Clinical guidance on the use of esketamine nasal spray for patients with treatment resistant depression: A European Delphi consensus report.

Authors

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

Published in

European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology. Volume 113. Pages 112907. Jul 17, 2026. Epub Jul 17, 2026.

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.

PMID:
42468081
Bibliographic data and abstract were imported from PubMed on 18 Jul 2026.

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