Middle aged woman with depression, lost hope of getting better.

A 50-year-old woman with recurrent depression requested to be seen.

The patient expressed frustration and a loss of trust in the antidepressants due to their lack of efficacy and unacceptable side effects. She stated they made her stoic and felt like she was not her usual self. 

We offered Esketamine initially without any antidepressant. She was hesitant because of its potential for addiction or its lack of effectiveness. The patient had some knowledge of this medication from her background in pharmacology. 

We explained to her in detail, through pictures, how this drug actually works and answered all the questions. She felt better about it.  We were unable to start the treatment due to high blood pressure during the exam.  Her BP was stabilized by her family physician. 

Treatment was started twice per week in the first month. After 4 treatments, we didn't see any improvement (ideally, some improvement is usually noticed after the first treatment itself). We discussed and increased her dose to 84 mg per treatment visit. There was still just a mediocre response. 

We sat down with her and discussed our plan to add an oral antidepressant because esketamine (Spravato) is approved in combination with an antidepressant, so ideally it should be taken that way.  She was hesitant due to previous experience but agreed. 

We recommended Vortioxetine (Trintellix) due to its unique mechanism of action and better side-effect profile.  As we went into more treatment visits with esketamine, her symptoms progressively improved, and we had no adverse effects with the addition of Trintellix. 

At a follow-up call, the patient stated to me that what she is feeling now is a ''miracle''. She had never thought that this combination would help her so much. The patient was so pleased that she requested maintenance treatment with Esketamine which is given once a month.