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Managing dissociative symptoms following the use of esketamine nasal spray: a case report

Sophia Pereira, Emily Brennan, Anjali Patel, Melissa Moran, Jenny Wallier, Michael R. Liebowitz

International Clinical Psychopharmacology 2021 DOI: 10.1097/yic.0000000000000327 (opens in new tab)

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Study at a glance

AI-extracted from the abstract
Characteristics Case study Case report Peer reviewed
Sample size 1
Population A 64-year-old woman with major depressive disorder and treatment-resistant depression enrolled in a clinical trial
Intervention Esketamine nasal spray
Dose 56 mg of esketamine nasal spray (two nasal spray devices, 28 mg per device); flexible doses of 56 or 84 mg twice weekly
Duration Twice weekly for 4 weeks
Topics Esketamine
Key findings The patient experienced a 40-minute dissociative episode with anxiety and confusion 20 minutes after receiving 56 mg of esketamine nasal spray. Listening to music of her choice during treatment sessions, along with staff reassurance, was associated with notable improvement in her symptoms. The authors propose that this nonpharmacologic approach may help manage dissociation-related anxiety and confusion after esketamine administration.

Abstract

Patients with treatment-resistant depression (TRD) treated with esketamine nasal spray commonly experience transient symptoms of dissociation. Manifestations of dissociation, such as feelings of detachment from the environment, can cause considerable anxiety for patients. Nonpharmacologic interventions may help clinicians to manage associated anxiety and confusion due to dissociation following administration of esketamine nasal spray. We present the case of a 64-year-old woman with major depressive disorder who participated in a clinical trial evaluating the efficacy and safety of esketamine nasal spray in conjunction with an oral antidepressant for TRD. The patient received flexible doses of esketamine nasal spray (56 or 84 mg) twice weekly for 4 weeks. On treatment day 1, the patient was administered 56 mg of esketamine nasal spray using two nasal spray devices (28 mg per device). Twenty minutes after the first esketamine nasal spray device was administered, the patient experienced a dissociative episode lasting 40 minutes that caused anxiety and confusion. The patient was encouraged to listen to music during treatment sessions, which resulted in notable improvement of her symptoms. Listening to music of choice immediately following esketamine nasal spray administration along with reassurance from staff may help manage confusion and anxiety associated with dissociation.

Comparable studies

Other case reports and case series on esketamine, most cited first.

Study Year Design Participants
Electroconvulsive Therapy, Ketamine, and Esketamine in a Patient with Major Depressive Disorder and Multiple Comorbidities: A Case Report over 10-year Treatment from Adolescence to Adulthood. A patient with treatment-resistant depression and comorbid generalized anxiety... 2025 Case report n = 1
Oral Administration of the NMDA Receptor Antagonist S-Ketamine as Add-On Therapy of Depression: A Case Series Four depressed patients taking standard antidepressants 2009 Case series n = 4
Effects of intranasal (S)-ketamine on Veterans with co-morbid treatment-resistant depression and PTSD: A retrospective case series Veterans with co-morbid depression and PTSD 2022 Retrospective case series n = 35
Case report: Intramuscular ketamine or intranasal esketamine as a treatment in four patients with major depressive disorder and comorbid anorexia nervosa Patients with anorexia nervosa and a comorbid depressive disorder treated at a private... 2023 Case report n = 4
Repeated oral esketamine in patients with treatment resistant depression and comorbid posttraumatic stress disorder Patients with treatment-resistant depression and comorbid PTSD 2023 Case series n = 5

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Esketamine Anxiety Depression