Our Therapies

SPRAVATO® Nasal Spray Therapy

Violet Health Outpatient Specialty Infusion Care

About SPRAVATO® Nasal Spray Therapy

SPRAVATO® (esketamine) is a nasal spray, not an infusion and not an injection. It is the S-enantiomer of ketamine, and it works through a pathway no other antidepressant on this site uses. SPRAVATO® is a non-selective, non-competitive antagonist of the NMDA receptor, which responds to glutamate rather than serotonin, norepinephrine, or dopamine. That difference is the point: conventional antidepressants act on monoamine systems and usually take four to six weeks to show benefit, while esketamine acts on glutamate signaling and can produce a measurable change within hours to days.

The exact way this relieves depressive symptoms is not fully understood. The working explanation is that blocking NMDA receptors triggers a downstream surge in glutamate signaling that appears to restore synaptic connections in brain regions involved in mood regulation. What is well established is the clinical pattern: faster onset than oral antidepressants, and benefit in people for whom several oral medications have already fallen short.

How this treatment is different from everything else we offer

You administer it yourself, under direct supervision. A member of the care team hands you the device and watches you use it. There is no IV, no needle, and no port.
You are monitored on site for at least two hours after each dose. That monitoring is not optional and is not shortened for convenience.
SPRAVATO® is available only through a restricted program called the SPRAVATO® REMS. The medicine is dispensed and used at a certified treatment center, and it is never taken home.
It is a Schedule III controlled substance, which shapes how it is stored, documented, and prescribed.

Dosing and administration

Each nasal spray device delivers two sprays totaling 28 mg of esketamine. A 56 mg dose is two devices and an 84 mg dose is three devices, with a five-minute rest between devices. The dose is fixed, not calculated from your weight.
Treatment-resistant depression, weeks 1 through 4 (induction): 56 mg on day 1, then 56 mg or 84 mg twice per week.
Weeks 5 through 8: 56 mg or 84 mg once per week.
Week 9 and beyond: 56 mg or 84 mg every two weeks, or weekly if needed. The instruction on the label is to find the least frequent dosing that maintains response or remission.
Major depressive disorder with acute suicidal ideation or behavior: 84 mg twice per week for four weeks, reduced to 56 mg if needed for tolerability, always alongside an oral antidepressant and comprehensive standard of care.

Unlike most of the medicines on this site, the dose here can be stepped down. If 84 mg is poorly tolerated, 56 mg is a legitimate maintenance dose rather than a compromise, and both were common final doses in the trials. The schedule also eases considerably over time, from twice weekly in the first month to as infrequently as once every two weeks.

Since January 2025, SPRAVATO® can be used on its own for treatment-resistant depression. Before that it had to be given with an oral antidepressant. The combination remains common, and it is still required for the acute suicidal ideation indication, but monotherapy is now an approved route for TRD.

Benefit is formally reviewed after four weeks of treatment. If there has been no meaningful change by then, continuing is reconsidered rather than assumed.

Conditions treated by this therapy

SPRAVATO® is FDA approved for adults in two settings:

Treatment-resistant depression (TRD)

Adults with treatment-resistant depression, used alone or in combination with an oral antidepressant
Treatment-resistant means an inadequate response to at least two different oral antidepressants, each taken at an adequate dose for an adequate length of time, during the current depressive episode. That history has to be documented, since it is what establishes eligibility

Major depressive disorder with acute suicidal ideation or behavior (MDSI)

Depressive symptoms in adults with major depressive disorder who have acute suicidal ideation or behavior, given in conjunction with an oral antidepressant

Limitations worth stating plainly

The effectiveness of SPRAVATO® in preventing suicide or in reducing suicidal ideation has not been demonstrated. It treats depressive symptoms. It is not a substitute for hospitalization when hospitalization is clinically needed
The monotherapy approval applies to treatment-resistant depression only. For the acute suicidal ideation indication, an oral antidepressant is still part of the regimen
Adults only. Safety and effectiveness have not been established in children, and SPRAVATO® is not approved for anyone under 18
SPRAVATO® is not approved for anxiety, PTSD, chronic pain, or any of the other conditions sometimes associated with ketamine clinics. It is also not an anesthetic and is not used for sedation here

One point of clarification patients often ask about: SPRAVATO® is not the same thing as an intravenous ketamine infusion. IV ketamine for depression is an off-label use of a generic anesthetic. SPRAVATO® is an FDA-approved nasal spray with a defined dose, a defined schedule, a required monitoring protocol, and a restricted distribution program. The two are related chemically and are not interchangeable clinically or administratively.

SPRAVATO® Price

The cost of prescription medications can vary depending on your insurance coverage. If you're concerned about the price of your medication:

Contact your insurance provider to understand your coverage
Ask your doctor or pharmacist about lower-cost alternatives
Check with the drug manufacturer about financial assistance programs
Explore patient assistance options if you're uninsured or underinsured

Remember, many resources exist to help patients access necessary medications. Don't hesitate to ask for help if you're struggling with medication costs. No patient should go without necessary treatment due to financial limitations. If you have questions about financial assistance opportunities, contact a member of our Violet Health team.

