Mental health professionals’ perspective on the use of esketamine in treatment-resistant depression and their motivation to adopt it: a Saudi cross-sectional study

Background: Esketamine is an innovative treatment for individuals with treatment-resistant depression (TRD). However, its adoption could depend on the perceptions and motivations of prescribing psychiatrists, among other factors. Objective: This study aims to explore the attitudes of psychiatrists (of all levels, including those in training) across Saudi Arabia toward the use of esketamine for TRD and investigate the motivational factors related to their willingness to adopt it. Methods: This is a cross-sectional study that utilized a convenience sampling method. The study tool consisted of a questionnaire developed by the research team and the Physician-Motivation Adoption Scale. Results: Of the 223 participants surveyed, 19.73% reported having prescribed esketamine, most commonly to 1-2 patients. The most frequently perceived adverse effects were dissociation/delusions/hallucinations (66.82%), followed by dizziness/vertigo (59.19%). Esketamine prescription was significantly associated with older age (p = 0.049), consultant-level practice (p = 0.003), practice in the Western Region (p < 0.001), lower concern about potential misuse (p = 0.027), perceiving easier access (p = 0.004), and fewer concerns about the administration process (p = 0.007). Ordinal logistic regression demonstrated that senior registrars, registrars, and residents were significantly less likely to prescribe esketamine than consultants (OR = 0.21, 0.17, and 0.10, respectively). "Not being sure" that cost was a barrier was associated with lower odds of prescribing (OR = 0.32, p = 0.022), whereas higher functional subscale scores were strongly associated with willingness to prescribe (OR = 1.62, p < 0.001). The most commonly reported barriers to prescribing esketamine included the administration process (66.37%) and cost (65.02%). Conclusion: Despite significant interest, actual adoption of esketamine is low, mainly due to logistical barriers, high costs, and availability issues. Concerns about side effects and potential misuse are also linked to hesitation. Accordingly, interventions to address the obstacles and concerns are needed.