Case Report: Intranasal esketamine and accelerated intermittent theta-burst stimulation for severe treatment-resistant depression with suicidal ideation
Chun-Hung Chang, Yu-Der Hsia, W Liu, Chien‐ho Lin, Jianjung Ying, Hsin-Chi Tsai
Frontiers in Psychiatry July 1, 2026 DOI: 10.3389/fpsyt.2026.1837402 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Case study Case report Peer reviewed |
|---|---|
| Sample size | 1 |
| Population | 29-year-old woman with treatment-resistant major depressive disorder and high-risk suicidal ideation |
| Interventions | Intranasal esketamine Accelerated intermittent theta-burst stimulation |
| Dose | 84 mg |
| Duration | 4 treatment days, 2-week follow-up |
| Topics | Depression Esketamine |
| Keywords | Suicidal ideation Beck depression inventory Depression economics Transcranial magnetic stimulation Hamd Rating scale Antidepressant Nasal administration Electroconvulsive therapy Anesthesia Adverse effect |
| Key findings | Combining intranasal esketamine with accelerated iTBS was feasible and associated with reduced depressive symptoms and suicidal ideation in a single patient. |
Abstract
Introduction: Treatment-resistant major depressive disorder with high-risk suicidal ideation is a psychiatric emergency that requires rapid and effective intervention. Although intranasal esketamine and intermittent theta-burst stimulation (iTBS) are time-efficient therapeutic options, clinical reports describing their combined use in an accelerated inpatient schedule are limited, particularly in acutely high-risk patients.
Methods: A 29-year-old woman with recurrent major depressive disorder was hospitalized for severe depressive symptoms and high-risk suicidal ideation after inadequate responses to several antidepressant trials, augmentation therapy, psychotherapy, and a standard course of repetitive transcranial magnetic stimulation. Her baseline symptom severity scores were as follows: Patient Health Questionnaire-9 (PHQ-9), 15; Hamilton Depression Rating Scale (HAMD), 27; and Beck Depression Inventory (BDI), 41. After providing written informed consent, she received intranasal esketamine (84 mg) and an accelerated iTBS protocol targeting the left dorsolateral prefrontal cortex (Beam F3 localization), with 10 iTBS sessions delivered over 4 treatment days (total 6,000 pulses).
Results: The patient’s depressive symptoms improved during the acute treatment course (PHQ-9: 15→11; HAMD: 27→20; BDI: 41→28), and she reported an improvement in suicidal ideation. Her clinical status remained stable at the 2-week follow-up (PHQ-9 = 8; HAMD = 17; and BDI = 23). An exploratory device-derived stress index obtained using the Stress Electroencephalogram Assessment (SEA) system decreased from 7 to 3, consistent with clinical improvement.
Conclusion: This case suggests that the combination of intranasal esketamine and accelerated iTBS is feasible in inpatient settings for treating severe depression with high-risk suicidal ideation. Additional controlled studies are required to evaluate the efficacy, optimal sequencing, safety monitoring, and durability of this combined approach.