How to Identify Candidates for Esketamine in Suicidal Major Depression
How do clinicians identify adults with major depressive disorder and active suicidal ideation with intent who fit the studied esketamine treatment setting?
Patients with major depressive disorder who have active suicidal ideation with intent present as psychiatric emergencies and need intervention within hours, not weeks. This guide applies to adults being evaluated shortly after presentation to an emergency department or inpatient psychiatric unit when clinicians are deciding whether the ASPIRE I esketamine pathway matches the patient's clinical profile.
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Confirm major depressive disorder without psychotic features
Verify that the patient has major depressive disorder without psychotic features according to DSM-5 criteria. In the study, diagnosis was confirmed with the Mini-International Neuropsychiatric Interview, so the guide applies to patients meeting that same diagnostic frame.
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Establish active suicidal ideation with recent intent
Assess for both suicidal thinking and intent to act in the past 24 hours. Eligibility required affirmative responses within 24 hours of randomization to MINI question B3 about thinking about suicide and B10 about intending to act on those thoughts.
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Determine need for acute psychiatric hospitalization
Use clinical assessment to determine whether the patient is at imminent suicide risk and in need of acute psychiatric hospitalization. The studied population was not an outpatient sample; all participants were in clinical need of hospitalization and entered treatment within that acute-care context.
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Confirm at least moderate to severe depressive symptom burden
Measure depressive severity with the Montgomery-Asberg Depression Rating Scale before dosing. Patients required a predose day 1 MADRS total score greater than 28, so this treatment framework is aligned with patients who are clearly above that threshold.
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Verify readiness for comprehensive standard-of-care
Confirm that the patient agrees to the full acute-care package used in the trial. This included initial hospitalization plus initiation or optimization of non-investigational oral antidepressant treatment for at least the duration of the 4-week double-blind phase.
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Screen for key exclusion factors from the studied population
Do not assume the trial findings apply unchanged if the patient has major excluded conditions. The study excluded patients with current bipolar disorder, obsessive-compulsive disorder, antisocial personality disorder, borderline personality disorder, current or prior psychotic disorder, moderate-to-severe substance or alcohol use disorder within 6 months, or positive urine testing for phencyclidine, cocaine, or amphetamines.
Clinical Considerations
- The study included only adults aged 18 to 64 years, so applicability outside that age range was not established here.
- The trial excluded major psychiatric comorbidities and recent moderate-to-severe substance or alcohol use disorder, which limits generalizability to more diagnostically complex patients.
- All patients were treated in the setting of hospitalization and newly initiated or optimized antidepressant therapy, so the findings do not describe esketamine as a standalone intervention.
- Patients had major depressive disorder without psychotic features, so this guide should not be extended to psychotic depression based on this article.
Bottom Line
Use this esketamine pathway only for adults closely matching the ASPIRE I population: major depressive disorder without psychotic features, MADRS greater than 28, suicidal ideation with intent in the past 24 hours, and clear need for acute psychiatric hospitalization plus full standard-of-care.
