Spravato and Ketamine for Depression Explained: What Treatment Sessions Involve, Side Effects, and Insurance Coverage

By the geminiwatermarksremover.com editorial team. Reviewed and updated on October 1, 2026.

This article is educational and independent. It is not medical advice, a diagnosis, or a treatment recommendation, and it is not a substitute for care from a qualified professional. Only a licensed clinician who has evaluated you can advise on your situation. Treatment approaches and availability vary by provider and by state.

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Ketamine has an odd reputation. Depending on who you ask, it is an anesthetic used in emergency rooms, a party drug, or a breakthrough depression treatment. All three are true, which is exactly why people feel uneasy when a psychiatrist brings it up.

If you have been told about Spravato, the brand name for esketamine nasal spray, or about ketamine infusions at a ketamine clinic, this guide explains what those treatments actually are, how they differ from each other, what happens during a treatment session, the side effects and safety rules, who they are generally considered for, and how insurance coverage and cost usually work. It does not tell anyone whether they should have the treatment. That conversation belongs with a prescriber.

Why ketamine-based treatments got attention

Most antidepressants work on the brain’s serotonin, norepinephrine, or dopamine systems, and they typically take several weeks to show their full effect. For people with treatment-resistant depression, who have tried more than one antidepressant without enough relief, that wait can repeat several times with little to show for it.

Ketamine acts differently. Its main action is on the glutamate system, the brain’s most widespread excitatory messenger, by blocking a receptor called the NMDA receptor. Researchers believe that this sets off downstream changes linked to the growth and strengthening of connections between nerve cells. The practical result that drew attention is that some people with hard-to-treat depression report improvement within hours or days rather than weeks. Not everyone responds, the effect can fade, and long-term evidence is still developing, but it represented a genuinely different mechanism. For background on the conventional route, see how antidepressants work.

Spravato (esketamine) versus ketamine infusions

These are related but not the same, and the differences affect regulation, insurance coverage, and what a session looks like.

Spravato compared with IV ketamine for depression
	Spravato (esketamine nasal spray)	IV ketamine infusion
What it is	One mirror-image form of the ketamine molecule, delivered as a nasal spray	Ketamine (a mix of both forms) delivered through a vein
FDA status for depression	FDA-approved for specific depression indications in adults	Not FDA-approved for depression; used off-label (ketamine itself is approved as an anesthetic)
Where it is given	Only at healthcare settings certified under a federal safety program (REMS)	Ketamine clinics, hospitals, and some psychiatry practices
Who administers it	You self-administer the spray under direct supervision	Clinician places an IV and controls the infusion
Insurance coverage	Often covered with prior authorization	Often not covered; frequently self-pay

What Spravato is approved for

The FDA approved Spravato in 2019 for adults with treatment-resistant depression, used together with an oral antidepressant. In 2020 it was approved for depressive symptoms in adults with major depressive disorder who have acute suicidal thoughts or behavior, again alongside an oral antidepressant. In early 2025 the FDA expanded its labeling so it can also be used on its own, without an oral antidepressant, for adults with treatment-resistant depression. Approval means the FDA judged its benefits to outweigh its risks for those specific uses. It is not a statement that it works for everyone, and it is not approved for children.

What off-label ketamine means

“Off-label” means a doctor is prescribing an approved drug for a use that is not on its FDA label. That is legal and common in medicine. But it also means there is no FDA-reviewed dosing standard for depression, practices vary between clinics, and insurers usually decline to pay. Some clinics also offer ketamine by intramuscular injection, lozenge, or other routes; evidence and oversight vary by route and by provider.

What a Spravato treatment session involves

Because of the risks described below, Spravato can only be given in a certified healthcare setting, never at home. A typical session runs roughly like this:

Check-in and blood pressure. Staff measure your blood pressure before treatment, because esketamine can raise it temporarily.
Self-administration. You use the nasal spray devices yourself while a staff member watches, with short pauses between devices.
Monitoring for at least two hours. You stay in a comfortable chair while staff check on you and recheck blood pressure. Many people put on headphones, rest, or listen to music.
Discharge assessment. A clinician confirms you are ready to leave.
Getting home. You cannot drive or operate machinery until the next day after a restful sleep, so someone else needs to take you home.

