Ketamine treatment for mental disorders is experienced as a three-stage journey. Before treatment, patients focus on expectations, hopes, and feelings about the drug. During treatment, the drug's complex psychotropic effects and how they are emotionally appraised become central. After treatment, attention shifts to whether clinically relevant effects occur. The meta-synthesis of 24 qualitative studies identified three main themes: the treatment as a staged journey with distinct clinical features at each stage; the multifaceted and complex nature of the acute subjective experience; and the range of positive effects alongside the reality that treatment may not work. This framework can guide further research and help clinicians understand patients' experiences.
A 28-year-old man with severe obsessive-compulsive disorder (OCD) and depression, who had not responded to cognitive-behavioural therapy, selective serotonin reuptake inhibitors, clomipramine, or antipsychotics, received off-label esketamine combined with psychotherapy. Over about 2 months he had 10 esketamine-plus-psychotherapy sessions, then two maintenance sessions, and later continued maintenance esketamine every 4-6 weeks with independent cognitive-behavioural therapy. His OCD symptoms improved markedly (Y-BOCS fell from >35 before treatment to 23 at week 8 and 14 at week 26), and depressive symptoms also decreased (MADRS fell from 47 before treatment to 12 at week 9 and 3 at week 26). At week 66, OCD symptoms remained mild (Y-BOCS 13) and depression was in remission (MADRS <6). This case suggests esketamine plus psychotherapy may be promising for difficult-to-treat OCD and depression.