Rapid reduction of suicidal ideation with transient dissociative and “drunken gait” symptoms after intranasal esketamine, with music intervention: a case report

Background: Treatment-resistant depression (TRD) is often accompanied by persistent suicidal ideation and poor response to conventional antidepressants. Intranasal esketamine, a non-selective NMDA receptor antagonist, provides rapid antidepressant and anti-suicidal effects; transient dissociation is common, whereas ataxia-like "drunken gait" is rarely described. Case presentation: A 19-year-old woman with recurrent depression and multiple prior suicide attempts received two courses of intranasal esketamine (56 and 84 mg, twice weekly for four weeks each). During the first course, she developed transient dissociative symptoms lasting approximately 55 minutes, predominantly characterized by depersonalization and accompanied by a "drunken gait. Under supervision, patient-selected music promptly reduced anxiety and disorientation, improving tolerability. From week 2, prophylactic oxazepam 25 mg prevented mild delayed dissociative episodes. The second course was uneventful. By the end of treatment, suicidal ideation had resolved. Discussion: This case illustrates rapid improvement of depressive symptoms and suicidality with esketamine and shows that dissociative reactions are typically self-limiting and manageable. Music intervention may attenuate these experiences by modulating prefrontal-amygdala circuits and autonomic regulation, thereby reducing anxiety and enhancing reality orientation. Individualized monitoring and psychological support are recommended components of esketamine services. Conclusion: Intranasal esketamine is a promising option for TRD with elevated suicide risk. Patient-selected music is a feasible adjunct to manage dissociative side effects and may improve safety and adherence. Further research should clarify mechanisms and long-term safety.