Case Report: Intranasal esketamine and accelerated intermittent theta-burst stimulation for severe treatment-resistant depression with suicidal ideation

A 29-year-old woman hospitalized for severe depression with high-risk suicidal ideation, who had not responded to multiple antidepressants, psychotherapy, and standard transcranial magnetic stimulation, received a combination of intranasal esketamine (84 mg) and an accelerated schedule of intermittent theta-burst stimulation (iTBS) over four days. Her depressive symptoms improved, with scores on the Patient Health Questionnaire-9 dropping from 15 to 11, the Hamilton Depression Rating Scale from 27 to 20, and the Beck Depression Inventory from 41 to 28. Suicidal ideation also improved, and gains were maintained at a two-week follow-up. The case suggests the combined treatment is feasible for inpatient settings, though controlled studies are needed.

Study at a glance

Abstract

Introduction Treatment-resistant major depressive disorder with high-risk suicidal ideation is a psychiatric emergency that requires rapid and effective intervention. Although intranasal esketamine and intermittent theta-burst stimulation (iTBS) are time-efficient therapeutic options, clinical reports describing their combined use in an accelerated inpatient schedule are limited, particularly in acutely high-risk patients. Methods A 29-year-old woman with recurrent major depressive disorder was hospitalized for severe depressive symptoms and high-risk suicidal ideation after inadequate responses to several antidepressant trials, augmentation therapy, psychotherapy, and a standard course of repetitive transcranial magnetic stimulation. Her baseline symptom severity scores were as follows: Patient Health Questionnaire-9 (PHQ-9), 15; Hamilton Depression Rating Scale (HAMD), 27; and Beck Depression Inventory (BDI), 41. After providing written informed consent, she received intranasal esketamine (84 mg) and an accelerated iTBS protocol targeting the left dorsolateral prefrontal cortex (Beam F3 localization), with 10 iTBS sessions delivered over 4 treatment days (total 6,000 pulses). Results The patient’s depressive symptoms improved during the acute treatment course (PHQ-9: 15→11; HAMD: 27→20; BDI: 41→28), and she reported an improvement in suicidal ideation. Her clinical status remained stable at the 2-week follow-up (PHQ-9 = 8; HAMD = 17; and BDI = 23). An exploratory device-derived stress index obtained using the Stress Electroencephalogram Assessment (SEA) system decreased from 7 to 3, consistent with clinical improvement. Conclusion This case suggests that the combination of intranasal esketamine and accelerated iTBS is feasible in inpatient settings for treating severe depression with high-risk suicidal ideation. Additional controlled studies are required to evaluate the efficacy, optimal sequencing, safety monitoring, and durability of this combined approach.