Spravato · Esketamine
Spravato for treatment-resistant depression — physician-supervised, in our office.
Spravato (esketamine) is an FDA-approved nasal-spray treatment for depression that hasn't responded to standard antidepressants. It's administered in-office under medical supervision, with the required two-hour monitoring after each dose.
Medically reviewed by C. Britt Beasley, MD · Last reviewed June 10, 2026
The treatment
What Spravato is
Spravato is the brand name for esketamine, delivered as a nasal spray. It is FDA-approved for adults with treatment-resistant depression — generally meaning depression that hasn't responded to two or more oral antidepressants. It also carries a separate FDA approval for depressive symptoms in adults with major depressive disorder who have acute suicidal ideation or behavior, used together with an oral antidepressant — a distinct clinical situation Dr. Beasley will discuss only if it applies to you.
Because of its safety profile, Spravato is available only through a restricted program (a REMS) and can only be administered in a certified healthcare setting under supervision. It is not a prescription you take home.
How it differs from oral antidepressants
Oral antidepressants generally act on the brain's serotonin and norepinephrine systems and are taken daily at home. Esketamine works through a different mechanism — the glutamate/NMDA system — and is given in-office on a defined schedule. For some patients who haven't responded to the standard medication classes, a different mechanism of action is the point.
What to expect in the office
Spravato is self-administered as a nasal spray while you're in the office, under supervision. After each dose, you're monitored for at least two hours, because esketamine can cause temporary sedation, a sense of dissociation, and blood-pressure changes. During monitoring you stay in a comfortable space; your blood pressure and oxygen are checked, and staff are present until you're clinically stable to leave.
Because of the temporary sedation, you cannot drive after a Spravato session — arrange a ride home, and plan not to drive for the rest of the day.
Induction & maintenance
Treatment is structured in phases:
- Induction: twice weekly for the first 4 weeks.
- Maintenance: weekly for 4 weeks, then spaced out as appropriate to sustain the benefit.
Dosing is titrated — typically starting at 56 mg and adjusting to 84 mg as appropriate — based on how you respond and tolerate it. The schedule and dose are individualized and managed by Dr. Beasley.
Candidacy
Are you a candidate?
Spravato is generally considered when:
- You have treatment-resistant depression — typically having tried two or more antidepressants without adequate response;
- You can attend in-office sessions and remain for the two-hour monitoring;
- You don't have medical conditions that make it unsafe, which Dr. Beasley screens for at evaluation.
As with every interventional treatment here, candidacy is a clinical judgment made with you — not a box you check online.
Specialty-pharmacy & insurance
Spravato is dispensed through a specialty-pharmacy model and is covered by many plans for treatment-resistant depression, though prior authorization is typically required. We use the manufacturer's Spravato With Me platform to coordinate access and verify benefits. We don't publish esketamine pricing — we walk through your specific coverage with you.
How insurance & access worksSpravato vs. IV ketamine — honestly
Both involve a ketamine-family molecule, but they aren't the same. IV ketamine is delivered intravenously, which allows precise, individualized dosing — and it has shown higher efficacy in clinical trials. Spravato (esketamine) is a nasal spray that carries an FDA approval for treatment-resistant depression, which makes it more likely to be insurance-covered.
At Richmond Brain & Behavior we offer both, delivered under physician monitoring. IV ketamine is a strong option when efficacy is the priority; Spravato offers an insurance pathway for treatment-resistant depression. Dr. Beasley will help you decide which is the better fit for your situation.
Spravato questions
Common questions
Is Spravato covered by insurance in Virginia?
How is Spravato different from IV ketamine?
Why do I have to stay two hours?
Can I drive home after a Spravato session?
Now accepting new patients
Ask whether Spravato is right for you.
Request an evaluation and Dr. Beasley will review your history, screen for safety, and tell you honestly whether Spravato fits. New patients are typically seen within days.