SUMMARY

• The SPRAVATO clinical program excluded patients with borderline personality disorder (BPD) or antisocial personality disorder. In addition, the treatment-resistant depression (TRD) program excluded patients with histrionic personality disorder or narcissistic personality disorder.^1-7
• A real-world, retrospective study in adult patients with TRD reported the influence of comorbid personality disorders on the effectiveness of SPRAVATO on depressive symptoms during the maintenance phase. The cohort with comorbid personality disorders did not significantly improve during the maintenance phase compared to the cohort without personality disorders.⁸
• Two case reports are presented, one in a 39-year-old female with bipolar I disorder (BD-1)⁹ and another in a 27-year-old female with TRD¹⁰, both with comorbid BPD and a history of drug use and suicide attempts, who achieved sustained response with SPRAVATO.

Clinical studies

Real-world Retrospective Study

Dvorak et al (2024)⁸ conducted a single-center, real-world, retrospective study in Israel from January 2021 to 2023 to evaluate the effectiveness of SPRAVATO in 62 adult patients with TRD, including 25 patients with comorbid personality disorders. Assessments were made using the Quick Inventory of Depressive Symptomatology (QIDS) score at baseline, acute (8 weeks), and maintenance phase (4-6 months).

In the overall population, patients had a mean age of 43.6 years, and 54.8% were female. QIDS scores significantly decreased from baseline (mean, 22.73) to the acute phase (mean, 16.55) and then to the maintenance phase (mean, 12.15) (P<0.001). The study found no influence of comorbid personality disorders on the QIDS scores during the acute phase, but a significant difference in mean QIDS scores was reported between patients with comorbid personality disorders and those without during the maintenance phase. Although the mean QIDS score in the cohort with a personality disorder did not further improve from the acute phase to the maintenance phase, a significant improvement was seen in the cohort without a personality disorder during this time. The authors noted limitations that may have affected outcomes and acknowledged that further research is needed to assess the effectiveness of SPRAVATO in this comorbid patient population.

Case Reports

de Filippis et al (2023)⁹ presented a case report of a 39-year-old female patient diagnosed with BD-I and BPD who presented to the hospital after a drug ingestion-related suicide attempt. The patient had a long history of alcohol and drug abuse, with prior reports of manic episodes, voluntary and compulsory hospitalizations, drug ingestion-related suicide attempts, and depression. A month after her recent drug ingestion-related suicide attempt, the patient was initiated on SPRAVATO as an adjuvant to the current treatment regimen, including fluoxetine, lithium, lurasidone, and quetiapine. She received a twice-weekly 56 mg SPRAVATO dose for 4 weeks followed by 56 mg once weekly.

After 3 months, a clinical response (50% reduction in the Montgomery-Åsberg Depression Rating Scale [MADRS] score) was reported, and at the 12-month follow-up, a clinical remission (MADRS<10) with improvements in global functioning, sleep cycle, suicidality risk, binge eating, and anxiety symptoms were reported. In the continuation phase, the patient had no clinical relapses or hospitalizations, held a part-time job, and started caring for herself and her daughters.

Nandan et al (2022)¹⁰ presented a case report of a 27-year-old female patient with TRD and BPD who initially presented to the hospital after a suicide attempt. The patient was diagnosed with MDD at age 7 and BPD by age 8-9. She had a history of drug and alcohol abuse with multiple impulsive suicidal and non-suicidal self-harm episodes. After discharge from the current hospitalization, the patient was initiated on SPRAVATO with daily citalopram 20 mg and buspirone for anxiety. SPRAVATO 56 mg was administered twice weekly for 4 weeks, followed by 56 mg once weekly, which was titrated to 84 mg once weekly.

Within 4-5 weeks, assessment using the Hamilton Depression Rating Scale (HAM-D) showed a response in terms of suicidal ideation and depression, with a significant improvement in core BPD symptoms. Nearly 2 years into treatment, the patient’s affective instability and impulsivity significantly improved, and the HAM-D score decreased. The patient and her mother reported a 70% improvement in depression and anxiety and an 80% improvement in behavioral symptoms. Attempts to self-harm decreased from once a week to once every 3 months, and she also maintained a steady job. The patient’s interpersonal relationships improved, and the frequency of anxiety and anger outbursts and emergency department visits decreased over time.

Literature Search

A literature search of MEDLINE^®, EMBASE^®, BIOSIS Previews^®, and DERWENT^® (and/or other resources, including internal/external databases) pertaining to this topic was conducted on 20 September 2024.