A breakthrough study finds esketamine nasal spray may deliver meaningful improvement for treatment-resistant depression within hours. For decades, patients struggling with major depressive disorder (MDD) have had to wait weeks sometimes months for antidepressant medications to show effects. For roughly one in three people, even after trying multiple drugs, relief never comes. This group, known as treatment-resistant depression (TRD), faces limited and often frustrating options.Now, a new clinical trial suggests there may be another path, esketamine nasal spray. Researchers report that when used as a standalone treatment, esketamine provided rapid and sustained relief for adults with TRD. Unlike traditional antidepressants that take weeks to work, improvements appeared within 24 hours and lasted throughout the study’s four-week duration. The findings were published in JAMA Psychiatry.Ketamine, a compound first approved in the 1970s as an anesthetic, has drawn increasing attention for its antidepressant effects at lower doses. Esketamine, a chemically refined version, works on similar pathways but is more targeted.In 2019, the U.S. Food and Drug Administration approved SPRAVATO, an esketamine nasal spray, for use alongside oral antidepressants in TRD. Until now, it was unclear whether the spray could stand on its own. This new phase 4 trial offers the strongest evidence yet that esketamine may be effective without an added oral drug.The study enrolled 378 adults across 51 U.S. outpatient centers between 2020 and 2024. To qualify, participants had to show a history of poor response—defined as less than 25% improvement—to at least two antidepressants during their current depressive episode.Key features of the trial included:Design: randomized, double-blind, placebo-controlledGroups: fixed doses of either 56 mg or 84 mg esketamine, or a placebo sprayTreatment schedule: twice-weekly dosing for four weeksPrimary measure: changes in Montgomery-Åsberg Depression Rating Scale (MADRS) scores, which capture depression severityMost participants were women (61%), and the average age was 45. All entered the study with moderate-to-severe depression.How Esketamine Nasal Spray Works?Within a single day of treatment, both esketamine groups reported noticeable improvements compared to placebo. By day 28, those on 56 mg showed a 5.1-point greater reduction in symptom scores versus placebo.The 84 mg group had an even stronger effect, with a 6.8-point advantage. For perspective, traditional antidepressants often take six to eight weeks to yield measurable changes. Esketamine’s speed is one of the factors making it so promising for TRD patients, many of whom live with intense, persistent distress.Patients who continued into the optional 12-week open-label phase—where all participants received esketamine—maintained or further improved their scores. This suggests the drug’s benefits may extend beyond the initial four weeks.The “number needed to treat,” a measure of clinical significance, was around 6–7 for symptom response. This means that for every six or seven patients treated, at least one more experienced a meaningful reduction in depression compared to placebo. For a psychiatric intervention, that is a robust effect size.Are There Any Side Effects of the Nasal Spray?Like other ketamine-based therapies, esketamine is not without side effects. In this trial, the most common were nausea, dizziness, headache, and dissociation, a temporary feeling of detachment from one’s surroundings.Importantly, these effects were short-lived, generally resolving within hours of dosing. Safety monitoring also showed no increase in suicidal thinking compared to placebo, an encouraging finding in depression research. No treatment-related deaths were reported.Still, the psychoactive nature of the drug meant some participants could guess whether they had received esketamine or placebo, a limitation that researchers acknowledged.For the estimated 280 million people worldwide living with major depressive disorder, and especially the one-third who don’t respond to conventional drugs, esketamine represents a potential paradigm shift.Traditional antidepressants work by altering serotonin, norepinephrine, or dopamine. Esketamine instead targets the glutamate system, offering a novel mechanism of action. That difference matters- before SPRAVATO, psychiatry hadn’t seen a new treatment pathway in over 30 years.Adam Janik, medical director at Johnson & Johnson and lead author of the study, emphasized the scale of the problem: “The size and scope of the global depression epidemic is staggering. Significant unmet needs remain for these patients.”While the findings are promising, experts caution against premature conclusions. The trial population was not racially diverse, and individuals with certain psychiatric conditions were excluded. That raises questions about how well the results will apply across broader patient groups.For decades, patients with treatment-resistant depression have cycled through medications, therapies, and hospitalizations, often with little relief. This study adds weight to a growing body of evidence that esketamine could break that cycle. While it is not a cure, the possibility of meaningful relief within hours rather than weeks could be life-changing for millions.