Spravato is a prescription nasal spray used to treat two specific forms of depression: treatment-resistant depression in adults, and depressive symptoms in adults with major depressive disorder who have acute suicidal thoughts or behavior. It contains esketamine, a compound related to the anesthetic ketamine, and works differently from traditional antidepressants. The FDA approved it in 2019, and it remains the only nasal spray antidepressant of its kind.
Treatment-Resistant Depression
Spravato’s primary use is for adults whose depression hasn’t improved after trying at least two different antidepressants at adequate doses for six to eight weeks each. This condition, called treatment-resistant depression, affects a significant portion of people with major depressive disorder. For these patients, standard medications simply aren’t enough.
In clinical trials, 52.5% of patients taking Spravato alongside an oral antidepressant achieved remission by week four, compared to 31% of those on a placebo plus an oral antidepressant. Remission here meant their depression scores dropped to near-normal levels. In a long-term extension study, about half of patients maintained remission during ongoing treatment. The medication can be used on its own or combined with an oral antidepressant, though most treatment plans pair it with one.
Depression With Suicidal Thoughts
The second approved use targets adults experiencing major depressive disorder with active suicidal ideation or behavior. What sets Spravato apart in this situation is speed. Traditional antidepressants typically take weeks to start working, but in clinical trials, patients receiving Spravato showed meaningful improvement in depression scores within four hours of their first dose. Patients on Spravato saw their depression scores drop by about 13 points on average at the four-hour mark, compared to roughly 9 points for placebo.
One important caveat: while Spravato reduces depressive symptoms quickly, the FDA has not established that it prevents suicide or reduces suicidal behavior itself. It can ease the depressive episode, but it doesn’t replace hospitalization or crisis intervention when those are needed.
How Treatment Sessions Work
Spravato isn’t something you pick up at a pharmacy and take at home. Every dose is self-administered under medical supervision at a certified healthcare facility. You spray the medication into your nose yourself, but a healthcare provider watches the entire process and monitors you afterward.
After each dose, you’re required to stay at the clinic for at least two hours. Staff monitor your blood pressure, oxygen levels, and mental state during that window. You can’t drive for the rest of the day after a session, so you’ll need someone to take you home.
For treatment-resistant depression, the schedule follows a tapering pattern. During the first four weeks (the induction phase), sessions happen twice per week at a dose of 56 or 84 milligrams. From weeks five through eight, sessions drop to once per week. After week nine, most patients move to every other week, though some continue weekly. The goal is to find the least frequent schedule that keeps your symptoms under control. For patients being treated for depression with suicidal thoughts, the standard protocol is 84 milligrams twice per week for four weeks.
Common Side Effects
Dissociation is the most notable side effect and the one most patients ask about. It can feel like a distortion of time or space, a sense of detachment from your body or surroundings, or visual and sensory changes. In clinical trials, roughly 40% of patients experienced some form of dissociation, and between 61% and 84% showed measurable perceptual changes on clinical scales. These effects typically begin shortly after dosing, peak around 40 minutes, and resolve within about 90 minutes. They also tend to become less intense with repeated sessions.
Other common side effects include dizziness, nausea, sedation, and vertigo. Blood pressure increases are also typical. Your provider will check your blood pressure before and after each session, since the spike can be clinically significant for some people.
Who Cannot Use Spravato
Certain vascular conditions make Spravato unsafe. It’s contraindicated if you have an aneurysm anywhere in your body, including in the aorta, brain, or peripheral arteries. People with arteriovenous malformations (abnormal tangles of blood vessels) or a history of bleeding in the brain are also excluded. These restrictions exist because of the blood pressure increases the medication causes. Anyone with an allergy to esketamine or ketamine cannot use it either.
The Certification Program
Because of the risks of sedation, dissociation, and potential for misuse, Spravato is distributed through a restricted federal safety program. Both the clinic and the patient must be enrolled before treatment can begin. The clinic must be specifically certified, and staff must complete training on monitoring protocols. Before every single session, the facility verifies your enrollment and confirms you haven’t been given the medication to take elsewhere. The medication never leaves the clinic.
After each session, your provider submits a monitoring form documenting how you responded. This level of oversight is unusual for an antidepressant, but it reflects the medication’s unique pharmacology and side effect profile. For patients who qualify, the structured program creates a framework where a powerful but carefully managed treatment can be delivered safely.