Spravato Treatment

Table of Contents

1. What Is Spravato?
2. How Spravato Works
3. FDA-Approved Indications
4. The REMS Program
5. Who Is a Candidate for Spravato?
6. What to Expect: Your Spravato Treatment Day
7. Spravato Side Effects & Safety
8. Spravato vs. Other Treatments
9. Insurance & Cost
10. How It Works at KwikPsych Austin
11. Frequently Asked Questions
12. References & Clinical Evidence

Key Takeaways

• Spravato is FDA-approved intranasal esketamine for treatment-resistant depression (TRD) and acute suicidal ideation/behavior with major depressive disorder
• Rapid symptom relief: Response possible within 2–4 hours of a single dose; acute phase involves twice-weekly administrations for 4 weeks
• REMS-controlled medication: Must be self-administered in a certified physician's office under supervision; 2-hour post-administration monitoring required
• Response rates: 25–65% in unipolar major depression; dissociation (most common adverse effect) occurs in 41% of patients vs. 9% placebo
• Mechanism advantage: S-enantiomer of ketamine has greater NMDA receptor affinity; maintains cognitive function long-term (unlike racemic ketamine)
• Insurance coverage: Aetna, BCBS, Cigna, UnitedHealthcare, Superior/Ambetter, Baylor Scott & White, Oscar, First Health, Optum, Medicare, and self-pay options available
• At KwikPsych: Board-certified psychiatrist Dr. Monika Thangada provides comprehensive psychiatric evaluation, REMS-certified Spravato administration, and integrated care planning

What Is Spravato?

Spravato is the brand name for esketamine, the S-enantiomer (active isomer) of ketamine. It is the first and only FDA-approved intranasal rapid-acting antidepressant medication. Approved in 2019 by the U.S. Food and Drug Administration, Spravato represents a breakthrough in psychiatric treatment for patients who have not responded to conventional antidepressants.

Unlike standard oral antidepressants—which typically take weeks to months to produce clinical benefit—Spravato can deliver measurable symptom relief within hours. This rapid onset makes it particularly valuable for patients experiencing acute suicidal crisis or those living with years of treatment-resistant depression (TRD) without adequate response.

Key Characteristics

• Route: Intranasal (self-administered nasal spray)
• Setting: Must be administered in a certified physician's office under direct supervision
• Mechanism: NMDA receptor antagonist with rapid glutamatergic effects
• Availability: Controlled under the FDA's REMS (Risk Evaluation and Mitigation Strategy) program
• Formulation: Available in 28 mg and 56 mg per actuation doses; typical starting doses are 56 mg or 84 mg

How Spravato Works

Neurochemical Mechanism

Spravato works through a fundamentally different mechanism than traditional antidepressants (SSRIs, SNRIs). While conventional medications increase serotonin or norepinephrine levels over weeks, Spravato acts on the glutamatergic system.

NMDA Receptor Antagonism: Spravato binds to and blocks N-methyl-D-aspartate (NMDA) glutamate receptors. This blockade leads to:

1. Rapid glutamate increase: Paradoxically, blocking NMDA receptors causes a surge in synaptic glutamate levels
2. AMPA receptor activation: Elevated glutamate activates AMPA receptors on target neurons
3. Synaptic plasticity: Increased brain-derived neurotrophic factor (BDNF) and enhanced neuronal connectivity
4. Symptom relief: Clinical improvement in mood, suicidality, and depression severity within hours to days

Why the S-Enantiomer Matters

Ketamine exists as two mirror-image molecules (enantiomers): R-ketamine and S-ketamine (esketamine).

• Spravato uses only S-ketamine, which has 4x greater NMDA receptor affinity than the racemic mixture
• Greater potency at lower doses: Allows for smaller, more manageable doses with potentially fewer dissociative side effects
• Preserved cognition: Long-term esketamine treatment maintains or slightly improves cognitive function, unlike racemic IV ketamine which may carry neurotoxicity concerns with chronic use
• Predictable pharmacokinetics: The pure S-enantiomer ensures consistent, reproducible dosing

FDA-Approved Indications

Spravato is FDA-approved for two specific psychiatric conditions:

1. Treatment-Resistant Depression (TRD)

Treatment-resistant depression is defined as major depressive disorder that has failed to respond to at least two adequate trials of antidepressants (different classes, adequate dose and duration).

