Spravato (esketamine) Nasal Spray Treatment Sessions for Depression (Adults)

Spravato is a fast-acting, localized, and effective treatment for severe cases of depression which is understood to swiftly produce positive effects in brain function and mood while minimizing the risk of side effects commonly encountered in other treatments for depression. Many people benefit from medical treatment for depression without issue but for some people these medications aren’t without their adverse effects. For these non-responders, the traditional modalities take too long to build up, upset their stomach, interfere with normal sexual function, or just don’t work at all. For this patient population, Spravato may be a viable option.

Spravato is determined by the FDA as safe for consideration in all patients meeting the eligibility criteria as outlined above. Patients with history of liver disease, heart disease, psychosis, suicidality, substance abuse, hypertension or are at risk of hypertension due to other medications as well as patients who are pregnant, may become pregnant, or are currently breastfeeding are all encouraged to disclose their history on consult to determine if Spravato is an appropriate treatment strategy for them. These are not considered hard contraindications by most facilities but we feel, based on our understanding of the literature, that they require a greater degree of scrutiny by a medical professional prior to treatment. Our providers prioritize the health and safety of our patients above all else and are dedicated to finding the safest and most effective treatment options for our patients.

Depression is characterized by a loss of normal brain function. This loss of function may be due to excess inhibitory chemicals in the brain. Spravato is in a class of drugs known as NMDA receptor antagonists, which can help counteract this condition. By antagonizing the function of NMDA receptors in the brain, the neuro-chemical environment therein is altered such that the impact of these inhibitory chemicals greatly limited, allowing for an increase in brain activity and function overall. Because it is a nasal spray, the medication is able to bypass the gastrointestinal system, delivering a quick and targeted effect directly on the brain.

Out of pocket, the medication itself will cost around $800 per dose and observation costs $100 per hour, although commercial insurance could bring the costs down to a $10 copay. In addition, there is the “spravato with me” (SWM) and spravato savings programs, which may cut down the cost significantly. Most people are recommended to receive between 21-30 sessions, although effects are generally seen within the first 2 weeks and patients are free to stop at any time. After the session, a claim is filed with insurance in exchange for an EOB. The patient will then submit the EOB to SWM for a rebate check.

We are currently only offering this service to our pre-established patients, although interested outside parties may call our office to request wait-listing. Eligibility for Spravato treatment sessions at our clinic is determined on a case-by-case basis upon completion of an emailed screening form and an initial consult appointment. We accept scheduling for consultation in all of our patients with a documented history of depression that hasn’t sufficiently responded to 3 or more medical therapies in the past at the maximum tolerated doses and do not have a history of aneurysm, arteriovenous malformation, intracranial bleeding, or allergy to esketamine, ketamine, or any of the other ingredients in Spravato.

You should know that you’ll need a ride home after the treatment session and that spravato will not replace your normal treatment for depression, although it may allow us to reduce the dose considerably if you are experiencing side effects. Patients may not be receiving Spravato treatments elsewhere while enrolled with CCBH and must disclose any history of prior attempts to receive treatment here or elsewhere. It is recommended to separate eating or taking nasal decongestants or steroids 2 hours from treatment.

The most common side effects people report with spravato are dissociation and sedation. Contrary to popular belief, dissociation is not necessary for the improvement of depressive symptoms with spravato treatments and is not universally observed, although it is common and predictable enough to bear mentioning here.

Due to regulations around its administration as well as the structure of spravato allowing for a smaller dose than its traditional counterpart in Ketamine, in combination with the absence of significant activity on certain receptors commonly associated with addiction such as the mu opioid receptor, Spravato is considered to have little to no potential for physiological addiction.

After approval, enrollment, transport arrangement, and reception of medication, the treatment sessions take place in a private space while under close monitoring by a trained staff member. Patients are encouraged to bring things to assist with their comfort such as books, blankets, or tablets, but entertainment options and recliner seating is provided on site as well. Vitals are documented at baseline read before administration, followed up after 40 minutes, and again on discharge at the 2 hour mark. An on-site provider is available at all times for guidance of management as needed.

Sessions are scheduled twice a week for the first four weeks and are adjusted to once a week to biweekly thereafter. Most experts recommend a treatment timeline of 6 months which could be between 21 to 30 sessions, although this is subject to individual treatment responses.