Ayahuasca is a traditional Amazonian hallucinogenic brew that has been used for centuries in shamanic ceremonies and is gaining popularity in the United States for its spiritual and psychotherapeutic benefits. The decoction combines a monoamine oxidase inhibitor from Banisteriopsis caapi with a serotonergic 2A receptor agonist from Psychotria viridis or Diplopterys cabrerana. Potential risks include psychotic episodes related to N,N-dimethyltryptamine and potentially life-threatening serotonin syndrome. Consequences of use remain uncertain due to poor quality control, unpredictability, and polydrug interactions. Healthcare providers need familiarity with its pharmacology, drug interactions, and management for optimal decision making.
Esketamine (Spravato), a nasal spray formulation of the NMDA receptor antagonist ketamine, was approved by the FDA in March 2019 for treatment-resistant depression in adults, to be used alongside an oral antidepressant. About one third of patients with major depressive disorder are treatment resistant to current antidepressants, and depression in bipolar disorder also responds poorly to them. Esketamine must be administered under direct healthcare provider supervision, with blood pressure monitoring before and after dosing, and patients observed for at least 2 hours. To reduce nausea and vomiting, patients should avoid food for 2 hours and liquids for 30 minutes before administration.