Delphi panel to obtain clinical consensus regarding the importance of rapid reduction in depressive symptoms in patients with major depressive disorder with acute suicidal ideation or behavior (MDSI)

Background: Though oral antidepressants can be effective at reducing depressive symptoms, they can take 4–6 weeks to reach full effect. Limitations relating to slow onset of action and resistance to current treatments for patients with major depressive disorder (MDD), particularly for MDD in a psychiatric emergency such as major depressive disorder with acute suicidal ideation or behavior (MDSI), is an issue across all countries and healthcare settings. Due to the current unmet needs and slow onset of action from oral antidepressants, patients with MDSI need interventions that provide a rapid relief of depressive symptoms. This study aimed to identify unmet needs in the treatment for MDSI, specifically exploring the potential clinical benefits of a rapid reduction of depressive symptoms, associated with treatment with rapid acting antidepressant such as esketamine nasal spray. Methods: A Delphi panel consisting of independent psychiatrists experienced in treating patients with MDSI (n=12) from the United States, Canada, United Kingdom, and European Union, was conducted between December 2020–June 2021. Psychiatrists were recruited and screened by an independent party to ensure that they had the required experience. Psychiatrists completed two rounds of anonymized questionnaires, and a virtual consensus meeting to collect their perceptive on current treatments for MDSI. Results: This research confirmed current unmet needs in the treatment of patients with MDSI. Hopelessness, functional impairment, worsening of symptoms, recurrent hospitalization and higher risk of suicide attempt were considered key consequences of the slow onset of action of oral antidepressants. Psychiatrists anticipated that treatment with rapid-acting antidepressants would provide benefits such as shorter hospital stays, improved patient engagement/compliance, and improved patient outcomes. For long-term benefits, psychiatrists agreed that improved daily functioning and increased trust/confidence in treatment options were key benefits of rapid-acting antidepressants. Conclusions: These findings suggest that the use of rapid-acting antidepressants such as esketamine nasal spray, in a psychiatric emergency, may help alleviate some of the current unmet needs experienced by patients with MDSI. This Delphi panel of psychiatrists highlighted that treatment with rapid-acting antidepressants can provide clinically meaningful benefits in the and long-term, as well as the immediate- and short-term, for patients with MDSI.