Spravato (Esketamine)

A guided, evidence-based option when depression won’t let go

Depression can carve deep grooves. Over time, the mind learns a familiar route: loops of self doubt, dread, and numbness. This isn’t weakness. It’s a nervous system that adapted to survive. But the pathways that keep you afloat aren’t always the ones that lead to an emboldened life.

Ketamine can help create new routes, so you’re not confined to the same worn trail. It can offer more room to move, see, and choose, and help you begin walking toward a life that feels fuller and more fully yours.

Spravato (esketamine) is an FDA approved ketamine based treatment for adults with treatment resistant depression, and major depressive disorder with acute suicidal ideation or behavior, when used alongside an oral antidepressant and given in a medically supervised setting.

At MBLDN Psychiatry & Wellness, Spravato is offered in a calm, grounded environment with medical monitoring and thoughtful support so the experience feels contained, safe, and purposeful.

What is Spravato?

Spravato is esketamine, a form of ketamine delivered as a nasal spray in the office. You self-administer it under supervision, then rest while we monitor you during the observation period (2 hours) required by the Spravato REMS safety program. (Spravato REMS)

How Spravato works

Spravato works primarily through glutamate.

Glutamate is one of your brain’s most important chemical messengers. It helps your brain with:

• communication between neurons

• learning and memory

• adaptability and cognitive flexibility

When glutamate signaling is balanced, the brain can shift gears and form healthier connections. When depression has been present for a long time, the brain can start running on the same worn tracks, predictable loops of hopelessness, self-attack, dread, numbness, and rumination.

Spravato affects NMDA/glutamate signaling in a way that appears to trigger downstream changes linked to synaptic strengthening and neuroplasticity (your brain’s ability to form new connections). Many people experience this as a loosening of rigidity, less stuckness, less grip, more space to choose differently. Researchers are still clarifying the full mechanism, but the clinical finding is that in many patients, esketamine can reduce depressive symptoms relatively quickly compared with traditional medication timelines.

How effective is Spravato?

Spravato (esketamine) has been studied in multiple clinical trials for treatment-resistant depression. Outcomes vary by person, but here are the real-world useful numbers people ask about.

Short-term improvement (first month)

In the Spravato clinical program, by the end of the 4-week induction phase (typically twice weekly dosing), a meaningful portion of patients achieved:

• Response (50% improvement on a depression rating scale): 40–55%

• Remission (symptoms reduced to below a threshold on the scale): about 20–36% by week 4

Longer-term: staying well and preventing relapse

If someone responds and continues treatment, the evidence is strongest for relapse prevention:

• In the relapse-prevention study (often referenced as SUSTAIN-1), continuing esketamine + oral antidepressant reduced relapse risk compared with switching to placebo nasal spray.

  • 51% lower relapse risk for remitters

  • 70% lower relapse risk for responders

Summary of efficacy

• Many patients notice relief during the induction phase, but response varies.

• Some people feel lighter quickly; others improve more gradually across several treatments.

• We track your progress systematically and adjust frequency based on response and tolerability, aiming for the least frequent schedule that maintains benefit.

What treatment feels like

During a session, you may notice changes in perception, a sense of distance from your usual thought patterns, or a dreamlike state. Some people experience dissociation or sedation; others simply feel quiet, reflective, or tired.

Because of these effects and safety considerations, Spravato must be given under supervision with monitoring afterwards. You will be required to get a ride home and should not drive the rest of the day after treatment.

Common short-term side effects can include dissociation, dizziness, nausea, headache, sleepiness, and temporary blood pressure increases, typically resolving the same day.

How often is Spravato given?

Induction and maintenance schedule

Spravato follows a structured schedule that’s designed to build momentum early, then taper to the least frequent dosing that still maintains response.

A typical plan looks like this:

Induction phase (Weeks 1–4):

• Twice weekly sessions

Maintenance phase (Weeks 5–8):

• Once weekly sessions

Ongoing maintenance (Week 9 and beyond):

• Every 2 weeks or once weekly, individualized to the least frequent schedule that maintains benefit

The role of therapy & integration

Ketamine can open a window. Therapy helps you walk through it.

Spravato can soften the grip of depression and create a period where your mind feels less rigid. That shift can be a relief, and it can also be tender. When the fog begins to lift, you may suddenly feel the emotions, needs, truths, or boundaries that depression numbed out for survival.

That’s why integration matters.

