| Description |
Background: Treatment-resistant depression (TRD) affects about 2.8 million Americans each year, with many patients not achieving remission after multiple antidepressant trials. Esketamine-assisted psychotherapy offers rapid and lasting symptom relief but remains underused in outpatient settings due to provider unfamiliarity, lack of confidence, and no standardized protocols, limiting patient access. Local Problem: At a suburban outpatient psychiatric clinic, providers had little experience with esketamine-assisted psychotherapy, significant concerns about adverse events, and no established clinic protocol. Insufficient training further reduced provider confidence and limited patient referrals. Methods: A quality improvement initiative used the Johns Hopkins Evidence-Based Practice model and Plan-Do-Study-Act cycles. Sixteen psychiatric providers at the clinic were assessed for baseline knowledge, confidence, and perceived barriers via survey. An evidence-based protocol and toolkit were developed through a literature review and stakeholder input, including eligibility criteria, safety guidelines, patient education, and psychotherapy integration resources. Providers received structured training and ongoing support over two months. Postintervention surveys and clinic data measured changes in knowledge, confidence, barriers, and referral patterns. Interventions: The intervention included developing and implementing a standardized protocol and toolkit for esketamine-assisted psychotherapy. The protocol covered patient screening, dosing, monitoring, and psychotherapy integration. Toolkit resources included quick-reference guides, patient handouts, and electronic health record templates. The training was delivered in four staff sessions with ongoing feedback and refinements to fit clinic workflows and ensure sustainability. Results: Thirteen providers completed the presurvey, and twelve completed the post-survey. Initially, none felt confident administering esketamine-assisted psychotherapy, and most cited a lack of protocol and training as significant barriers. After implementation, all reported improved knowledge, and 25% felt at least moderately confident. Referrals increased, and concerns about adverse events and liability were eliminated. However, the need for more training and concerns about patient costs remained. Esketamine was administered 35 times during the project, with concurrent psychotherapy in eight sessions, both increases from baseline. Conclusion: Developing and implementing a protocol and toolkit improved provider knowledge, confidence, and referral rates for esketamine-assisted psychotherapy in the outpatient clinic. Continued training and attention to barriers like cost and education are needed to sustain and expand access to this intervention for TRD. |
