Holding on or letting go? Patient experiences of control, context, and care in oral esketamine treatment for treatment-resistant depression: A qualitative study
This qualitative IPA study of 17 patients with treatment‑resistant depression found that the key determinant of esketamine session experience and subsequent outcomes was patients’ ability to “let go” of control during overwhelming psychoactive effects, which was strongly shaped by preparation, emotional/physical support, and the treatment setting. The authors recommend better pre‑session education, optimised settings and targeted training for nurses/support staff to facilitate surrender and improve quality of care.
Authors
- Robert Schoevers
- Jeanine Kamphuis
- Eric Vermetten
Published
Abstract
Background
Ketamine and its enantiomer esketamine represent promising new treatments for treatment-resistant depression (TRD). Esketamine induces acute, transient psychoactive effects. How patients perceive esketamine treatment, and which conditions facilitate optimal outcomes, remains poorly understood. Understanding patient perspectives on these phenomena is important to identify unmet needs, which can be used to improve (es)ketamine treatments.
Aims
To explore the perspectives of TRD patients participating in “off label” oral esketamine treatment.Materials and methodsIn-depth interviews were conducted with 17 patients (11 women) after a six-week, twice-weekly esketamine treatment program, and subsequently after six months of at-home use. Interviews explored participants’ perspectives, expectations, and experiences with esketamine treatment. Audio interviews were transcribed verbatim and analysed following an Interpretative Phenomenological Analysis (IPA) framework.
Results
Key themes included overwhelming experiences; inadequate preparation; letting go of control; mood states influencing session experiences; presence and emotional support, and supportive settings. Patients’ attempts to let go and give into vs. attempts to maintain control over occasionally overwhelming experiences was a central theme. Multiple factors influenced patients’ ability to give into the experience and appeared to impact their mood and anxiety about future sessions, including level of preparation and education, physical and emotional support, and setting during the session.
Conclusion
Better preparation beforehand, an optimized treatment setting, and emotional and psychological support during (es)ketamine sessions can help patients to “let go” and may lead to better quality of care and outcomes. Recommendations to improve quality of patient care in (es)ketamine treatment are provided, including suggestions for the training of nurses and other support staff.
Research Summary of 'Holding on or letting go? Patient experiences of control, context, and care in oral esketamine treatment for treatment-resistant depression: A qualitative study'
Introduction
Over the past two decades, intravenous ketamine and its S-enantiomer esketamine have emerged as rapidly acting antidepressant options for patients with major depression, particularly those with treatment-resistant depression (TRD). Alternative routes such as intranasal and oral administration have also shown promise, and intranasal esketamine is now a licensed option for TRD. These agents produce acute psychoactive effects—commonly described as dissociative or psychedelic-like—that include perceptual changes, altered body awareness, and experiences of detachment or unity. While the role of "set and setting" (preparation, expectation, psychological support, and the treatment environment) is well established in classic psychedelic therapies, its relevance to (es)ketamine treatments is poorly understood. Existing psychometric instruments for dissociation may not capture the phenomenology of drug-induced experiences, and there are no clear consensus guidelines on how to address non-pharmacological elements of (es)ketamine care. This study aimed to explore how patients undergoing an "off-label" oral esketamine programme for TRD experienced the treatment, which aspects of care facilitated or hindered those experiences, and how patients made sense of the acute psychoactive effects. Using an interpretative phenomenological approach, the researchers sought to identify unmet needs and practical factors that could improve the quality and safety of (es)ketamine treatment from the patient perspective.
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Study Details
- Study Typeindividual
- Journal
- Compounds
- Topics
- Authors
- APA Citation
Breeksema, J. J., Niemeijer, A., Kuin, B., Veraart, J., Kamphuis, J., Schimmel, N., van den Brink, W., Vermetten, E., & Schoevers, R. (2022). Holding on or letting go? Patient experiences of control, context, and care in oral esketamine treatment for treatment-resistant depression: A qualitative study. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.948115
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Mathai, D. S., Hilbert, S., Sepeda, N. D. et al. · Psychedelic Medicine (2023)
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