If you’ve tried more than one antidepressant without real relief, you’ve probably heard the term treatment-resistant depression. It’s not a verdict — it’s simply a description of where standard treatment has left off, and where other options begin. Spravato® is one of those options, and it’s the one I’m asked about most often these days.
I want to walk through what it actually is, who it’s for, and what a treatment session looks like in practice — not the marketing version, but what I tell patients sitting across from me in Portsmouth.
What Spravato® is
Spravato® is the brand name for esketamine, a nasal spray approved by the FDA for treatment-resistant depression and, more recently, for major depressive disorder with acute suicidal ideation. It’s derived from ketamine, but it’s a distinct, regulated pharmaceutical — not the same as ketamine used recreationally or in unsupervised settings.
What makes it different from a standard antidepressant is the mechanism. Most antidepressants work on serotonin or norepinephrine pathways, and they typically take four to six weeks to show effect, if they work at all. Esketamine acts on the glutamate system instead, which is part of why some patients notice a shift in mood within hours or days of their first few sessions — though it’s important to say clearly that response varies, and it isn’t a cure or a guarantee.
Who qualifies
Spravato® isn’t a first-line treatment, and it shouldn’t be. The FDA approval is specifically for adults who have tried at least two oral antidepressants at adequate doses for adequate durations without sufficient improvement. That history matters — it’s part of what I review carefully before recommending it.
- You’ve tried two or more antidepressants without adequate relief
- You’re currently working with a psychiatrist on an ongoing medication plan
- You’re able to arrange a ride home after each session — driving isn’t permitted
- You’re willing to attend in-person monitoring sessions in our Portsmouth office
Eligibility is determined after a thorough evaluation of your treatment history, current medications, and overall health — not from a questionnaire alone. I look closely at what’s already been tried and why it didn’t work, because that often points toward whether esketamine is actually the right next step, or whether something else in your medication plan needs adjusting first.
What a session actually looks like
This is the part patients are usually most curious about, and understandably so. Here’s the sequence:
- You arrive at our Portsmouth office. No driving on treatment days — please arrange a ride in advance.
- I administer the nasal spray myself, in a quiet, monitored setting. The session lasts approximately two hours.
- You rest and are observed during the monitoring window, as required by the REMS program. Many patients use this time for guided reflection, journaling, or quiet audio.
- You’re cleared before leaving. A ride home is required.
The REMS monitoring requirement — Risk Evaluation and Mitigation Strategy — is mandated by the FDA, not something individual practices choose to add. It exists because esketamine can cause temporary dissociation, sedation, and changes in blood pressure during the dosing session, all of which need to be observed by a healthcare provider until they resolve.
What to expect afterward
Treatment is typically delivered in a series — more frequent at first, tapering to less frequent maintenance sessions over time, depending on how you respond. Some patients notice changes in mood within the first few sessions; for others, it takes longer, and for some, esketamine isn’t the right fit at all. I track response carefully and adjust the plan accordingly, in conversation with you at every step.
It’s also not a replacement for your existing care — Spravato® works alongside an oral antidepressant, not instead of one, and ongoing psychiatric follow-up remains part of the plan throughout treatment.
Is it right for you?
If you’ve been through multiple medications without the relief you were hoping for, it’s worth a conversation — not necessarily because Spravato® is automatically the answer, but because a thorough review of your treatment history sometimes uncovers options that haven’t been tried yet, esketamine included. That conversation is where I’d want to start.