What to Expect During SPRAVATO® Nasal Spray Therapy

SPRAVATO® was first approved by the FDA in March 2019, with the acute suicidal ideation indication added in 2020 and monotherapy for treatment-resistant depression added in January 2025. It can only be given at a REMS-certified treatment center, where you stay for monitoring after every dose.

Plan on a longer visit than any other treatment on this site. From check-in to walking out is usually around three hours, and the two-hour monitoring period that makes up most of it is a requirement rather than a precaution we can shorten on a quiet day.

Before you arrive

Do not eat for at least two hours before your appointment, and do not drink liquids for at least 30 minutes before. This meaningfully reduces nausea and vomiting.
If you use a nasal corticosteroid or decongestant spray, take it at least one hour before your dose rather than at the clinic.
Arrange a ride. You cannot drive yourself home, and this applies to every single session, not just the first.

During your visit

Your blood pressure is checked before dosing. If it is too high, the session is rescheduled rather than pushed through, because esketamine raises blood pressure further.
You use the nasal spray yourself while a clinician watches. Two devices for 56 mg or three for 84 mg, with a five-minute rest between each. Each device is one spray in each nostril.
You then rest in a private, quiet room. Many patients bring headphones or an eye mask. Blood pressure is rechecked at 40 minutes and after that as needed, and your breathing and oxygen levels are monitored throughout.
You stay for a minimum of two hours after dosing and leave only when a clinician judges that you are ready.

What the experience itself feels like

Most people feel something within 10 to 20 minutes. The common description is a sense of detachment, as though you are observing yourself or the room from slightly outside it, often with altered perception of time, sound, or your own body. It can feel strange and some people find it unpleasant, but it is expected, it is temporary, and it is one of the reasons the monitoring period exists. The effect generally peaks around 40 minutes and has largely settled by 90 minutes to two hours. It also tends to become less pronounced over repeated sessions.

After you leave

Do not drive, operate machinery, or do anything requiring full alertness until the next day, after a restful night's sleep. Plan the rest of the day as a quiet one. Most people feel back to normal by the following morning.

The rhythm over time

The first month is the heaviest commitment: two sessions a week for four weeks. From week 5 it drops to once a week, and from week 9 it can go to every other week. That is eight visits in the first month and potentially two a month later on. Benefit is formally assessed at the four-week mark, and if you continue, the goal is the least frequent schedule that holds your response. Unlike oral antidepressants, you do not take anything at home between sessions unless an oral antidepressant is also part of your plan.

SPRAVATO® Side Effects

The most common side effects reported in trials of SPRAVATO® with an oral antidepressant in treatment-resistant depression were:

Dissociation, meaning a feeling of detachment from yourself, your surroundings, or time
Dizziness and vertigo
Nausea and vomiting
Sedation and lethargy
Reduced sensation or numbness, often around the mouth or face
Anxiety, a feeling of being drunk, increased blood pressure, headache, taste changes, and nasal discomfort

What stands out about this list is the timing. Almost all of it happens inside the two-hour window you spend with us, and almost all of it resolves before you go home. That is a different shape from most medicines, where side effects turn up in the days between visits.

Dissociation

This is the most common effect and the one patients most want to understand in advance. Roughly four in 10 patients experience it. It starts shortly after dosing, peaks around 40 minutes, and generally resolves within two hours. It tends to lessen with repeated sessions. It can include distorted perception of time, altered sound or vision, a sense of unreality, or feeling disconnected from your body. It is monitored at every session using a formal scale, and it is not a sign that something has gone wrong.

Blood pressure increases

SPRAVATO® causes a rise in blood pressure that peaks at about 40 minutes after dosing and usually lasts about four hours. This is why blood pressure is checked before the dose, again at 40 minutes, and afterwards as needed. In people with known cardiovascular or cerebrovascular disease, the risk is higher, and treatment is only started after that has been weighed. Report chest pain, severe headache, sudden vision changes, shortness of breath, or weakness on one side right away.

Longer-term considerations

Bladder and urinary tract symptoms, including interstitial or ulcerative cystitis, have been reported with long-term use. Tell your care team about pain with urination, urgency, frequency, or blood in the urine.
Effects on thinking and memory have been studied over a year of treatment and no decline was seen, but cognition is still something to raise if you or those close to you notice a change.

Get emergency help right away if you experience:

Chest pain, a severe or sudden headache, or an irregular heartbeat
Sudden weakness or numbness on one side of the body, trouble speaking, or sudden vision loss
Trouble breathing, swelling of the face, throat, or tongue, or a widespread rash
New or worsening thoughts of suicide or self-harm, or any sudden change in mood or behavior

Important Safety Information

Boxed warning

SPRAVATO® carries a boxed warning covering four risks. Together they explain nearly every rule around how this treatment is delivered:

Sedation, including the possibility of losing consciousness. This is why you are observed rather than sent home.
Dissociation, including altered perception and distortions of time and reality.
Abuse and misuse. Esketamine is a Schedule III controlled substance with the potential for misuse and dependence, which is why the medicine stays at the treatment center.
Suicidal thoughts and behaviors. Antidepressants as a class increased this risk in children, adolescents, and young adults in short-term studies. SPRAVATO® is not approved for anyone under 18, and patients of all ages are monitored closely for worsening or emergent suicidal thinking.