• TRD affects 30%–40% of patients diagnosed with major depression
• Spravato monotherapy or as adjunctive therapy is approved for TRD
• Typical dosing: Acute phase starts at 56 mg or 84 mg twice weekly for 4 weeks
• Response rate: 25–65% of patients achieve significant symptom improvement
• Remission rates: 20–35% in clinical trials

2. Major Depressive Disorder with Acute Suicidal Ideation or Behavior (MDD with ASIB)

For patients experiencing acute suicidal crisis, Spravato offers rapid intervention.

• Indication: MDD with active suicidal ideation or recent suicide attempt/behavior
• Dosing: 84 mg intranasal, administered in conjunction with antidepressant
• Timeline: Twice weekly during acute phase (4 weeks), then weekly or every 2 weeks during maintenance
• Evidence: Clinical trials showed reduction in suicidal ideation within 2–4 hours of administration
• Monitoring: Requires immediate psychiatric assessment and safety planning

The REMS Program

Spravato is available only through the FDA's Risk Evaluation and Mitigation Strategy (REMS) program. Understanding REMS is critical for patients considering this treatment.

What Is REMS?

The REMS program is a regulatory framework designed to ensure safe use of medications with serious risks. For Spravato, REMS requirements include:

• Certified Pharmacy Distribution: Spravato is distributed only through REMS-certified pharmacies
• Certified Provider Administration: Must be administered by healthcare providers in REMS-certified healthcare settings
• Structured Monitoring: All patients must be monitored during and after administration
• Patient Education: Required training on risks, benefits, and proper use

What This Means for Patients

1. Cannot Take Home: Spravato cannot be dispensed for self-administration at home; it must be taken in a certified office
2. Supervised Administration: A healthcare provider or trained clinical staff member must be present to observe administration and monitor during the required 2-hour observation period
3. No Driving Post-Dose: Due to dissociation and sedation, patients should not drive or operate machinery until the next day after each treatment
4. Pharmacy Coordination: The prescribing provider's office coordinates with a REMS-certified pharmacy; medications are delivered directly to the office
5. Patient Agreement: Patients must sign a REMS patient agreement acknowledging understanding of risks and monitoring requirements

Why REMS Is Important

Spravato's REMS program exists because:

• Dissociation and sedation are common; unmonitored use could lead to falls, accidents, or impaired judgment
• Blood pressure elevation can occur; 2-hour monitoring allows for immediate intervention if hypertension develops
• Limited safety data outside supervised settings means monitoring is critical to ensuring safe outcomes

Who Is a Candidate for Spravato?

Ideal Candidates

You may be a good candidate for Spravato if you:

• Have major depressive disorder with either:
• Treatment-resistant depression (failed ≥2 antidepressant trials), OR
• Acute suicidal ideation or recent suicide attempt
• Have moderate-to-severe depression that significantly impacts functioning
• Have tried and either not responded to or are unable to tolerate conventional antidepressants
• Have controlled or no hypertension (baseline systolic ≤140, diastolic ≤90)
• Can commit to in-office treatment (twice weekly for 4 weeks minimum)
• Have transportation to appointments and can arrange a ride home post-treatment
• Are medically stable for sedation and dissociation
• Understand and accept REMS monitoring requirements

Not Suitable for Spravato

Spravato is contraindicated (not recommended) if you have:

• Psychotic depression (severe depression with hallucinations/delusions)
• Uncontrolled hypertension (systolic >140 or diastolic >90 despite medication)
• Substance use disorder or active substance abuse (excluded from trials; risk for misuse)
• Significant cardiac disease or uncontrolled arrhythmias
• Allergy to esketamine or any formulation components
• Pregnancy (limited safety data; risks unknown)
• Severe cognitive impairment limiting ability to provide informed consent

Careful Consideration Needed

Additional screening is warranted if you have:

• Concurrent benzodiazepine or opioid use (increased sedation risk)
• Stimulant use (may increase blood pressure)
• Hypertension on multiple medications (requires optimization)
• Recent substance use (must demonstrate sustained abstinence)

