Spravato (esketamine nasal spray) is taken twice a week for the first four weeks, then the frequency gradually decreases. After that initial stretch, sessions drop to once a week for four weeks, then to once every one or two weeks during long-term maintenance. Every session happens at a certified healthcare setting, not at home.
The Induction Phase: Weeks 1 Through 4
Treatment starts with twice-weekly sessions for four weeks, totaling eight visits. Most people begin at the 56 mg dose, which involves two nasal spray devices used five minutes apart. If the response isn’t sufficient and side effects are manageable, your provider may increase the dose to 84 mg (three devices) during this phase. This intensive schedule is designed to build up the medication’s effect quickly. Some patients notice changes in mood or emotional heaviness within 24 to 72 hours of their first session, a dramatically faster timeline than traditional antidepressants, which typically need several weeks.
Transition Phase: Weeks 5 Through 8
After the first month, sessions drop to once a week for the next four weeks. Your provider will use this period to evaluate how well you’re responding. The dose stays at either 56 mg or 84 mg based on what was working during the induction phase. This step-down is intentional: it tests whether less frequent dosing can sustain the improvement you gained in the first four weeks.
Maintenance Phase: Week 9 and Beyond
Starting at week nine, sessions typically move to once every one or two weeks. Most patients in long-term clinical trials ended up on the every-two-weeks schedule. Your provider will likely try to stretch the interval between sessions as far as possible while monitoring your depression scores with standardized questionnaires and checking whether your daily functioning is holding steady.
There’s no fixed end date. Long-term trials have followed patients on maintenance dosing for one to three years. Because Spravato is generally prescribed for treatment-resistant depression, meaning other medications haven’t worked well enough, many patients need ongoing sessions to maintain their improvement. At each visit, the goal is to confirm the medication is still providing meaningful, sustained relief rather than just temporary mood shifts during the session itself.
What Happens at Each Session
You can’t pick up Spravato at a pharmacy and use it at home. It’s only available through a federal safety program called REMS, which requires you to enroll before your first dose. At every visit, you self-administer the nasal spray under a provider’s supervision, then stay for at least two hours of monitoring. During that window, the clinical team checks your blood pressure and watches for sedation and dissociation, the two most common side effects. You’re assessed before you leave, and you’ll need someone to drive you home afterward. Plan for each appointment to take roughly two and a half to three hours total.
Spravato Is Always Paired With an Oral Antidepressant
Spravato isn’t a standalone treatment. It’s prescribed alongside a daily oral antidepressant, which you take at home as usual. The nasal spray works through a different brain pathway than conventional antidepressants, which is why it can produce faster symptom relief, but the two medications are meant to complement each other. Stopping your oral antidepressant without your provider’s guidance could undermine the results you’re getting from the combined approach.
How the Dose Is Structured
Each nasal spray device delivers 28 mg of esketamine. A 56 mg session uses two devices, and an 84 mg session uses three. You spray once into each nostril per device, rest for five minutes, then move on to the next device. The entire self-administration process takes about 10 to 15 minutes before the monitoring period begins.
If You Miss a Session
The FDA labeling doesn’t outline a specific make-up protocol for missed doses, so handling a skipped appointment is something to work out directly with your provider. Missing sessions during the induction phase is more likely to affect your trajectory than missing one during maintenance, simply because those early twice-weekly visits are building the initial treatment response. If scheduling conflicts come up, let your clinic know as soon as possible so they can help you stay as close to the recommended timeline as your situation allows.