# Personalizing esketamine treatment in TRD and TRBD: the role of mentalization, cognitive rigidity, psychache, and suicidality

## TL;DR

Esketamine helps treat-resistant depression by improving mental processes like emotional awareness and reducing suicidal thoughts, with most patients showing significant improvement over six months.

## Contribution

The study identifies psychological factors that predict response to esketamine, supporting a personalized treatment approach for TRD and TRBD.

## Key findings

- 69% of patients achieved remission after six months of esketamine treatment.
- Esketamine significantly improved mentalization, psychache, social cognition, and cognitive rigidity.
- Reduction in depressive symptoms was confirmed by decreased MADRS scores over time.

## Abstract

Treatment-Resistant Depression (TRD) remains a major challenge in the management of Major Depressive Disorder (MDD). Esketamine, the S-enantiomer of ketamine and a glutamatergic modulator, was approved by the FDA and EMA for TRD in 2019. Beyond its rapid antidepressant effects, esketamine may enhance neuroplasticity, facilitating the reconnection with emotional and cognitive processes, improving mentalization and social cognition, and promoting resilience.

This prospective multicenter observational study aimed to evaluate esketamine’s therapeutic impact on both depressive symptoms and key psychological factors—including mentalization, psychache, social cognition, suicidality, and cognitive-emotional rigidity—that could predict treatment response and enable a more personalized approach to TRD and TRBD management.

Thirty-six treatment-resistant depressive episode patients, including TRD and TRB, treated with esketamine were assessed over a six-month follow-up period using psychometric measures of depression severity, suicidality, mentalization, social cognition, psychache, and cognitive-emotional rigidity.

A significant improvement in depressive symptoms was observed, as indicated by a reduction in Montgomery-Åsberg Depression Rating Scale (MADRS) scores over time. Moreover, improvement was observed in different key psychological domains, such as mentalization, psychache, social cognition, suicidality, and cognitive-emotional rigidity. By six months, 69% of patients achieved remission, confirming a robust and sustained therapeutic response.

These findings highlight the importance of a personalized treatment approach in treatment- resistant depressive episode patients. Esketamine may be particularly beneficial in reducing cognitive rigidity, improving mentalization, and breaking the cognitive inflexibility that contributes to sustained negative depressive thinking patterns. Further research is needed to refine patient stratification and optimize treatment strategies for individuals with treatment-resistant depressive episode patients.