Explaining esketamine for TRD and safety rules (CASC)

Station instructions (candidate)

You have 7 minutes. Explain why esketamine is being considered after multiple adequate antidepressant failures, how supervised clinic dosing works (not take-home), what happens in the observation period, common short-term effects (dissociation, nausea, blood-pressure rise), and how this differs from recreational ketamine harm. Compare with ECT using ELEKT-D-level honesty for nonpsychotic TRD without declaring ECT obsolete. Do not guarantee cure. Do not minimise addiction/diversion concerns — explain clinic controls.[1][2][3][4][5]

Marking domains

Empathy and agenda setting; accurate plain-language TRD rationale; clear supervised-dosing rules; BP/observation explanation; balanced AE and misuse discussion; realistic timeline (induction then possible maintenance); ECT comparison without false dichotomy; collaborative plan and written information/crisis contacts.[1][2][3][4][5]

Model communication map

1. Open: thank them; check understanding of why previous antidepressants failed; name shared goals (mood lift, function, safety).[5]
2. Why now: several proper medicine trials have not controlled depression; guidelines and trials support considering rapid-acting options such as esketamine in treatment-resistant depression, given with another oral antidepressant under supervision.[1][5]
3. How it is given: in clinic only; typical adult doses are fixed device strengths (for example 56 or 84 mg); she stays for observation (about two hours) with blood-pressure checks; she should not drive until the next day after a treatment day.[1][5]
4. What she may feel: floating/dream-like feelings, dizziness or nausea can happen and usually settle; we monitor and support through the session.[3]
5. Misuse fears: recreational high-dose ketamine is different from supervised medical dosing; we do not send the regulated spray home; bladder problems are mainly linked to chronic heavy non-medical use — still we take symptoms seriously.[3][5]
6. Staying well: if she responds, continuing treatment for a period can reduce relapse risk compared with stopping early — maintenance is part of the plan, not one miracle dose.[2]
7. ECT: for nonpsychotic treatment-resistant depression, research comparing IV ketamine with ECT found ketamine was not worse on the main outcome in that trial; ECT remains very important, especially for psychotic depression or when ketamine is unsuitable — we decide together.[4]
8. Close: questions, written info, crisis contacts, first booking, partner role in escort if needed.[5]

Common fails

• Offering take-home nasal spray "to save clinic time."[1][5]
• Guaranteeing permanent cure or zero addiction risk.[3][5]
• Terrifying them with bladder injury without distinguishing recreational misuse from supervised care.[3]
• Saying ECT is never needed after ELEKT-D.[4]
• Ignoring ongoing suicide safety planning if ideation has been present.[5]