Treatment typically starts with sessions twice a week for several weeks, then reduces to weekly and later to every week or two, depending on response. The schedule is set by the prescriber according to the FDA label; we do not provide dosing details here.

That means the realistic commitment for the first month is several half-days a week, including transport. As with TMS therapy, the calendar is often the hardest part to arrange.

What an IV ketamine infusion session involves

At a ketamine clinic, a session usually starts with vital signs and a check-in. A nurse or physician places an IV, and the ketamine is infused slowly, commonly over around 40 minutes, while heart rate, blood pressure, and oxygen levels are monitored. Recovery takes a while longer afterward. Clinics often recommend an initial series of several infusions over two to three weeks, followed by occasional maintenance sessions for those who respond. As with Spravato, you need a ride home.

Because this is off-label, you should ask any ketamine clinic who supervises the infusion, what medical training they have, what monitoring and emergency equipment are present, how they screen patients, and how they coordinate with your psychiatrist or therapist.

What it feels like

The most common experience during treatment is dissociation: a sense of being detached from your body or surroundings, altered perception of time, sounds or colors seeming different, or feeling dreamlike. For most people it builds in the first part of the session and fades within an hour or two. Some find it pleasant, others unsettling. Staff are used to it and can help you through it. It tends to become more familiar over repeated sessions.

Other short-term effects people report include dizziness, nausea, sleepiness, a heavy or numb feeling, and an unusual taste from the nasal spray.

Side effects, risks, and safety rules

The FDA requires Spravato to carry a boxed warning, its most serious level of warning, and to be distributed only through a restricted program. Understanding why helps explain the rules.

Sedation and dissociation. These are why monitoring for at least two hours after each dose is mandatory.
Increased blood pressure. Usually temporary, peaking soon after dosing. People with certain heart and blood vessel conditions may not be candidates.
Potential for misuse. Ketamine and esketamine are controlled substances with abuse potential, which is one reason they are not dispensed for home use and why a history of substance use is discussed before treatment. If substance use is part of the picture, our explainer on dual diagnosis treatment may be relevant.
Suicidal thoughts and behavior. Like other antidepressants, Spravato carries a warning about suicidal thoughts and behaviors in younger people, and close monitoring during treatment is standard.
Other effects. With frequent, high-dose recreational ketamine use, bladder problems and cognitive effects have been reported. These are part of why medical use is supervised and why long-term safety continues to be studied.

People with certain conditions are generally not candidates, including some types of blood vessel disease, a history of bleeding in the brain, and known allergy to ketamine or esketamine. Pregnancy and breastfeeding require specific discussion. Only a prescriber who knows your full medical history can assess this.

The REMS program, in plain terms

REMS stands for Risk Evaluation and Mitigation Strategy. For Spravato, it means the clinic and pharmacy must be certified, patients are enrolled, the medication is administered and monitored on site, and patients never take the devices home. It is a safety framework, and it is the main reason Spravato is only available at certain clinics.

Who these treatments are generally considered for

In general terms, clinicians tend to discuss Spravato or ketamine when:

An adult has major depression that has not responded adequately to at least two antidepressant trials of adequate dose and duration.
An adult with major depression has acute suicidal thoughts or behavior, where Spravato may be used alongside other treatment. This does not replace emergency care.
Other options such as psychotherapy, medication changes, augmentation, or TMS have been tried or considered.

A full evaluation comes first. Our explainers on what happens at a psychiatric evaluation and the different types of mental health providers may help you prepare.

Ketamine-based treatments are usually one part of a broader plan rather than the whole plan. Psychotherapy, such as cognitive behavioral therapy, often continues alongside.