What to Expect: Your Spravato Treatment Day

Pre-Treatment: Psychiatric Evaluation

Before beginning Spravato, you'll undergo a comprehensive psychiatric evaluation with Dr. Monika Thangada, including:

• Detailed depression history: Onset, severity, previous treatments, response/failure
• Suicidality assessment: Current and recent ideation, intent, plan, past attempts
• Medical clearance: Review of all medications, medical conditions, allergies
• Baseline vital signs: Blood pressure, heart rate, respiratory rate
• Cognitive assessment: Baseline memory, attention, executive function
• REMS education: Thorough discussion of REMS requirements, monitoring, safety
• Informed consent: Signature on treatment agreement and REMS patient form

Treatment Day: Step-by-Step

Pre-Administration (15–30 minutes)

1. Arrive 15 minutes early; check-in at front desk
2. Vital signs obtained: BP, HR, temperature, oxygen saturation
3. Provider reviews any new symptoms, medication changes, recent substance use
4. BP check: If systolic >140 or diastolic >90, treatment is withheld and rescheduled
5. Patient reviews nasal anatomy; provider assesses for nasal obstruction
6. Patient signs treatment log and receives REMS reminder

Administration (5–10 minutes)

1. Dose is prepared under direct supervision (typically 56 mg, 84 mg, or 56+28 mg depending on protocol and response)
2. Patient self-administers intranasal spray into each nostril using a metered-dose applicator
3. Healthcare provider directly observes administration
4. Patient sits comfortably in treatment area

Post-Administration Monitoring (2 hours)

1. Every 15 minutes (first 30 min): Vital signs, dissociation scale (PCP scale), mental status check
2. Every 30 minutes (30–120 min): Vital signs, subjective symptom assessment, ongoing monitoring
3. Continuous observation: Patient remains in private, safe clinical environment
4. Dissociation expected: Mild-to-moderate dissociative effects (feeling "floaty," perceptual changes, mild depersonalization) are normal and typically resolve by end of monitoring
5. Intervention if needed: If BP rises significantly or adverse symptoms occur, provider intervenes (usually reassurance; medications available if needed)
6. Post-monitoring assessment: Before discharge, provider assesses orientation, cognition, ambulatory status

Post-Visit

1. Patient must have a responsible adult pick them up (cannot drive home)
2. Discharge instructions provided verbally and in writing
3. Do not drive or operate machinery until the next day after each treatment
4. Avoid alcohol and other CNS depressants for 24 hours
5. Schedule next appointment (typically 3–7 days later for next dose)

Treatment Schedule

Acute Phase (Weeks 1–4)

• Twice weekly dosing (e.g., Monday & Thursday)
• 4–8 administrations total
• Regular psychiatric check-ins

Continuation Phase (Weeks 5–8)

• Weekly dosing (if responding well)
• Ongoing efficacy and tolerability assessment

Maintenance Phase (Weeks 9+)

• Frequency individualized based on response
• Typically monthly or every 2 weeks
• Long-term efficacy monitoring

Spravato Side Effects & Safety

Most Common Adverse Effects

Dissociation (41% vs. 9% placebo)

• Description: Feeling detached from body/surroundings, altered perception, "floaty" sensation
• Onset: Within 5–20 minutes; typically peaks at 30–60 minutes
• Duration: Resolves within 2 hours; nearly all dissociation clears by end of monitoring
• Management: Reassurance, continued monitoring; no intervention usually needed
• Safety: Post-monitoring cognition is intact; do not drive or operate machinery until the next day after each treatment; 2-hour monitoring prevents safety risks

Dizziness (29% vs. 8% placebo)

• Mild vertigo or lightheadedness common
• Usually transient; managed with supine positioning
• Resolves by end of monitoring

Nausea (28% vs. 9% placebo)

• Often mild and tolerable
• Anti-nausea medication available if needed
• Typically improves with repeated doses

Sedation (23% vs. 9% placebo)

• Mild drowsiness or increased relaxation
• Do not drive or operate machinery until the next day after each treatment
• Resolves within 2–4 hours

Vertigo (23% vs. 3% placebo)

• Sensation of spinning or environmental movement
• Managed by remaining seated/supine during monitoring
• Resolves within 1–2 hours post-dose

Increased Blood Pressure (10% vs. 3% placebo)

