Esketamine therapy in a young patient with treatment-resistant depression: a case report

Abstract

Approximately 30% of individuals undergoing treatment for a major depressive episode fail to achieve remission after two or more trials of first-line antidepressants and are classified as having treatment-resistant depression (TRD). The 25-year-old patient first sought psychiatric help eight years ago, reporting persistent symptoms, including low mood, inner tension, self-blame, sleep disturbances, and fatigue. Since symptom onset, she has received outpatient psychiatric care and has been hospitalized multiple times in various psychiatric clinics. Although treatment courses provided partial remissions, her condition never returned to pre-illness levels. Despite trials with various combinations of antidepressants, anxiolytics, and mood stabilizers, her symptoms worsened after six years of treatment. One year ago, due to ineffective response to traditional medications, her depression was classified as treatment-resistant, and Esketamine (Spravato) therapy was initiated at 56 mg twice a week. The medication was titrated and gradually tapered according to the protocol, eventually being administered at 84 mg of Esketamine once per month. According to the medication prescribing guidelines, since Esketamine is combined with an SSRI or SNRI group antidepressant, the patient was also taking Paroxetine 60 mg per day, continued pharmacotherapy with Mirtazapine 45 mg per day, Quetiapine 100 mg per day, Trihexyphenidyl 2 mg per day, and attended psychotherapy. Upon achieving successful treatment results and the patient no longer expressing complaints, the Esketamine treatment, which lasted 13 months, was concluded. Treatment-resistant depression (TRD) is a prevalent and difficult condition that often results in negative outcomes and has few available treatment options. While often associated with adults over 45 years old, TRD can also affect younger individuals, leading to substantial impairment in daily functioning. Esketamine, when used in combination with SSRI or SNRI antidepressants, has been approved as an effective treatment for individuals with TRD, relieving existing symptoms and preventing relapses. Esketamine treatment for patients with TRD generally lasts 6 to 12 months; however, the duration should be tailored individually based on the patient’s clinical condition and therapeutic response. This case underscores the complexities of managing TRD and highlights the importance of innovative treatment approaches for diverse patient populations.