Two patients with treatment-resistant depression initially improved with intranasal esketamine but then experienced rapid worsening of depressive symptoms and suicidal ideation. After stopping esketamine, both patients clinically improved and their suicidal thoughts diminished. The cause of this paradoxical reaction is unclear, but the report highlights that such adverse responses can occur even when treatment initially appears effective. Clinicians should be aware of this potential complication.
An 88-year-old woman began experiencing visual hallucinations 20 years after starting propranolol for hypertension, with symptoms persisting for 20 years. Hallucinations included plants, insects, and vivid human figures of various types, occurring daily upon awakening and lasting 10-20 seconds. After switching to atenolol, hallucinations became rare and non-frightening, indicating a drug-induced cause. This case highlights that iatrogenic causes should be considered even when hallucinations appear decades after starting a medication.