FDA-approved nasal spray · Accepting new patients
Spravato Treatment for Treatment-Resistant Depression
Spravato treatment uses esketamine, an FDA-approved nasal spray, for adults with depression that has not improved after at least two antidepressants. You spray it yourself in a certified clinic while a clinician watches, then stay at least two hours for monitoring. Most people start with two sessions a week for four weeks, then taper to weekly or every other week.
If two antidepressants have already failed you, that is not a sign you are out of options. It is the clinical definition of treatment-resistant depression, and it is the point at which Spravato is worth discussing with a psychiatrist.
What Spravato is
Spravato is the brand name for esketamine nasal spray. Ketamine is made of two mirror-image forms of the same molecule, and esketamine is one of them, purified and given at a measured dose. Each device holds 28 mg and delivers two sprays, one per nostril.
Because it went through full FDA trials for depression, Spravato is approved where most ketamine use for depression is still off label. It is a Schedule III controlled substance available only through a federal safety program called REMS, so it is given only in certified clinics and never picked up at a pharmacy or taken home.
- 2019 FDA approves Spravato for treatment-resistant depression, taken with an oral antidepressant
- 2020 Approval extended to depressive symptoms in major depression with active suicidal thoughts or behavior
- 2025 Approved on its own for treatment-resistant depression, no oral antidepressant required
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Nasal, not a pill
A metered spray you use yourself while a clinician watches
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A different target
Acts on the glutamate system rather than serotonin
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Fast for some
In trials, improvement over placebo appeared as early as 24 hours
Who Spravato treatment is for
Approved for adults 18 and older with
- Treatment-resistant depression, meaning major depression that has not responded well enough to at least two antidepressants given at a proper dose for long enough. Spravato can be used on its own or with an oral antidepressant.
- Depressive symptoms in major depression with active suicidal thoughts or behavior, used together with an oral antidepressant.
Who should not take it
- Anyone with an aneurysm or an arteriovenous malformation in the brain, chest, abdomen or limbs
- Anyone who has had bleeding in the brain
- Anyone allergic to esketamine or ketamine
It also needs extra care, and sometimes a different plan, for people with high blood pressure, heart or blood vessel disease, pregnancy or breastfeeding, liver problems, or a history of substance misuse. It is not approved for anyone under 18. Not sure where you stand? Read how to tell if you have treatment-resistant depression.
How Spravato works
Conventional antidepressants
Act on serotonin, norepinephrine or dopamine. They usually need four to six weeks at a full dose before anyone can judge whether they help.
Esketamine
Acts on glutamate, the brain's main excitatory messenger, by blocking NMDA receptors. Researchers think the effects that follow help restore connections between nerve cells in the regions that regulate mood. The FDA label states plainly that the exact way it relieves depression is not known.
For a side by side look, see Spravato vs traditional antidepressants.
What happens during a Spravato treatment session
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Before you arrive
Skip food for 2 hours and liquids for 30 minutes beforehand, since some people feel nauseated. Arrange a ride home.
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Check in
A clinician checks your blood pressure and asks how the past few days have gone.
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Self-administer
You use each nasal spray device yourself while the clinician watches. A 56 mg dose uses two devices and an 84 mg dose uses three, with five minutes between devices.
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Two hours of monitoring
You stay at least two hours. Blood pressure is checked again at about 40 minutes and until you are stable. This is a federal REMS requirement.
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Ride home
You cannot drive or operate machinery until the next day, after a night's sleep. Plan on about two and a half hours in total.
For why the monitoring rule exists, see how the Spravato REMS program works.
What Spravato feels like, and side effects to know
Most people feel some dissociation during monitoring, often described as floating, dreamlike or detached from the room. It usually peaks early in the session and fades before you leave. Many people find the first session unsettling and later sessions easier.
- Dissociation
- Dizziness or vertigo
- Nausea, sometimes vomiting
- Sleepiness
- A short-term rise in blood pressure
- Temporary numbness
Nearly all of these happen during or right after the session, which is why every dose is followed by two hours of monitoring. See our full guide to Spravato side effects.
The Spravato treatment schedule
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Getting started
Weeks 1 to 4
Two sessions a week at 56 mg or 84 mg, set by your prescriber.
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Building progress
Weeks 5 to 8
One session a week at 56 mg or 84 mg.
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Ongoing care
Week 9 onward
One session a week or every two weeks, at the least frequent schedule that keeps symptoms under control.
For major depression with active suicidal thoughts, the usual course is 84 mg twice a week for four weeks, together with an oral antidepressant. Your prescriber reviews progress at the end of week 4, and if there is no clear benefit by then, the plan changes rather than simply continuing.
The first four weeks are the demanding part, eight visits in a month, each taking most of a morning or afternoon. People who plan for it do far better than people caught off guard by it. For a week by week picture, see how long Spravato takes to work.
Spravato alone or with an antidepressant
On its own
Since January 2025, Spravato can be used on its own for treatment-resistant depression, so side effects from oral antidepressants no longer rule you out.
With an antidepressant
For major depression with active suicidal thoughts it is still used with an oral antidepressant, and many people with treatment-resistant depression do better on both. The choice depends on your history and how you have responded before.
