Table 6 Patient case of dissociation associated with esketamine nasal spray

Initial presentation

 • Thirty-two-year-old male healthcare worker with a history of MDD and IBS referred by primary care physician for psychiatric evaluation

 • Patient had been symptomatic for 13 years and had been on various medications with little/no effects

 • The patient was being treated in a private clinic with fluoxetine (60 mg), clonazepam (2 mg), desvenlafaxine (100 mg), sulpiride (400 mg) and melatonin (6 mg)

 • Upon presentation, the patient had severe anhedonia, passive suicidal ideations, intermittent self-injurious behavior, low appetite and poor sleep, all of which had worsened over the previous year. A recent change in job had triggered panic attacks and more intense suicidal ideations

Treatment

 • Esketamine nasal spray was initiated at 56 mg, and the patient’s previous medications were changed by gradual tapering to olanzapine (2.5 mg) and venlafaxine (225 mg)

Follow-up

 • During administration of the initial dose at Week 1, the patient experienced a transient episode of dissociation; esketamine was otherwise well tolerated, with no further AEs. The patient was monitored in the clinic for 90 min, then discharged

 • Esketamine was increased to 84 mg for the second dose of Week 1 and there were no reports of dissociation or any other AEs

Outcome

 • The patient tolerated the rest of the induction phase without any AEs and showed significant improvements in suicidal ideations, self-injurious behavior, mood and appetite

 • PHQ-9 and GAD-7 scores at the time of initial presentation were 26 and 24, respectively, and dropped to 10 and 8, respectively, by the end of the induction period

 • Blood pressure remained within reference range pre- and post-dosing session during each visit, with no significant increase after treatment

 • The patient stated: “I am looking forward to life with positivity each day when I wake up. Suicidal thoughts seem to be a distant nightmare that I can no longer relate to.”