Esketamine for The Treatment of Complex PTSD and TreatmentResistant Depression: A Case Report

Abstract

Complex post-traumatic stress disorder (C-PTSD) frequently co-occurs with treatment-resistant depression (TRD), resulting in severe functional impairment, persistent suicidal ideation, and poor response to conventional treatments. We report the case of a 30-year-old woman with recurrent major depressive disorder, Complex PTSD, and borderline personality disorder, characterized by childhood neglect, sexual abuse, emotional dysregulation, recurrent self-harm, multiple psychiatric hospitalizations, and inadequate response to several pharmacological treatments. Because of persistent depressive symptoms and chronic suicidal ideation, intranasal esketamine was initiated at 56 mg for the first session and increased to 84 mg thereafter, alongside ongoing psychopharmacological treatment. Clinical outcomes were assessed using the MontgomeryÅsberg Depression Rating Scale (MADRS), Hamilton Anxiety Rating Scale (HAM-A), and Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) over a 12-month follow-up. Sustained clinical improvement was observed, with MADRS decreasing from 36 to 4, HAM-A from 38 to 7, and CAPS-5 from 55 to 15, accompanied by complete remission of suicidal ideation. Improvements also involved core trauma-related symptoms, including intrusive recollections, hyperarousal, emotional dysregulation, and avoidance behaviors. This case suggests that intranasal esketamine may represent a promising therapeutic option for patients with treatment-resistant depression and comorbid Complex PTSD, producing sustained benefits across depressive, anxiety, and trauma-related symptom domains. Although limited by the single-case design, these findings support further investigation of esketamine in complex trauma-related psychopathology.