What the research shows
- 22.5% in remission at week 4
- 7.6% in remission on placebo
From the trial behind the 2025 approval of Spravato on its own for treatment-resistant depression. Remission meant a depression rating score (MADRS) of 12 or lower. The same trial showed improvement over placebo as early as 24 hours.
For response and remission rates across studies and real-world data, see the Spravato success rate guide.
How Spravato compares with ketamine infusions and TMS
| Feature | Spravato (esketamine) | IV ketamine infusion | TMS therapy |
|---|---|---|---|
| What it is | Nasal spray of esketamine | Intravenous drip of ketamine | Magnetic pulses to the brain |
| FDA status | Approved for treatment-resistant depression and for major depression with suicidal thoughts | Not FDA approved for depression, used off label | Devices FDA cleared for depression, and Deep TMS for OCD |
| How it is given | You self-administer in a certified clinic under supervision | Infusion in a clinic, about 40 to 60 minutes | Coil placed on the head, about 20 to 30 minutes |
| Insurance | Covered by most plans with prior authorization | Rarely covered, usually self-pay | Covered by most plans with prior authorization |
| Speed of effect | Hours to days for some people | Hours to days for some people | Usually two to three weeks |
| Schedule | Twice a week, then weekly, then weekly or every two weeks | About six infusions over two to three weeks, then boosters | Five days a week for four to six weeks |
| Monitoring | At least two hours after each dose | Monitored during the infusion | None, you can drive yourself home |
Because Spravato is FDA approved, most insurers cover it where they will not cover ketamine infusions. Which one fits is a consultation conversation, not a website decision. Compare them in more depth in TMS vs Spravato and Spravato vs IV and IM ketamine.
Insurance, cost and getting prescribed
Most commercial plans cover Spravato for treatment-resistant depression, and Medicare Part B generally covers it when it is given in a certified clinic. Many Medicaid plans cover it too, but the rules vary by state and plan.
Coverage almost always needs prior authorization. Insurers usually want records showing at least two antidepressants tried at a proper dose for long enough, a confirmed diagnosis of major depression, and treatment at a REMS-certified clinic. If a request is denied, it can be appealed, usually with more detailed treatment records.
Johnson and Johnson runs a savings program that can lower copays for people with commercial insurance. It does not apply to Medicare or Medicaid.
For dollar figures, see how much Spravato costs with and without insurance. For plan by plan detail, see our insurance coverage guide.
What to avoid during Spravato treatment
- Driving or operating machinery until the next day, after a night's sleep
- Food for 2 hours and liquids for 30 minutes before each session
- Alcohol and other sedating substances on treatment days, since they add to drowsiness
- Starting new medicines without telling your prescriber, especially stimulants or others that can raise blood pressure
- If you need a nasal decongestant or steroid spray on a treatment day, use it at least an hour before your dose
Getting Spravato at Bright Horizons Psychiatry
Bright Horizons Psychiatry is a REMS-certified Spravato provider with two offices, in Rockville and Frederick, Maryland. Each office has its own page with directions, insurance details and booking.
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Rockville
Spravato at our Rockville office -
Frederick
Spravato at our Frederick office
Both offices are led by Dr. Amir Etesam, a Johns Hopkins-affiliated psychiatrist, with psychiatric nurse practitioners trained in Spravato administration. We submit the prior authorization, follow up with your insurer, and tell you your out-of-pocket cost before you start. We accept Medicare and Maryland Medicaid along with most commercial plans. 4.8 stars across more than 216 reviews.
We treat adults. Spravato at our offices is not the right path if you have bipolar disorder (bipolar I or II), a psychotic disorder, a substance use disorder or a personality disorder, and we will point you to the right program instead.
Common questions
Is Spravato the same as ketamine?
Not exactly. Ketamine is a mix of two mirror-image forms of one molecule. Spravato contains only one of them, esketamine, given as a nasal spray at a fixed dose, and it is FDA approved for depression. IV and IM ketamine use the full mixture and are prescribed off label for depression.
How long before Spravato works?
In the trial behind the 2025 approval, improvement over placebo showed up as early as 24 hours. Most people need two to four weeks for a clear change, and prescribers review the benefit at the end of week 4.
Can I take Spravato at home?
No. Federal REMS rules require every dose to be taken in a certified clinic, followed by at least two hours of monitoring.
How hard is it to get prescribed Spravato?
It takes a psychiatric evaluation, a record of at least two antidepressants that did not work well enough, and usually prior authorization from your insurer. A REMS-certified clinic handles most of that paperwork for you.
Why won't insurance cover Spravato?
The usual reasons are that prior authorization has not been approved yet, the records do not show two adequate antidepressant trials, or the clinic is not REMS-certified or in network. A denial can be appealed with fuller records.
How long do people stay on Spravato?
There is no fixed endpoint. Some people taper off after several months, and others continue a weekly or every other week schedule long term. Your prescriber reviews it with you as you go.
Do I need to stop my current antidepressant?
No. For treatment-resistant depression, Spravato is approved both on its own and alongside an oral antidepressant. Your prescriber decides with you which makes sense.
How do I find a certified Spravato treatment center?
Only REMS-certified clinics can give Spravato. Johnson and Johnson runs an online locator of certified centers, and our own offices are listed under Getting Spravato at Bright Horizons Psychiatry on this page.