Intranasal esketamine, recently approved for resistant depression, costs around $600 per dose, whereas plain injected ketamine costs less than $20 per dose. Research indicates that intranasal esketamine is less effective and has more unwanted effects than injected ketamine. The approval means this intranasal formulation will now be the form used and researched. While the approval of an inferior treatment mode is understandable given medicine approval processes, careful thought is needed before embracing this particular form of a promising treatment.
A young woman with a history of substance-induced hallucinatory symptoms and occipital lobe epilepsy experienced a resurgence of visual pseudo-hallucinations. She saw several emergency and specialist doctors and received stigmatising diagnoses, which led to anxiety and depressive symptoms. Her symptoms were finally recognised as hallucinogen persisting perceptual disorder (HPPD), and she was treated appropriately with lamotrigine. The case illustrates that the chronology and phenomenological nature of hallucinatory symptoms can provide clues towards alternative diagnoses beyond primary psychotic and affective disorders. Delayed or misdiagnosis of HPPD prolongs functional impairment and social decline and predisposes patients to anxiety, depression, and increased risk of suicide.