The adults who qualify for Spravato have treatment-resistant depression, or depression with acute suicidal thoughts or behavior, and none of the four conditions the U.S. Food and Drug Administration (FDA) label rules out. A prescriber makes the final call after reviewing your treatment history, blood pressure, and current medicines. That review is the first step in our Spravato program.
Key takeaways
- Spravato has two FDA-approved adult uses: treatment-resistant depression, and depression with acute suicidal thoughts or behavior.
- Only four conditions rule it out outright: two kinds of blood vessel disease, a past brain bleed, and an allergy to esketamine or ketamine.
- The clinic rules are part of qualifying: every dose comes with at least two hours of monitoring, and no driving until the next day.
- You do not need a referral with us: we require an official diagnosis and coordinate with your current prescriber.
What does treatment-resistant depression mean?
Treatment-resistant depression means depression that has not responded to two or more antidepressants. The diagnosis underneath it is major depressive disorder, the medical name for clinical depression.
Each past medicine has to count as a real try. In the Spravato trials, people had not responded to at least two antidepressants “of adequate dose and duration” in their current episode. A federal review found this two-failure rule is the most common definition, though experts still disagree on what counts as adequate. Our depression care team gathers that history before recommending any treatment.
Which adults are eligible for Spravato treatment?
Adults 18 and older are eligible for Spravato treatment when they fit one of the two uses on the FDA label. The use decides whether Spravato can be taken alone and whether earlier antidepressants must have failed:
| Labeled use | Alone or with an oral antidepressant | Earlier antidepressants must have failed |
|---|---|---|
| Treatment-resistant depression | Either | Yes, two or more |
| Major depressive disorder with acute suicidal thoughts or behavior | With an oral antidepressant only | Not required by the label |
For the second group, the label adds a limit: Spravato has not been shown to prevent suicide and does not replace a needed hospital stay. If you or someone you love is in crisis, call or text 988.
What health conditions can rule out Spravato?
Four conditions rule out Spravato completely: three involve blood vessels that a short rise in blood pressure could endanger, and one is an allergy. Other conditions do not rule you out, but your prescriber weighs them first.
Conditions that rule it out
These are the label’s contraindications. You should not take Spravato if you have any of them:
- Aneurysmal vascular disease: a weakened, bulging artery in the brain, chest, abdomen, arms, or legs.
- Arteriovenous malformation: an abnormal tangle of connected arteries and veins.
- Intracerebral hemorrhage: any past bleeding inside the brain.
- Hypersensitivity: an allergy to esketamine, ketamine, or any other ingredient in the spray.
Conditions your prescriber weighs
Spravato raises blood pressure after every dose, peaking at about 40 minutes and lasting about four hours. These conditions get a careful look first:
- High blood pressure: if your reading is above about 140/90 before a dose, your prescriber weighs a delay against the expected benefit.
- Heart and brain conditions: such as a past heart attack or stroke, heart valve disease, heart failure, or a brain injury.
- Severe liver disease: the label does not recommend Spravato for severe liver impairment.
- Pregnancy and breastfeeding: the label does not recommend Spravato during pregnancy or while breastfeeding.
- Certain medicines: sedatives, opioids, and alcohol can deepen sleepiness, while stimulants and monoamine oxidase inhibitor (MAOI) antidepressants can push blood pressure higher.
In our clinics, we check your blood pressure before every dose, again at about 40 minutes, and before you leave.
Can you get Spravato with bipolar disorder, anxiety, or other conditions?
None of these diagnoses is on the label’s list of absolute exclusions. Each one still changes how eligibility is judged.
Bipolar disorder and psychosis
Spravato has not been studied in, and is not approved for, bipolar disorder. The label also asks prescribers to assess anyone with psychosis carefully and to start only if the benefit outweighs the risk. We pause or refer out for active, untreated psychosis or mania, and our bipolar depression page covers other options.
Substance or alcohol use
A past substance or alcohol use disorder does not automatically rule you out. Because Spravato is a Schedule III controlled substance, the label calls for careful consideration first and monitoring for misuse. We also confirm that any such use is not current before you start.
Anxiety, PTSD, and OCD
Spravato is not FDA-approved for anxiety, post-traumatic stress disorder (PTSD), or obsessive-compulsive disorder (OCD) on their own. Both of its approved uses are forms of depression.
Age limits
Spravato is not approved for anyone under 18, and the label sets no upper age limit. In a trial of adults 65 and older, it did not beat placebo by a statistically significant margin at four weeks. The gap over placebo was larger at ages 65 to 74 than at 75 and older.
What does Spravato treatment require from you?
Spravato’s safety rules are part of qualifying, because you follow them at every session. They come from the label and the Spravato REMS, the safety program the FDA requires for this medicine:
- A certified clinic: Spravato goes only to certified healthcare settings, never home with you, and you enroll in the program first.
- Two hours of monitoring: you use the spray under observation, then staff track your blood pressure and breathing, including with a pulse oximeter.
- No driving that day: you cannot drive until the next day after a restful sleep, so you need a ride home.
- A set schedule: for treatment-resistant depression, twice a week for weeks 1 to 4, weekly for weeks 5 to 8, then every one or two weeks.
All five of our clinics are REMS-certified.
How is Spravato eligibility evaluated?
A Spravato eligibility evaluation is a prescriber’s review of your diagnosis, past treatments, and health. You do not need a referral, but we require an official diagnosis of depression.
The evaluation usually runs in this order:
- Consultation: a free 30-minute conversation with a clinician about your history.
- Treatment history review: which antidepressants you took, at what dose, and for how long.
- Records to bring: your current medication list, records of past antidepressants with doses and dates, and your insurance card.
- Risk and benefit review: your prescriber weighs the conditions above and confirms which labeled use applies.
- Insurance approval: most plans require prior authorization with proof of a qualifying diagnosis, and we submit it for you.
If you already see a therapist or psychiatrist, we coordinate with them with your permission. Our insurance coverage page lists the Spravato plans we accept by state.
What if you do not qualify for Spravato right now?
Not qualifying today does not always mean not qualifying later. High blood pressure, a pregnancy, a manic episode, or fewer than two adequate antidepressant trials can all change, and then you can be evaluated again.
Other options are worth discussing with a clinician. IV ketamine therapy is used off-label for depression and dosed by weight. For some people, a different medicine or therapy plan fits better, and we refer out when it does. Individual results vary.
Where can you get a Spravato evaluation in DC, Maryland, and Virginia?
We offer Spravato evaluations at all five of our clinics, with monitored, in-clinic care since 2018 under protocols set by Dr. Ladan Eshkevari.
Our five clinics:
- Washington, DC: our Washington DC clinic.
- Bethesda, Maryland: our Bethesda, Maryland clinic.
- Columbia, Maryland: our Columbia, Maryland clinic.
- Tysons, Virginia: our Tysons, Virginia clinic, in Vienna.
- Norfolk, Virginia: our Norfolk, Virginia clinic, our newest location, serving Hampton Roads veterans and military families.
Payers and prices stay current on our Spravato treatment page.
To find out whether you qualify, book a free 30-minute consultation. We check your benefits before you commit to anything.