Spravato cost and insurance coverage

Spravato is a brand-name medication with a high list price per treatment session, plus separate charges for the clinic’s monitoring time. Because the schedule is frequent in the first weeks, total costs add up quickly without coverage.

The good news is that many commercial insurance plans, Medicare plans, and state Medicaid programs do cover Spravato, usually with conditions:

Prior authorization is almost always required. The prescriber typically documents the diagnosis, the antidepressants already tried, and why Spravato is appropriate.
Step therapy rules may require that specific other treatments have been tried first.
Billing route matters. Depending on the plan, Spravato may be billed under the medical benefit, the pharmacy benefit, or a specialty pharmacy, and the monitoring visit is billed separately. This affects your copay or coinsurance.
Manufacturer support programs may help with eligible commercially insured patients’ out-of-pocket medication costs; rules differ for government insurance.

IV ketamine for depression is a different story. Because it is off-label, most insurers do not cover the infusion itself, and clinics frequently charge per infusion as self-pay. Some plans may cover part of the associated office visit. Always ask for a written price for the full initial series, what monitoring is included, and whether any part can be submitted to insurance.

If an insurer denies coverage, that decision can often be appealed. On our sister site, see how prior authorization works for mental health treatment, how to appeal a denied mental health claim, and does insurance cover mental health treatment.

Questions to ask before starting

Why are you recommending Spravato or ketamine for me now, and what alternatives should we weigh?
Is this clinic REMS-certified for Spravato? For IV ketamine, who supervises, and what training do they have?
How will we decide whether it is working, and when would we stop?
What is the session schedule for the first month, and how long will each visit take door to door?
How will my blood pressure, heart conditions, or other medications be handled?
Do I continue my current antidepressant and therapy?
What will I pay per session, and has prior authorization been approved in writing?
What happens if I have an uncomfortable dissociative experience during a session?

Frequently Asked Questions

Is Spravato the same as ketamine?

Not exactly. Esketamine is one of the two mirror-image forms that make up ketamine. Spravato is an FDA-approved nasal spray of esketamine for specific depression uses, while IV ketamine for depression is an off-label use of an anesthetic.

How fast does Spravato work?

Some people notice changes within the first days or weeks, which is faster than typical antidepressants, but response varies and some people do not respond. Prescribers usually reassess after the initial weeks of treatment.

Can I take Spravato at home?

No. Under the FDA’s REMS program it is only administered in a certified healthcare setting with at least two hours of monitoring afterward.

Can I drive after a session?

Not for Spravato until the next day after a restful sleep, and clinics give similar instructions after ketamine infusions. Arrange a ride before each appointment.

Is ketamine therapy addictive?

Ketamine and esketamine have misuse potential, which is why medical use is restricted and supervised. In supervised treatment settings this risk is screened for and monitored. A history of substance use should be discussed openly with the prescriber.

Does insurance cover ketamine infusions?

Usually not, because IV ketamine for depression is off-label. Spravato, which is FDA-approved, is covered by many plans with prior authorization.

Final Thoughts

Ketamine-based treatment is neither a miracle nor a gimmick. For some adults whose depression has not responded to other options, it offers a different mechanism and sometimes faster relief, delivered under strict supervision for good reasons.

If it has been suggested to you, bring three things to the next appointment: your list of past treatments and how each went, your calendar for the next month, and your insurance card. Those three things will answer most of the practical questions, and leave you free to focus on the clinical one.

Sources

This article is for general informational and educational purposes only. It does not constitute medical advice, a diagnosis, a treatment recommendation, or a substitute for evaluation and care by a qualified health professional. Descriptions of conditions, therapies, procedures, and medications are general and educational; individual experience, suitability, risks, and outcomes vary substantially, and treatment practices change over time. This site is independently operated. It is not a healthcare provider, a treatment facility, a licensed clinician, or a government agency, and it cannot evaluate, diagnose, or treat anyone. Never start, stop, or change any medication or treatment based on anything you read here. Always consult a licensed clinician about your own care, and if you are in crisis, use the free resources listed above.