Mode
Text Size
Log in / Sign up

Intranasal esketamine provides rapid acute improvement and reduced relapse risk in treatment-resistant depressionEsketamine shows rapid relief for treatment resistant depression

AI-generated summary of the cited source, checked by automated accuracy review. How we work

Key Takeaway
Consider intranasal esketamine for rapid acute improvement and reduced relapse risk in treatment-resistant depression.

This meta-analysis of randomized controlled trials evaluates the efficacy and safety of intranasal esketamine combined with an oral antidepressant for patients with treatment-resistant depression (TRD). The analysis included 1,836 participants across acute induction and maintenance phases.

Key findings indicate that esketamine leads to rapid symptom reduction. At day 2, MADRS scores showed a mean difference of -3.25 (95% CI -4.65 to -1.85). By day 28, the mean difference was -2.99 (95% CI -5.10 to -0.89). Response rates at day 28 were higher with esketamine (RR 1.44; 95% CI 1.20-1.74), and remission rates were also increased (RR 1.52; 95% CI 1.20-1.92). Functional outcomes improved significantly, with a mean difference of -1.70 in SDS scores.

During the maintenance phase, continued esketamine was associated with a reduced risk of relapse (HR 0.51; 95% CI 0.42-0.62). Safety data indicate that while maintenance safety was similar between groups, acute administration increased the rate of any treatment-related adverse events (RR 1.37), dissociation (RR 7.33), and blood pressure increases (RR 3.96). Discontinuation due to adverse events was higher in the acute phase (RR 2.68).

How this fits prior evidence

This meta-analysis extends findings from a previous meta-analysis that identified esketamine improves response in treatment-resistant depression with dose-dependent adverse events and a systematic review confirming substantial symptom reduction and remission likelihood in real-world settings. This study specifically quantifies the rapid acute improvement (MADR -3.25 at day 2) and provides specific hazard ratios for relapse prevention during maintenance.

Living with treatment-resistant depression can feel like a constant uphill battle. For many, standard medications simply do not provide the relief needed to manage daily life. New data from 1,836 participants suggests that adding an intranasal spray called esketamine to a daily oral antidepressant may change how patients experience their treatment.

The study found that people using esketamine saw faster improvements in symptoms as early as two days into treatment. By the fourth week, those on the nasal spray showed greater symptom reduction and higher rates of remission compared to those who only took an oral antidepressant with a placebo spray. The results also suggested that continuing the esketamine helped lower the risk of falling back into a depressive state during maintenance phases.

While the treatment offers faster relief, it does come with some immediate side effects. During the initial phase, patients using esketamine reported more instances of high blood pressure and feelings of dissociation. However, these issues were primarily seen in the early stages of treatment. Because every person reacts differently to medication, talk to your doctor about how this specific combination might fit into your personal care plan.

What this means for you:
Esketamine nasal spray can provide faster relief and lower relapse risk for those with treatment-resistant depression.

Common questions

How quickly does esketamine work for depression?

The study showed rapid improvement in symptoms as early as day 2 of treatment. By day 28, patients using the nasal spray showed greater symptom reduction and higher remission rates compared to those who only took an oral antidepressant with a placebo.

What are the side effects of esketamine?

During the initial phase, esketamine was associated with more instances of high blood pressure and feelings of dissociation. These issues were primarily reported during the acute treatment period rather than during the maintenance phase.

Can esketamine help prevent a relapse?

The study found that continuing esketamine during the maintenance phase reduced the risk of relapse for patients who had already stabilized. This suggests it may help keep symptoms away over time.

Study Details

Study typeMeta analysis
EvidenceLevel 1
PublishedJul 2026
View Original Abstract ↓
Treatment-resistant depression (TRD) remains a major clinical challenge. Intranasal esketamine, used adjunctively with an oral antidepressant, has been evaluated in randomized trials, but uncertainty persists regarding the magnitude and consistency of benefit, durability, and key harms. This systematic review and meta-analysis included randomized controlled trials comparing intranasal esketamine plus an oral antidepressant versus placebo nasal spray plus the same oral antidepressant in TRD. Acute induction (≈4 weeks) and maintenance randomized-withdrawal phases were analyzed separately. Depression outcomes were assessed primarily using the Montgomery–Åsberg Depression Rating Scale (MADRS), and functional outcomes using the Sheehan Disability Scale (SDS). Two reviewers independently screened studies, extracted data, and assessed risk of bias using RoB 2.0. Random-effects models pooled mean differences (MD) for continuous outcomes, risk ratios (RR) for binary outcomes, and hazard ratios (HR) for relapse prevention. Certainty of evidence was rated using GRADE. From 1,518 records, nine reports representing six unique RCTs (1,836 participants) were included. Four acute induction RCTs (n=937) showed greater symptom reduction at day 28 with esketamine (MADRS MD −2.99, 95% CI −5.10 to −0.89; I²=48.5%). Rapid improvement was evident by day 2 (MD −3.25, 95% CI −4.65 to −1.85). Esketamine increased day-28 response (RR 1.44, 95% CI 1.20–1.74) and remission (RR 1.52, 95% CI 1.20–1.92), corresponding to approximately +154 responders and +106 remitters per 1,000 patients, respectively, based on pooled control risks. Functioning improved (SDS MD −1.70, 95% CI −2.61 to −0.79). Two maintenance randomized-withdrawal RCTs (n=899) demonstrated reduced relapse risk with continued esketamine (HR 0.51, 95% CI 0.42–0.62; I²=0%). In acute induction, esketamine increased any treatment-emergent adverse event (TEAE) (RR 1.37, 95% CI 1.25–1.50) and discontinuation due to adverse events (RR 2.68, 95% CI 1.35–5.29), with notable increases in dissociation (RR 7.33, 95% CI 4.49–11.98) and blood pressure increased events (RR 3.96, 95% CI 2.24–7.01). Maintenance TEAE rates were similar between groups (RR 1.07, 95% CI 0.99–1.17). Intranasal esketamine plus an oral antidepressant provides rapid, modest acute improvement and reduces relapse risk during maintenance among stabilized responders/remitters, but increases acute adverse events, supporting use within supervised care and individualized benefit–risk assessment.
Free Newsletter

Clinical research that matters. Delivered to your inbox.

Join thousands of clinicians and researchers. No spam, unsubscribe anytime.