Dose Escalation: When Clinicians Push the Dose

Typical escalation pathway (IV)

1. Standard induction at 0.5 mg/kg.
2. If partial response at session 3-4: increase to 0.6-0.75 mg/kg.
3. If still partial: titrate up to 1.0 mg/kg over subsequent sessions.
4. If no response by 1.0 mg/kg: consider switching modality, adding KAP, or stopping.

Why higher isn't always better

• Cardiovascular load: Blood pressure and heart rate rise dose-dependently.
• Dissociation: Intensity scales fast; can become destabilizing.
• Nausea & vomiting: More common at higher doses.
• Tolerance: Frequent high-dose use may accelerate neuroadaptation.

When to consider modality change instead

If IV at 0.75 mg/kg isn't producing response, escalating further is less promising than: (a) adding therapy / KAP, (b) trying IM (which produces a different pharmacokinetic profile), or (c) switching to intranasal esketamine, which has its own FDA-approved dose range.

The de-escalation conversation

Once response is established, many clinicians taper dose downward during maintenance to find the minimum effective dose. This is good practice — ask whether your provider builds this in.