What Is Spravato® and Is It Right for Me? A Complete Guide

If you've been living with depression that hasn't responded to treatment, you've likely reached a point where hope starts to feel like a liability. You try a medication, wait weeks for it to work, feel partial improvement or nothing at all, adjust the dose, try another one — and somewhere in that cycle, the idea that things could actually get better starts to feel naive.

Spravato® exists for exactly this situation. It is not a miracle cure and it is not right for everyone. But for a specific population of people with depression that has not responded to standard treatments, it represents a genuinely different option — one that works through a different mechanism, produces effects on a different timeline, and has changed the clinical picture for people who had run out of conventional options.

This article explains everything you need to know about Spravato® — what it is, how it works, who qualifies, what treatment actually involves, and how to access it in New York.

What Spravato® Is

Spravato® is the brand name for esketamine, a derivative of ketamine, delivered as a nasal spray. It was approved by the FDA in 2019 — first for treatment-resistant depression (TRD), and subsequently for major depressive disorder with acute suicidal ideation or behavior (MDSI).

It is manufactured by Janssen Pharmaceuticals and is available only through certified treatment centers registered with the FDA's REMS (Risk Evaluation and Mitigation Strategy) program. It cannot be prescribed as a take-home medication. Every dose is administered in a clinical setting under direct supervision.

It is always used as part of a broader treatment plan — alongside an oral antidepressant — not as a standalone replacement for other psychiatric care.

How It Works: The Glutamate Difference

To understand why Spravato® matters, you need to understand why standard antidepressants don't work for everyone.

SSRIs and SNRIs — the most commonly prescribed antidepressants — work primarily on the serotonin and norepinephrine systems. They are effective for many people, but approximately 30% of individuals with major depressive disorder do not achieve remission with first or second-line antidepressants. For these individuals, the serotonin pathway is not the core problem — or not the only problem.

Esketamine works on the glutamate system, specifically as an NMDA receptor antagonist. Glutamate is the brain's primary excitatory neurotransmitter and plays a central role in synaptic plasticity — the brain's ability to form and strengthen connections. Depression is associated with reduced synaptic plasticity, particularly in areas of the brain involved in mood regulation, cognition, and stress response.

By blocking NMDA receptors, esketamine triggers a cascade of neurobiological events that rapidly increase synaptic plasticity — essentially helping the brain rebuild connections that depression has degraded. This is why some patients experience meaningful symptom relief within hours to days of their first session rather than the weeks required by serotonergic antidepressants.

This is not a subtle pharmacological distinction. It is a fundamentally different approach to treating depression at the neurobiological level.

Who Qualifies for Spravato® Treatment

Spravato® is not a first-line treatment and is not appropriate for everyone with depression. Qualification requires meeting specific clinical criteria:

For treatment-resistant depression (TRD):

• A diagnosis of major depressive disorder

• Inadequate response to at least two antidepressants, each at an adequate dose and for an adequate duration

• A comprehensive psychiatric evaluation confirming clinical appropriateness

For major depressive disorder with acute suicidal ideation or behavior (MDSI):

• Active or recent suicidal ideation with intent or behavior

• Evaluation confirming clinical appropriateness for this indication

Contraindications — Spravato® is NOT appropriate for individuals with:

• A history of psychosis or schizophrenia

• Active or unstable cardiovascular or cerebrovascular disease

• Certain aneurysmal vascular conditions

• Active substance use disorder (specific assessment required)

• Hypersensitivity to esketamine or ketamine

• Pregnancy

A thorough psychiatric evaluation screens for all of these factors before treatment begins. Candidacy is never determined by checklist alone — it requires clinical judgment from an experienced provider.

What Treatment Actually Looks Like

Many people who are interested in Spravato® have no idea what the treatment process involves day-to-day. Here is what to expect:

Before starting: You will have a comprehensive psychiatric evaluation to confirm diagnosis, review treatment history, assess candidacy, and obtain prior authorization from your insurance if applicable.

The treatment schedule: Spravato® follows a structured protocol:

• Induction phase (weeks 1–4): Two sessions per week

• Optimization phase (weeks 5–8): One session per week

• Maintenance phase (week 9 onward): One session every one to two weeks, based on individual response

Each session:

• You arrive at the clinic and are assessed — blood pressure, current symptoms, how you're feeling

• You self-administer the nasal spray under clinical supervision

• You remain in the office for a mandatory two-hour monitoring period

• Staff monitors for side effects including dissociation, dizziness, nausea, and blood pressure changes

• Before leaving, you are assessed for stability

• You cannot drive yourself home — you must arrange transportation in advance for every session

During the session: Many patients experience dissociative effects — a sense of detachment from surroundings, altered perception of time, unusual sensory experiences. These effects are temporary, typically peak within the first hour, and resolve before the monitoring period ends. They are not dangerous in a supervised clinical setting, but they are significant enough that unsupervised administration is not permitted.

What you may notice: Some patients experience meaningful symptom reduction after the first or second session. Others notice gradual improvement across the induction phase. A minority do not respond adequately and may need to explore other approaches. Response is not guaranteed, and managing expectations realistically is part of the clinical conversation before starting.

Insurance Coverage for Spravato® in New York

Spravato® is covered by most major insurance plans when clinical eligibility criteria are met. The prior authorization process can be involved and requires thorough clinical documentation. A practice with experience managing Spravato® cases will handle this process on your behalf, which matters — incomplete or poorly documented prior authorization requests are a common reason for denial.

Out-of-pocket costs without insurance are substantial. Janssen's patient assistance program (Spravato® Support) provides financial assistance for patients who qualify based on income and insurance status.

It is worth having a direct conversation with the clinical team before starting about what your specific coverage looks like and what to expect financially.

Common Questions About Spravato®

Is it the same as ketamine infusions? Esketamine and ketamine are related but not identical. Ketamine infusions are administered intravenously with ketamine and are not FDA-approved for depression — they are used off-label. Spravato® is FDA-approved, delivered nasally, and covered by insurance when criteria are met. The mechanisms overlap, but the regulatory status, administration route, and clinical protocols are different.

How long do results last? This varies significantly by individual. Maintenance sessions are designed to sustain improvement. Some patients do well on every-two-week maintenance indefinitely. Others find that they can eventually reduce frequency. Response durability is an active area of research.

Can I stop my other medications? No. Spravato® is used alongside an oral antidepressant, not instead of one. Decisions about your broader medication regimen are made collaboratively with your psychiatric provider.

Accessing Spravato® in New York

Spravato® must be administered at a certified treatment site. When choosing a provider in New York, confirm that the practice is REMS-certified, that a psychiatrist will conduct a full pre-treatment evaluation, and that ongoing psychiatric follow-up is integrated — not just the Spravato® sessions in isolation.

At Aurora Wellness, we are a certified Spravato® treatment site with locations in Brooklyn and White Plains. Every patient begins with a comprehensive psychiatric evaluation, and Spravato® treatment is integrated into a broader care plan that includes medication management and therapy as appropriate. We accept most insurances. Telehealth psychiatric care and therapy are available throughout New York State for ongoing support between in-person sessions. If you've been living with depression that hasn't responded to standard treatment, we'd welcome the conversation about whether Spravato® is the right next step for you.