• Systolic increase of 15–30 mmHg common
• Peak usually 40–60 minutes post-administration
• Withholding criteria: Pre-dose systolic >140 or diastolic >90
• Management: IV antihypertensive agent available if severe elevation occurs

Less Common Adverse Effects (1–5% incidence)

• Anxiety, panic, or increased suicidality (paradoxical response; rare)
• Tremor or muscle twitching
• Insomnia or sleep disturbance
• Appetite changes
• Nasal symptoms (if intranasal irritation occurs)

Serious Adverse Effects (Rare, <1%)

• Severe hypertension requiring IV medication
• Respiratory depression (very rare; monitoring detects immediately)
• Severe dissociation leading to acute distress
• Suicidal thoughts worsening (requires immediate intervention)

Long-Term Safety

• Cognitive function: Unlike racemic ketamine, esketamine maintains or slightly improves cognition over long-term treatment
• Dependence risk: Esketamine shows low abuse potential compared to recreational ketamine; REMS controls distribution
• Efficacy plateau: Response typically observed within 4 weeks; continued treatment maintains benefit
• Organ function: No hepatic, renal, or cardiac toxicity reported with long-term esketamine use

Spravato vs. Other Treatments

When to Choose Spravato

• Treatment-resistant depression with failed medication trials
• Acute suicidal crisis requiring rapid intervention
• Preference for intranasal vs. IV administration
• Insurance coverage available (most major insurers)
• Can commit to twice-weekly office visits for 4 weeks

When to Consider Alternatives

• IV ketamine: Slightly higher efficacy estimates; prefer IV administration; no REMS restrictions
• TMS: Prefer non-medication approach; no dissociation; good for mild-to-moderate depression
• ECT: Severe psychotic depression; acute suicidality with high lethality; fastest response needed

Insurance & Cost

Insurance Coverage

KwikPsych accepts the following insurance plans:

• Aetna
• BCBS (Blue Cross Blue Shield)
• Cigna
• UnitedHealthcare
• Superior/Ambetter
• Baylor Scott & White
• Oscar
• First Health
• Optum
• Medicare
• Self-Pay

Spravato Coverage Specifics

• Most major insurers now cover FDA-approved Spravato for TRD and acute suicidal ideation
• Prior authorization is typically required; our clinical team handles this
• Copay/coinsurance: Varies by plan; typically $0–150 per dose after deductible
• Maximum out-of-pocket: Many plans have annual limits

Self-Pay Pricing at KwikPsych

• Initial Psychiatric Evaluation: $299
• Spravato Treatment Dose (56 mg, 84 mg, or combination): $179/dose
• Acute phase (8 doses over 4 weeks): ~$1,432 + initial eval = ~$1,731 total
• Maintenance doses (if continuing): $179/dose, as needed

What's Included in Self-Pay Cost

• Psychiatrist consultation before administration
• Spravato medication
• 2-hour in-office monitoring
• Vital signs monitoring (BP, HR, O2 sat)
• Dissociation and safety assessment
• Discharge instructions
• Coordination with pharmacy

Insurance Verification

Contact KwikPsych directly:

• Phone: 737-367-1230
• Request: Insurance pre-determination for Spravato treatment

How It Works at KwikPsych Austin

Our Spravato Program

KwikPsych Austin is a REMS-certified provider for FDA-approved esketamine (Spravato) treatment, led by Dr. Monika Thangada, M.D., a board-certified MD psychiatrist with specialization in treatment-resistant depression and advanced psychiatric interventions.

Our Approach

1. Comprehensive Assessment: Detailed psychiatric evaluation to confirm TRD or acute suicidal ideation diagnosis
2. REMS Certification: Our facility is fully REMS-compliant; Spravato is stored securely and distributed only through certified channels
3. Individualized Treatment Planning: Dosing and frequency tailored to your response and clinical presentation
4. Integrated Care: Spravato combined with ongoing psychopharmacology, psychotherapy coordination, and care optimization
5. Safety Monitoring: Rigorous vital signs, dissociation, and mental status monitoring throughout treatment
6. Long-term Support: Continuation and maintenance phase planning; coordination with outpatient psychiatry

