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

 A 50 yo woman with recurrent depression requested to be seen.

Patient expressed frustration and 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 lack of effectiveness. Patient had some knowledge of this medication with her background in pharmacology. 

We explained to her in detail through picutres 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 upon exam.  BP was stabilized by her family physician. 

Treatment was started as 2 x per week in the 1st month. After 4 treatments we didnt see any improvment ( ideally some improvement is usually noticed after 1st 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 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 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. Patient was so pleased that she requested maintenance treatment of Esketamine which is given once a month.