Clinical guidance on the use of esketamine nasal spray for patients with treatment resistant depression: A European Delphi consensus report.
Allan H. Young, Bernhard T Baune, Beatrice Benatti, Djamila Bennabi, Sven Estercam, Philip Gorwood, Luis Gutiérrez-Rojas, Vassilis Martiadis, Patricio Molero, Claus Normann, Richard Perry, William Pitchot, Andreas Reif, Gianluca Rosso, Eduard Vieta, Andrea Fagiolini
European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology July 17, 2026 DOI: 10.1016/j.euroneuro.2026.112907 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Modified Delphi panel Peer reviewed |
|---|---|
| Sample size | 30 |
| Population | European psychiatrists experienced in managing patients with treatment-resistant depression receiving esketamine nasal spray |
| Intervention | Esketamine nasal spray |
| Dose | 84 mg weekly |
| Duration | Acute phase (4-12 weeks), continuation phase (6-9 months), maintenance phase (≥12 months) |
| Topics | Esketamine Depression |
| Keywords | Assessment patient outcome Decision-making shared Delphi method Treatment resistant depression |
| Key points | Expert consensus supported continuing esketamine nasal spray even with modest acute-phase improvement and advocated for dose/frequency maximization, while prolonging maintenance treatment depended on clinical worsening during tapering and relapse risk. |
Abstract
Esketamine nasal spray (NS) is an established treatment for patients with treatment resistant depression (TRD). To further optimise real-world outcomes, consensus is needed regarding strategies to enhance patient outcomes and decision-making factors for pivotal timepoints in esketamine NS treatment. This modified Delphi panel (3 rounds) established expert consensus (≥80% agreement) from 30 European psychiatrists experienced in management of patients with TRD receiving esketamine NS. During the acute phase (4-12 weeks), modest/subjective reductions in core symptoms important to both patients and physicians supported esketamine NS continuation, especially with long disease course/resistance to multiple therapies. Consensus was reached that such a modest improvement during the acute phase should justify esketamine NS continuation (and supplementation of other treatment modalities with esketamine NS). Esketamine NS dose/frequency maximisation (84 mg weekly) was advocated for, to enhance acute phase outcomes, alongside strategies reflective of individual clinical characteristics. Monitoring in the continuation phase (6-9 months) should prioritise residual/fluctuating symptoms, changes in symptom severity, functional recovery status and comorbidity management/emergence. Should residual symptoms persist, dose/frequency escalation, among other all-phase options, were supported. Prolonging maintenance phase treatment (≥12 months) depended on the degree of clinical worsening when tapering, the risks/consequences of relapse, chronicity of the last depressive episode, residual symptoms and recurrence history. Across all phases, recommended treatment plans included integration of psychotherapy, optimisation of concomitant antidepressants/augmentation strategies, comorbidity management and strengthening support networks. Overall, the consensus advocated for an approach reflective of TRD complexities, prioritising meaningful outcomes for individual patients.