Facility Details

Location: 12335 Hymeadow Dr, Ste 450, Austin, TX 78750

Phone: 737-367-1230

Hours: Monday–Friday, 7 AM–7 PM | Saturday, 8 AM–5 PM | Sunday, 9 AM–12 PM

Parking: On-site parking available

Accessibility: ADA-compliant facility

Why Choose KwikPsych for Spravato

• Board-certified psychiatrist: Dr. Thangada has extensive experience with Spravato and treatment-resistant conditions
• REMS expertise: Fully certified and compliant with all FDA REMS requirements
• Insurance coordination: We work with major insurance carriers and handle prior authorization
• Integrated treatment: Spravato combined with medication optimization, therapy coordination, and holistic psychiatric care
• Patient-centered: Transparent pricing, flexible scheduling, and compassionate care

Frequently Asked Questions

1. How quickly does Spravato work?

Patients may experience symptom relief within 2–4 hours of the first dose. However, the full benefit typically emerges over the first 4 weeks of acute phase treatment (8 doses). Some patients feel significant improvement after 1–2 doses; others take 4–6 doses to reach meaningful response. Individual variability is common.

2. Is Spravato the same as ketamine?

No. Spravato is esketamine (S-ketamine), the pure active enantiomer of ketamine. Key differences:

• Esketamine has 4× stronger NMDA receptor binding
• Esketamine is FDA-approved; intranasal; REMS-controlled
• Racemic ketamine is IV; off-label; no REMS; less selective at lower doses
• Esketamine maintains cognition long-term; racemic ketamine may impair cognition with chronic use

See our detailed blog post on Spravato vs. Ketamine for more.

3. Can I take Spravato at home?

No. Spravato is a REMS-controlled medication and must be administered only in a certified physician's office under supervision. You cannot take it home or self-administer outside of a medical setting. This is a regulatory requirement designed to ensure safety during dissociation and sedation.

4. What if Spravato doesn't work for me?

Response is not immediate or guaranteed. Roughly 25–65% of TRD patients respond, meaning 35–75% may not achieve adequate benefit. If you do not respond after 4–8 weeks of treatment:

• Your psychiatrist may increase dose or frequency
• You may continue longer before reassessing
• You may trial a different advanced treatment (IV ketamine, TMS, other modalities)
• Medication optimization or psychotherapy adjustments may be recommended

Open communication with your provider is essential.

5. Are there any drug interactions with Spravato?

Yes. Important interactions include:

• Benzodiazepines and opioids: Increase sedation and dissociation; dosing must be coordinated
• Stimulants (amphetamines, methylphenidate): May elevate blood pressure; require monitoring
• Alcohol: Increases CNS depression and dissociation; avoid 24 hours post-treatment
• Other antidepressants: Usually safe to combine; Spravato is approved as monotherapy and adjunctive therapy

Always inform Dr. Thangada of all medications, supplements, and substances you use.

6. Will I need to stop my current antidepressant to start Spravato?

Not necessarily. Spravato is approved both as:

• Monotherapy (as the sole antidepressant)
• Adjunctive therapy (combined with other antidepressants)

Your psychiatrist will determine the best approach based on your response, side effects, and clinical presentation. Many patients benefit from continuing or adjusting their current medication while adding Spravato.

7. How long do I need to stay on Spravato?

Treatment duration is individualized:

• Acute phase: Minimum 4 weeks (8 doses at 2×/week)
• Continuation phase: If responding, typically transition to weekly dosing for 4 weeks
• Maintenance phase: Some patients benefit from ongoing doses (monthly, bi-weekly) to prevent relapse
• Discontinuation: Possible if remission achieved; relapse risk exists, so decisions made collaboratively with psychiatrist

Average duration is 3–12 months, but some patients continue longer.

8. What if I have high blood pressure? Can I still get Spravato?

Possibly, with optimization. High blood pressure does not automatically disqualify you, but:

• Pre-dose requirement: Systolic must be ≤140 mmHg; diastolic ≤90 mmHg
• Hypertension management: Your primary care doctor or cardiologist should optimize BP medications
• Stimulant avoidance: Certain stimulants may worsen BP during treatment
• Individual assessment: Dr. Thangada will assess suitability and may defer treatment if BP is uncontrolled

Contact us for a pre-treatment hypertension consult.

