patients they discharged from October 2012 to March 2013 – indicating that thousands of patients may have left facilities without adequate treatment and medication plans.

A C-HIT analysis of the federal data, released by the Centers for Medicare & Medicaid Services for the first time, show that Connecticut ranks in the top fourth of states (11^th highest) in the use of physical restraints in inpatient psychiatric facilities – and is the third highest state in restraining patients 65 and older.

Two psychiatric units – at Bridgeport Hospital and Masonicare Health Center in Wallingford – have the 10^th and 12^th highest rates of restraint use, respectively, among the 1,753 psychiatric facilities nationwide that are included in the federal reports, which cover October 2012 through March 2013.

State and federal guidelines – tightened over the past 15 years, partly in reaction to deaths in Connecticut facilities – say that restraints should be used only in cases of imminent physical danger to a patient or others. They call for less restrictive interventions when patients are acting out aggressively.

But the data show that Bridgeport Hospital, Masonicare and three other Connecticut hospitals — Waterbury, Hartford, Danbury  — restrain patients at more than triple the national rate.

James McGaughey, director of the state Office of Protection and Advocacy for Persons with Disabilities, said he was disturbed by both the high rate of restraint use and the low rate of post-discharge plans.

“The numbers are pretty compelling,” he said. “Some of our hospitals have done a significant amount of work on this, but clearly there’s more to be done.”

He suggested that the state Department of Public Health, which oversees hospitals and is charged with reviewing annual reports of restraint and seclusion, should “get a little less timid in looking at this.” Hospitals rarely have been cited or penalized in recent years for improperly using restraints, a review of inspection reports shows.

McGaughey noted that the state-run Connecticut Valley Hospital has pursued a reduction in restraints and seclusion that has cut its restraint rate significantly in the last five years. The new data show CVH’s rate at .52 hours per 1,000 patient hours – below the statewide rate of 1 hour per 1,000. The national average is .39.

“It’s ironic that our one remaining large state hospital has done such a good job of reducing restraint and seclusion, but you have some very different results at private institutions,” McGaughey said of CVH, which was cited for excessive restraint use in 2007 by the U.S. Justice Department. “What it shows is that it’s possible to address this issue, but you need leadership to effect this kind of culture change.”

Mental health advocates say seclusion and restraint should be avoided because they are traumatic and dangerous to patients and staff.

Alternatives include individualized aggression-management plans, the use of “comfort rooms” or time-out spaces, and one-on-one interventions. Among the innovations at CVH are 22 “comfort rooms,” designed to calm agitated patients, and a reduction in the time interval that a physician’s order of restraint or seclusion can remain in effect, according to a state report.

James McGaughey.

Officials at Connecticut hospitals with high rates of restraint say they are working to reduce those incidents, and they stressed that even minimal mobility restrictions, such as soft wrist restraints or brief therapeutic holds, are counted in the federal numbers.

Robert Bernstein, executive director of the Bazelon Center for Mental Health Law, a national advocacy group which successfully sued Connecticut in 2006 to stop housing psychiatric patients in three nursing homes, said he worried that progress made in the early 2000s to reduce restraints might be slipping in some hospitals because of staff shortages and “pushback” from clinicians.

“Some of the procedures put in place may have been weakened, because it’s a lot of work” to use alternative interventions, he said.

Although patients subjected to improper restraint can file complaints, few speak out, Bernstein and others said. Among the exceptions in Connecticut is Pamela Spiro Wagner, a Wethersfield writer and artist with schizophrenia who has cycled in and out hospitals.

In an April “open letter” to the director of a Connecticut psychiatric hospital, Wagner readily conceded that she is a difficult patient – “easily roused to irritability and hostility” – but insisted that her behavior has not warranted her repeatedly being placed in restraints and seclusion, for hours at a time.

“Once they decided to use four-point restraints, there was no going back . . . So they used them again and again, and more and more freely and without justification,” she wrote of a recent hospitalization.

“Once you allow staff to use restraints a little, it only takes a little to use them a lot.”

Connecticut vs. The Nation

Nationally, the states with the highest restraint use are Minnesota, Washington, South Dakota, Tennessee and New Hampshire. For patients 65 and older, only Nevada and New Hampshire have rates higher than Connecticut, which restraints elderly patients at an average of 7.69 hours per 1,000 hours. Thirty-five states have rates of less than 1 per 1,000 hours; the national average is 1.01 hours per 1,000 hours.

The U.S. facility with the highest restraint rate is Park Ridge Health in North Carolina, which reports 722 hours of restraint use per 1,000 patient hours overall. Among facilities that report serving children ages 2 to 12, Lakeland Regional Medical Center in Florida has the highest restraint use, at 200 hours.

The federal data show Connecticut psychiatric facilities fare well in some categories, including lower-than-average rates of restraint for children and teenagers. Five hospitals reported no use of restraints for any age group: Sharon, MidState Medical Center, Bristol, John Dempsey and Natchaug hospitals.

