The Story on Spravato

(Note to casual browsers- I am NOT planning on becoming a Spravato provider in the near future. For the reasons why, read on. . .)

This week the FDA approved the new antidepressant adjunct Spravato (esketamine) nasal spray for treatment-resistant depression, defined as patients who have failed 2 or more antidepressant drugs. There’s a lot of buzz about it in the media- what’s it all about?

Ketamine is an anesthetic drug primarily used in children and animals. It’s also been a recreational drug popular among ravers- known on the street as “Special K”. It gets digested and becomes inactive when taken by mouth, so it has to be given intravenously or through nasal inhalation.

It’s also been researched for years as a possible treatment for depression. There are numerous published studies showing short-term, rapid onset of antidepressant effects. “Ketamine Clinics” have popped up around the country, including one in Greenwood, which offer so-called off-label use of IV Ketamine for depression sufferers. Since it’s off-label (not approved by the FDA), it’s not covered by insurance, and the cost has been prohibitive for many potential users (typically $500 per injection).

Since ketamine has long been generic (i.e., there’s no money to be made in it by pharma companies), Johnson and Johnson researched and got approved the closely related compound esketamine, the active stereoisomer of ketamine (think Lexapro and Celexa as a similar set of drugs). Part of the excitement around Spravato has been that it has a unique mechanism of action unrelated to the serotonin and norepinephrine reuptake inhibitors we’re all familiar with. They posit it’s supposed to work through the glutamate system, although some research indicates it’s the opioid system that’s actually responsible for the antidepressant effect.

Spravato can’t be used at home- you have to take it in a medically supervised setting. The initial phase is twice weekly treatments for a month, then once weekly for a month, then either once weekly or every 2 weeks thereafter. You have to be monitored for side effects for at least 2 hours after the nasal inhalation, and can’t drive that day. Side effects include sedation, dissociation, and high blood pressure, with rare bladder problems possible.

It’s always exciting to have new treatments for depression available, and particularly new treatments with a unique mechanism of action. Time will tell how widely used Spravato becomes. The cost of the drug is a concern- Spravato’s list price will be $590 to $885, depending on the dose, so 8 treatments for the first month will run from $4720 to $7080. We can expect pushback and resistance from insurance companies to paying for it.

The other question will be how much you’ll have to pay for the monitoring after the inhalations. Insurance companies are very resistant to paying for this kind of thing, and Spravato clinics will likely have to charge the patient out-of-pocket for the monitoring. How much will that be, and how many Spravato clinics will pop up around the country? We’ll see! Due to the cost and monitoring issues it’s not something I personally plan on getting into, at least for now . There’s a website,, that’s supposed to have a map to help you find Spravato providers activated later this month. I’d advise checking there if you’re interested- or consider going to an IV Ketamine clinic and paying out of pocket, which realistically may end up not being much more expensive.

That’s the story on Spravato!