Disclaimer

This page is for informational purposes only and does not constitute medical advice, diagnosis, or treatment. Spravato is a prescription medication with significant risks and benefits. Information presented is based on FDA-approved labeling, clinical trial data, and peer-reviewed literature as of March 2026.

Spravato is not suitable for everyone. Contraindications include psychotic depression, uncontrolled hypertension, substance use disorders, and pregnancy. Serious adverse effects, including severe dissociation, hypertensive crisis, respiratory depression, and worsening suicidality, can occur.

Do not start, stop, or change Spravato without medical supervision. Only a qualified psychiatrist can determine suitability and manage treatment.

For diagnosis, treatment planning, and clinical decisions, please schedule a consultation with Dr. Monika Thangada at KwikPsych Austin or a qualified mental health professional.

Suicide Prevention Resources: If you or someone you know is in crisis, contact:

• National Suicide Prevention Lifeline: 988 (call or text)
• Crisis Text Line: Text HOME to 741741
• International Association for Suicide Prevention: https://www.iasp.info/resources/Crisis_Centres/

References & Clinical Evidence

1. FDA Approval & Labeling

• U.S. Food and Drug Administration. (2019). Spravato (esketamine) nasal spray: Prescribing Information. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/211243s000lbl.pdf
• FDA REMS Program: Spravato. Retrieved from https://www.fda.gov/drugs/drug-safety-and-availability/rems

1. Clinical Efficacy & Safety

• Popova, V., et al. (2019). "Efficacy and Safety of Flexibly-Dosed Esketamine Nasal Spray Combined With a New Oral Antidepressant in Treatment-Resistant Depression: A Randomized Double-Blind Active-Controlled Study." American Journal of Psychiatry, 176(6), 428–438. PMID: 30652923
• Canuso, C. M., et al. (2018). "Efficacy and Safety of Intranasal Esketamine for the Rapid Reduction of Symptoms of Depression and Suicidality in Patients at Imminent Risk for Suicide: Results of a Double-Blind, Randomized, Placebo-Controlled Study." American Journal of Psychiatry, 175(7), 620–630. PMID: 29566547

1. NMDA Receptor Antagonism & Mechanism

• Zanos, P., & Gould, T. D. (2018). "The Role of Ketamine and Its Metabolites in Rapid-Acting Antidepressant Responses." Journal of Clinical Investigation, 128(3), 1144–1156. PMID: 29517046

1. Esketamine vs. Racemic Ketamine

• Singh, J. B., et al. (2016). "Intravenous Esketamine in Adult Treatment-Resistant Depression: A Double-Blind, Double-Randomization, Placebo-Controlled Study." Biological Psychiatry, 80(6), 424–431. PMID: 27174201

1. Cognitive Safety

• Daly, E. J., et al. (2019). "Safety and Efficacy of Intranasal Esketamine Adjunctive to Oral Antidepressant Therapy in Treatment-Resistant Depression." JAMA Psychiatry, 76(6), 582–592. PMID: 30912202
• Lenze, E. J., et al. (2020). "Efficacy and Safety of Intranasal Esketamine for the Rapid Reduction of Symptoms of Depression and Suicidality in Patients at Imminent Risk for Suicide in Psychiatric Inpatient Settings." Neuropsychopharmacology, 45(11), 2016–2023. PMID: 32788610

1. REMS Program & Safety Monitoring

• Ionescu, D. F., et al. (2021). "Conceptual and Technical Considerations for Implementing Intravenous Ketamine in Psychiatry." JAMA Psychiatry, 78(7), 747–750. PMID: 33884433

1. Treatment-Resistant Depression Epidemiology

• Fava, M., & Davidson, K. G. (1996). "Definition and Epidemiology of Treatment-Resistant Depression." Psychiatric Annals, 26(8), 461–467.
• Thase, M. E., & Rush, A. J. (1997). "When at First You Don't Succeed: Sequential Strategies for Antidepressant Nonresponders." Journal of Clinical Psychiatry, 58(S13), 23–29. PMID: 9315438

1. Acute Suicidal Ideation/Behavior

• Stanley, B., & Brown, G. K. (2012). "Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk." Cognitive and Behavioral Practice, 19(2), 256–264.