And Connecticut’s rate of keeping patients in seclusion is lower than the national average, with half of the state’s psychiatric facilities reporting that they did not use seclusion at all. Nationally, South Dakota, Montana and Washington report the highest use of seclusion, defined as involuntary confinement where a patient is prevented from leaving.

But the state’s over-65 restraint rate is fueled by excessive rates at Masonicare (35.99 hours), Bridgeport Hospital (37.92) and Hartford’s Institute of Living (9.19).

Officials at those hospitals say they have taken steps in the year since the data-reporting period ended to reduce restraint use.

This is the first time that quality measures from psychiatric facilities have been made available by CMS. The federal agency does not penalize facilities for high rates of restraint or inadequate discharge plans. Instead, an agency spokeswoman said, the public reporting is intended to encourage quality improvements and help consumers to make informed decisions.

At Bridgeport Hospital, Dr. Ryan O’Connell, vice president for performance and risk management, said the hospital’s geriatric psychiatric unit serves many patients with dementia and behavioral problems that cannot be managed in other facilities. About 18 months ago, he said, the hospital put in place an “action plan” to reduce restraints, including using “comfort” rooms. Also, in January, a new policy was implemented requiring that the nurse manager be called before any patient is restrained.

“We realized we were going in the wrong direction with restraints” and have since seen a “dramatic drop” in their usage, O’Connell said.

Hartford Hospital’s Institute of Living (IOL), which has a geriatric unit for complex dementia patients, has made similar changes over the past few years, nursing director Ellen Blair said. She said restraints are now rarely used, and only for patient safety. The IOL requires that a physician’s restraint order be reviewed every two hours, rather than every four, which is the standard of care.

“We look at our data every single day” to ensure that restraint and seclusion are being used only as “a last resort,” Blair said.

Masonicare’s acute psychiatric unit serves geriatric patients who frequently are referred because of difficult behaviors and aggression, said spokeswoman Margaret Steeves. When restraints are needed, the hospital uses “the least restrictive restraint, which is typically a seat belt,” she said. Masonicare has an interdisciplinary team reviewing restraint use.

Statewide, the Connecticut Hospital Association has been working with the state Department of Public Health to minimize the use of restraints, said Dr. Mary Cooper, the group’s vice president and chief quality officer. She said the new federal data “indicate that there is more work to be done in this area” and will help to identify best practices.

Nationally, the federal government tightened rules on the use of restraints and seclusion between 2001 and 2007, including time limits on physician orders and strict documentation requirements. The changes were prompted by a series in The Hartford Courant, “Deadly Restraint,” which documented restraint-related deaths in psychiatric facilities nationwide.

In 2007, the U.S. Department of Justice cited the state-run CVH for excessive overuse of unnecessary restraint and seclusion. Since then, policy and training initiatives have significantly reduced restraint episodes – from 26,290 hours in 2000, to 529 hours in 2012 – a state report shows.

State DPH spokesman Bill Gerrish said the agency collects restraint and seclusion reports from hospitals and works to “ensure that care is appropriate.”

Lags In Discharge Planning

McGaughey and Bernstein said they were especially troubled by the failure of many hospitals to develop continuing care plans for discharged patients, and to transmit those plans to the next level of care.

Statewide, Connecticut facilities developed adequate discharge plans 69.4 percent of the time – lower than the national average of 73.5 percent. For teens, hospitals transmitted care plans only 55 percent of the time – lower than the national average of 74 percent – and for seniors, just 42.7 percent of the time, below the national average of 56 percent.

Discharged patients are supposed to receive care plans containing their diagnoses, reasons for hospitalization, medications and treatment recommendations.

The federal data show that 10 Connecticut hospitals, including Waterbury Hospital, Masonicare and Yale-New Haven Hospital, properly transmitted care plans to the next provider in less than half of cases.

A few hospitals – St. Mary’s, Bristol, Norwalk, Natchaug Hospital and Southwest Connecticut Mental Health – transmitted care plans more than 90 percent of the time.

McGaughey said that without continuing care plans directing further treatment, many discharged patients may languish in nursing homes, shelters or land back in the hospital.

“The lack of continuity of care, to me, is a huge issue,” he said. “It’s a pretty brutal business – insurance companies want you to medicate and discharge as fast as possible. The question is, what happens after they’re out?”

Bernstein said the lack of attention to continuing care plans was “jaw-dropping.”

“Those numbers should be at 100 percent,” Bernstein said. “It’s shameful.”

Hospitals with low rates of discharge care plans blamed much of that lag on their failure to document that the paperwork was done.

At Masonicare, for example, Steeves said the 31.3 percent rate of developing care plans was due to problems with the “tracking of the discharge document . . . not that it wasn’t actually sent.”