Esketamine Administration in Clinical Practice for Treatment Resistant Depression

In this episode, Dr Anita Clayton and panelists discuss introduction and administration of esketamine in clinical practice.

Dr Albright shared her firsthand experience introducing esketamine into a solo practice in 2019, driven by a conviction that patients deserved better than the status quo. Despite starting without industry support, she navigated REMS enrollment, pharmacy certification, and prior authorization processes — finding the protocol straightforward once established.

The two-hour in-office monitoring session was described in practical detail: baseline blood pressure must be under 140/90 given esketamine's transient hypertensive effect, with repeat vitals and pulse oximetry at 40 minutes and at discharge. Rating scales including the PHQ-9 and GAD-7 are completed during the session, providing a valuable opportunity to review suicidality — particularly important given the boxed warning for increased SI risk in adolescents and young adults. Mental status is formally assessed before discharge.

Contraindications are relatively few — arteriovenous malformation, aneurysmal vascular disease, and known hypersensitivity — though use in pregnancy or breastfeeding is not recommended due to insufficient safety data. Patients must arrange transportation, avoid driving until after a full night's rest, and refrain from operating heavy machinery. Post-session REMS documentation must be submitted within seven days. Overall, panelists characterized the administration process as manageable, safe, and ultimately highly rewarding for both clinician and patient.

In the next episode panelists share their concluding remarks about TRD.