Clinical Edge

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Esketamine nasal spray effective in patients with MDD who have active suicide ideation

Key clinical point: Patients with MDD who had active suicide ideation with intent who used esketamine nasal spray (84mg) over 4 weeks had a rapid and robust reduction in depressive symptoms.

Major finding: Greater improvement in Montegomery-Asberg Depression Rating Scale (MADRS) total score was observed with esketamine (mean [SD]: –15.7 [11.56]) over placebo (-12.4 [10.43]).

Study details: This randomized, double-blind study involved 230 patients

Disclosures: Dr. Hough is a former employee of Janssen Research & Development, LLC.


“This paper by Ionescu et al. was a pivotal regulatory trial that showed that the use of esketamine nasal spray for depressives with active suicidal ideation may rapidly lower this dire target symptom that many patients present with and often entails a detailed risk assessment and sometimes inpatient psychiatric hospitalization. It will be interesting to see if this approach can be further investigated to see if patients may be treated in an ambulatory or ER setting to avoid an inpatient stay. It may be possible to lower acute suicide risk enough with an intervention to allow a patient to remain in their outpatient setting with a team that often knows them the best and allows for greater continuity of care. This glutamatergic antidepressant now joins lithium and clozapine for bipolar disorder and schizophrenia respectively which also garner regulatory ability to state they lower a specific symptom (suicidality) that is associated with a categorical DSM psychiatric disorder.”

Thomas L. Schwartz, MD

Senior Associate Dean of Education, Interim Chair/Professor of Psychiatry

SUNY Upstate Medical University


Ionescu, D F. et al. International Journal of Neuropsychopharmacology. 29 Aug 2020.