In treatment-resistant depression, esketamine nasal spray combined with an SSRI or SNRI led to remission in 27.1% of patients at week 8, compared to 17.6% for extended-release quetiapine plus an SSRI or SNRI. Over 32 weeks, 21.7% of patients on esketamine had no relapse after remission versus 14.1% on quetiapine. The open-label, single-blind, randomized trial included 676 patients. Adverse events matched known safety profiles. Esketamine was superior to quetiapine for achieving remission and preventing relapse.
Modern electroconvulsive therapy (ECT) and nasal esketamine have significantly improved treatment for treatment-resistant depression (TRD), defined as non-response to at least two adequate antidepressant courses. This literature review presents evidence on efficacy and safety, comparing advantages, disadvantages, and response rates. Both treatments are highly effective for TRD. The choice between esketamine nasal spray and ECT should consider contraindications, age, severity, psychotic symptoms, patient preference, and accessibility. Pragmatically, esketamine is chosen before ECT when both are indicated, but studies on ECT in ketamine non-responders are missing.