Plan for a visit of more than 2 hours, with the rest of the day kept free. You check in and have your blood pressure taken, use the nasal spray yourself under supervision, and then rest while staff monitor you for at least 2 hours. A clinician decides when you are ready to leave, and someone else needs to drive you home.
Part of our guide: A Patient’s Guide to Ketamine and Spravato
The timeline below comes from the current FDA label and Medication Guide and the REMS safety program. Those set minimum requirements. Each certified setting has its own way of running a visit, so ask for details at your own clinic.
If you are thinking about suicide or are in danger, call or text 988 (988 Suicide & Crisis Lifeline), call 911 or go to the nearest ER.
Before your visit
- Food and drink. Because nausea and vomiting can happen, the label advises no food for at least 2 hours before the dose and no liquids for at least 30 minutes before.
- Nasal sprays. If you need a nasal corticosteroid or decongestant that day, use it at least 1 hour before your session.
- Your ride. Arrange it ahead of time. You should not drive or use machinery until the next day, after a restful sleep.
- Your medicines. Your prescriber should already know everything you take, especially central nervous system depressants, psychostimulants and MAOIs. Ask them whether anything should change on treatment days. Do not decide on your own.
- Your day. Leave the rest of it open. Think about childcare and work ahead of time, since you should avoid activities that need you to be fully alert.
Arrival and blood pressure check
Under the REMS, people treated in outpatient settings must be enrolled in the program before their first dose, and enrollment is verified before each dose. Staff will check your blood pressure. The label notes that if it is elevated, as a general guide above 140/90, the clinician weighs whether to delay treatment. So a session can be postponed, and that is part of keeping you safe.
This is a good time to mention anything new, such as illness, a new medicine or changes in your mood.
The spray: two or three devices, with 5-minute rests
You spray the medicine yourself while a healthcare provider watches. Spravato comes in single-use devices, and each delivers two sprays, one per nostril. The label describes two or three devices per session, based on the dose your prescriber has set. Staff follow the Instructions for Use:
- You blow your nose before the first device only.
- You recline your head to about 45 degrees and spray into one nostril while closing the other, then sniff gently.
- You repeat this in the other nostril.
- Staff check the device to confirm that it is empty.
- You rest for 5 minutes, ideally semi-reclined, before the next device. If liquid drips, dab it with a tissue, and do not blow your nose.
Up to about 40 minutes after the last spray: drug level and blood pressure peak
Esketamine reaches its highest level in the blood 20 to 40 minutes after the last spray. Blood pressure rises peak around 40 minutes, and the label calls for a recheck at about that point.
The experience differs between people, and sometimes between sessions. Effects the Medication Guide and label describe include:
- feeling disconnected from yourself, your thoughts, your surroundings, or from space and time
- sleepiness
- dizziness or a spinning sensation
- numbness
- nausea
- anxiety
- feeling drunk
- feeling very happy or excited
In trials, 61% to 84% of people had dissociative or perceptual changes, and 48% to 61% had sedation, so these effects are expected. Less commonly, 0.3% to 0.4% lost consciousness. Tell staff right away if you feel you cannot stay awake or you might pass out. Tell them too about chest pain, shortness of breath, a sudden severe headache, a change in vision or a seizure.
At least 2 hours after dosing: rest and monitoring
You will stay in the healthcare setting throughout this period, while staff check on you. Under the REMS, the setting must have a prescriber onsite and must have healthcare providers and a pulse oximeter available, because Spravato can slow or stop breathing. The boxed warning covers:
- Sedation, dissociation and respiratory depression. Patients can become sleepy, feel disconnected, or have slowed or stopped breathing after a dose, so they must be monitored for at least 2 hours at each session and then assessed before they can leave.
- Abuse and misuse. Spravato is a Schedule III controlled substance. Risk should be weighed before prescribing and watched for during treatment.
- Suicidal thoughts and behaviors in young people. Antidepressants increased these risks in pediatric and young adult patients in short-term studies. All antidepressant-treated patients should be watched closely for worsening or new suicidal thoughts. Spravato is not approved for anyone under 18.
Whether you may use your phone, listen to music or have someone with you varies by clinic, so ask. In the trials, dissociation was temporary and occurred on the day of dosing, and the REMS calls for monitoring until sedation, dissociation and breathing effects have resolved. In a study of healthy volunteers, thinking performance and mental effort were comparable to placebo at 2 hours after a single dose.
Going home: a clinician's decision
Two hours is the minimum and does not guarantee you can leave then. The label requires an assessment to determine when you are clinically stable and ready to go. If blood pressure is falling and you appear stable for at least 2 hours, you may be discharged. If not, monitoring continues.
After each outpatient dose, the clinic also has to send a monitoring form to the REMS program within 7 days. That paperwork happens behind the scenes.
The rest of the day
Blood pressure increases can last about 4 hours after a dose. Plan a quiet evening. Sleepiness in the healthy-volunteer study was comparable to placebo after about 4 hours, but people differ, and you should still avoid driving and other risky activities. The Medication Guide says common side effects usually go away the same day. Call your provider for medical advice about any side effect.
The next morning
The label says to wait until the next day, after a restful sleep, before driving. In driving studies, performance looked similar to placebo at 18 hours, though two people in one study stopped a driving test at 8 hours because of side effects. If you still feel off, do not drive.
Over the following weeks
The label's schedule for treatment-resistant depression starts with sessions twice a week for 4 weeks, followed by a review of whether you are benefiting. Treatment may then continue less often. This article on what comes after the first series explains the next phase.
Between sessions, watch for changes in mood, and tell your provider right away about new or worse depression, thoughts of suicide, severe restlessness, or other unusual changes. Also mention any bladder symptoms, such as urgency or pain, and any trouble with thinking or memory.
Where to learn more
You can read how Mind Body Seven describes treatment on its Spravato page, and this overview of Spravato covers the basics. Costs and coverage are addressed in this guide. If you have questions about how visits are scheduled, the intake team can help. Ketamine visits are a separate topic, since ketamine for depression is off-label and sessions follow no FDA label. See what to expect in a ketamine session.
FAQs
Is a taxi or rideshare home acceptable?
The label says you need transportation arranged and should not drive. Ask your clinic whether it has specific rules about who may take you home.
What happens after a missed session?
Call your clinic. The label says that if depression has not worsened, the current schedule generally continues, and that a prescriber may return to a more frequent schedule if symptoms worsen during maintenance.
What if a session feels frightening?
Tell the staff right away. Dissociation and anxiety are known effects, and being monitored in a clinic means someone is there to help. Afterward, talk it through with your prescriber.
What about work the next day?
The label limits driving and activities that need full alertness until the next day, after a restful sleep. If your job includes driving or safety-sensitive tasks, ask your prescriber how to plan around sessions.