Integration is the process of making meaning out of what shifts, so insight becomes choice, and choice becomes a life that actually feels worth living. Because I don’t provide psychotherapy as part of Spravato treatment, it is strongly recommended that you have a therapist you see weekly (sometimes more during the induction phase). Professional standards around ketamine care emphasize preparation, ongoing support, and thoughtful follow-up, not just the medication experience alone. (askp.org)

When should I schedule therapy after a Spravato session?

In most cases, the best time for therapy is about 24–48 hours after your session. That timing tends to be the sweet spot: you’re usually clearer and more grounded than you are immediately after treatment, but still close to the “window” where new perspectives, emotional shifts, and nervous system change can be more easily integrated into your real life. (This 24–48 hour timing is also consistent with research approaches pairing ketamine treatments with psychotherapy.) (PubMed)

If you can’t schedule therapy the next day, within 72 hours is still very helpful. If you see your therapist on the same day, I recommend a gentler, supportive, reflective, and grounding session with less deep analysis, so your system can settle and you can keep what opened without feeling overwhelmed.

What the process looks like at MBLDN

1. Evaluation / intake
   We review your history, what you’ve tried, current medications, safety considerations, and whether Spravato is appropriate.

2. Treatment sessions in-office
   Spravato is self-administered under supervision. You’ll stay for the required observation period (at least 2 hours), and we’ll monitor vital signs and ensure you’re stable before you leave.

3. Tracking + personalization
   We monitor your response across the induction phase and adjust maintenance frequency thoughtfully, aiming for the least frequent schedule that maintains benefit.

Spravato compared with IV and IM ketamine

Spravato is esketamine, a ketamine based medication that is FDA approved for treatment resistant depression and is delivered as a nasal spray in a certified clinic setting with required monitoring.

IV and IM ketamine typically use racemic ketamine and are most often provided as an off label treatment for depression and related conditions. Professional consensus guidance describes IV ketamine research most commonly using 0.5 mg/kg over 40 minutes, and notes that evidence for alternative routes exists but is less standardized.

Both approaches can be meaningful options. The best fit depends on your history, your medical profile, your urgency, your budget, and what kind of structure and support will help you sustain change.

Differences to consider when making your decision

1) Approval and insurance
Spravato is FDA approved and, when you are eligible, it is commonly covered by insurance with prior authorization. The medication must be administered in clinic under the Spravato REMS program with at least 2 hours of monitoring.

IV and IM ketamine for depression are usually off label, and coverage is much less consistent. A superbill is provided which can be sent to insurance companies for possible reimbursement.

2) Feel and intensity of the experience
Spravato is absorbed through the nasal route and can feel gentler for some people, though dissociation and sedation can still occur, which is why monitoring is required.

Many providers find IV ketamine more dose precise because the rate and total dose can be carefully controlled throughout the session. It can be stopped abruptly if need be.

IM often has a faster onset and a more wave like arc, with less moment to moment adjustability than IV.

3) How they compare in outcomes
Research comparing IV ketamine and intranasal esketamine (spravato) suggests both can be effective, with some analyses finding similar overall improvement rates, while others find IV ketamine may be somewhat more efficacious on average. The right choice is often less about which is universally “better,” and more about which approach you can sustain, tolerate, and integrate.

4) Age for coverage
Spravato is approved for adults age 18 and older. If someone is under 18, Spravato is not an option, and ketamine treatment would need to be discussed through other routes (such as IV or IM) or deferred until adulthood, depending on clinical appropriateness.

Insurance and in network coverage at MBLDN

MBLDN Psychiatry and Wellness is in network with select plans, specifically Aetna, Anthem, Cigna, Optum, and Blue Shield of California plans only. If you have one of these plans, Spravato sessions are often covered, but coverage still depends on your specific benefits and medical necessity criteria, and almost always requires prior authorization.

Because Spravato is provided under a REMS program in a monitored clinic setting, there are typically separate insurance components, such as the medication and the supervised administration and observation time. We will help guide you through what to expect and verify details, but your final out of pocket cost depends on your plan’s copays, coinsurance, deductible, and authorization outcome.

An invitation

If you’re exhausted from surviving, if you’re ready to feel your inner life begin to soften, brighten, and move again, Spravato may be a meaningful next step. Not because it erases what you’ve lived through, but because it can help you step off the worn, over traveled paths your mind has been stuck on and begin to move through your inner landscape with more freedom, flexibility, and a wider perspective on life.

Contact us to schedule an intake and find out if this path is right for you.