The SPRAVATO® REMS

Because of those risks, SPRAVATO® is available only through a Risk Evaluation and Mitigation Strategy program. Patients, prescribers, pharmacies, and treatment centers all have to be enrolled. The medicine is dispensed and self-administered on site under supervision, and is never dispensed for home use.

Contraindications

SPRAVATO® should not be used if you have:

Aneurysmal vascular disease, including of the thoracic or abdominal aorta, the intracranial vessels, or the peripheral arteries
An arteriovenous malformation
A history of intracerebral hemorrhage
Hypersensitivity to esketamine, ketamine, or any of the ingredients

The first three all come down to the same thing: a sudden rise in blood pressure is dangerous if a vessel is already vulnerable. This is a genuine exclusion rather than a caution, and it is why vascular history is asked about carefully before the first dose.

Other important warnings

Impaired ability to drive and operate machinery. Do not drive or use machinery until the day after your session, following restful sleep.
Other central nervous system depressants, including benzodiazepines, opioids, sleep medicines, and alcohol, add to sedation. Your full medication list matters here, including anything taken only occasionally.
Psychiatric symptoms. SPRAVATO® can worsen psychosis, and people with a psychotic disorder were not included in the trials. A history of mania or bipolar disorder also needs to be disclosed.
Bladder problems, including interstitial and ulcerative cystitis, have been reported with long-term use.

Pregnancy and breastfeeding

SPRAVATO® is not recommended during pregnancy, based on animal data suggesting potential harm to a developing fetus. Pregnancy status is confirmed before starting. Breastfeeding is not recommended during treatment, since esketamine is present in human milk. There is a National Pregnancy Registry for Antidepressants that collects information on outcomes in women treated with antidepressants during pregnancy, and your care team can help you enroll. Notably, there is no fixed contraception window after the last dose here, which differs from most of the medicines on this site.

Before you start, tell your care team if you

Have heart or blood vessel disease, high blood pressure, or have had a stroke, heart attack, or brain injury
Have liver problems, since moderate impairment may require longer monitoring and severe impairment has not been studied
Have ever misused or been dependent on alcohol, prescription medicines, or street drugs, including ketamine
Have a history of psychosis, mania, or bipolar disorder
Are pregnant, planning to become pregnant, or breastfeeding

Keep the Medication Guide you are given at your first session. If you need urgent care elsewhere on a treatment day, tell the treating clinician that you received esketamine, since sedation, blood pressure changes, and dissociation are easy to misread without that context.

What Your Referral Should Include

Eligibility for SPRAVATO® rests on documented treatment history and on a careful vascular and psychiatric review, and the REMS program adds enrollment steps on both sides. A complete referral moves scheduling along considerably. Please include:

Diagnosis and whether treatment is intended for treatment-resistant depression or for major depressive disorder with acute suicidal ideation or behavior, since this sets both the dose and the schedule
For treatment-resistant depression, documentation of at least two prior oral antidepressant trials in the current episode, each with the drug, dose, duration, and response. This is the single most common reason a referral stalls
Whether SPRAVATO® is intended as monotherapy or alongside an oral antidepressant, and if the latter, which one and at what dose
A baseline depression severity score, such as MADRS or PHQ-9, with the date, so that the four-week benefit review has something to measure against
Vascular history in detail: any aneurysm of the aorta, intracranial or peripheral vessels, any arteriovenous malformation, and any history of intracerebral hemorrhage, with imaging if available. These are contraindications, not cautions
Recent blood pressure readings, hypertension history, current antihypertensives, and any history of heart attack, stroke, heart failure, significant valve disease, or brain injury
Psychiatric history including any psychotic disorder, mania, or bipolar diagnosis, and current suicide risk assessment
Substance use history, including any prior ketamine or esketamine use, whether medical or otherwise
A full medication list with particular attention to benzodiazepines, opioids, sedatives, stimulants, MAO inhibitors, and any other central nervous system depressants
Hepatic function, since moderate impairment may call for a longer monitoring period and severe impairment has not been studied
Nasal history: chronic rhinitis, recent nasal surgery, structural problems, and any nasal corticosteroid or decongestant in use
Urinary and bladder symptoms at baseline, given the cystitis signal with long-term use
Pregnancy status for patients of reproductive potential, along with pregnancy plans and breastfeeding status
Confirmation that the patient has reliable transportation home after every session, since this is a condition of treatment rather than a convenience
REMS enrollment status for the prescriber, and prescriber contact details for the four-week benefit review and for ongoing coordination of the oral antidepressant if one is being used