Starting Spravato® (esketamine) raises practical questions. How often will I come in? How long will each visit last? What happens if I miss one? And how do the visits change over time?
This guide walks through the full treatment journey, from the first four weeks of induction to long-term maintenance, including what happens during a visit and why medical monitoring is a required part of every session.
Please note: This article is educational and is not medical advice. The schedule below reflects FDA labeling for adults, but your prescriber individualizes your dose and frequency based on your response and tolerability.
Your Spravato Schedule at a Glance
For adults with treatment-resistant depression (TRD), the FDA-approved schedule has an induction phase followed by a maintenance phase (Janssen Pharmaceuticals, Inc., 2025):
| Phase | Timing | How often | Dose |
|---|---|---|---|
| Induction | Weeks 1 to 4 | Twice per week | 56 mg or 84 mg |
| Maintenance | Weeks 5 to 8 | Once weekly | 56 mg or 84 mg |
| Maintenance | Week 9 and after | Every 2 weeks or once weekly | 56 mg or 84 mg |
Dose adjustments are based on how well you respond and how well you tolerate treatment. From week 9 onward, the label directs prescribers to use the least frequent dosing that maintains remission or response (Janssen Pharmaceuticals, Inc., 2025).
Adults with major depressive disorder who have acute suicidal ideation or behavior follow a different, shorter plan: 84 mg twice per week for 4 weeks, together with an oral antidepressant. The dose may be lowered to 56 mg if needed for tolerability, and benefit is reassessed after 4 weeks because use beyond that point has not been systematically evaluated for this indication (Janssen Pharmaceuticals, Inc., 2025).
Induction Phase: Weeks 1 to 4
Induction is the most frequent stage of treatment, with two visits each week for four weeks. At the end of that period, your clinician evaluates whether you are benefiting to decide whether continued treatment makes sense (Janssen Pharmaceuticals, Inc., 2025).
In the key 4-week study of Spravato plus a newly started oral antidepressant (Popova et al., 2019), depression scores on the MADRS, a 0-to-60 clinician-rated scale on which higher scores mean more severe symptoms, fell by an average of 19.8 points with Spravato, compared with 15.8 points with placebo nasal spray (a 4.0-point difference). Most of that difference appeared within 24 hours of the first dose (Janssen Pharmaceuticals, Inc., 2025). A separate study of Spravato used alone also showed greater improvement than placebo at Day 28 (Janssen Pharmaceuticals, Inc., 2025).
These are group averages, and individual responses vary. The early visits are also when most patients learn how their bodies respond. Reports of nausea and vomiting decreased over time across dosing sessions in clinical trials (Janssen Pharmaceuticals, Inc., 2025), and the intensity of dissociative symptoms lessened with repeated administration during induction in the long-term maintenance study (Daly et al., 2019).
Maintenance Phase: Week 5 and Beyond
If you are benefiting, visits taper to weekly in weeks 5 through 8 and then to either weekly or every other week from week 9 onward (Janssen Pharmaceuticals, Inc., 2025).
How is your maintenance frequency chosen?
In the major relapse-prevention trial, clinicians reassessed dosing every four weeks using a depression rating scale. Patients in remission were dosed every two weeks, and those who had not reached or kept remission were dosed weekly (Daly et al., 2019). Your clinic’s approach will be individualized to your symptoms and how you tolerate treatment.
What does the research say about continuing treatment?
In that trial, adults who reached remission or a stable response after 16 weeks of Spravato plus an oral antidepressant were randomly assigned to continue Spravato or to switch to placebo nasal spray, both with their oral antidepressant. Among patients in stable remission, relapse occurred in 26.7% of those who continued Spravato versus 45.3% of those who switched. Among patients with a stable response, relapse occurred in 25.8% versus 57.6%. Continuing treatment lowered the risk of relapse by 51% in the remission group and 70% in the response group (Daly et al., 2019).
Longer-term data point the same way on safety and durability. In SUSTAIN-3, an open-label extension study of 1,148 adults, participants in maintenance received intermittent dosing for an average of 31.5 months. About 46% were in remission at the end of the maintenance phase, and no new safety signal appeared over up to 4.5 years of treatment (Zaki et al., 2023). Because that study had no placebo group, it supports the durability and safety of treatment rather than proving its effect on its own.
What if you miss a session?
If you miss a session and your depression has not worsened, you continue on your current schedule. If you miss sessions during maintenance and your symptoms worsen, your prescriber may consider returning to your previous schedule, for example going back from weekly to twice-weekly dosing (Janssen Pharmaceuticals, Inc., 2025). Whether to continue, space out, or stop treatment is a decision to make together with your prescriber.
What Happens During Each Spravato Visit
Every visit follows a consistent routine, described in the FDA labeling (Janssen Pharmaceuticals, Inc., 2025). For a longer walkthrough, see What Happens During a Spravato Session.
- Before you arrive. Avoid food for at least 2 hours and liquids for at least 30 minutes before your dose, since nausea and vomiting can occur. If you use a nasal steroid or nasal decongestant on a treatment day, take it at least 1 hour beforehand. Arrange a ride home.
- Check-in and blood pressure. Staff check your blood pressure before dosing. If it is elevated (as a general guide, above 140/90 mmHg), your clinician weighs the risks and benefits and may delay your dose.
- Administration. You blow your nose before the first device only. Each 28 mg device delivers two sprays, one in each nostril. A 56 mg dose uses two devices and an 84 mg dose uses three, with a 5-minute rest between devices. You tilt your head back about 45 degrees and administer the spray yourself while staff observe and confirm that each device is empty.
- Observation. Your blood pressure is checked again about 40 minutes after dosing, and you are monitored for at least 2 hours, including pulse oximetry, until your clinician determines you are clinically stable.
- Going home. You will need someone to drive you. Do not drive or operate machinery until the next day after a restful sleep.
Plan for at least two hours of observation after your dose, plus time for check-in, blood pressure checks, and dosing itself. Ask your clinic for a realistic window so you can plan your day.
Side Effects and Safety Monitoring
The most common side effects in clinical trials were dissociation (feeling disconnected from yourself, your thoughts, or your surroundings), dizziness, nausea, sedation, vertigo, numbness or decreased sensation, anxiety, lethargy, increased blood pressure, vomiting, feeling drunk, and headache (Janssen Pharmaceuticals, Inc., 2025). In the long-term SUSTAIN-3 study, nearly all dissociation events (99.8%) and sedation events (99.4%) began and resolved on the day of dosing, and more than 89% of participants were ready for discharge by 1.5 hours after their dose (Zaki et al., 2023).
The reasons for monitoring are specific:
- Blood pressure: Spravato raises blood pressure at all recommended doses, peaking about 40 minutes after dosing and lasting about 4 hours. Between 3% and 19% of treated patients in trials, depending on the study, had a rise of at least 40 mmHg in systolic or 25 mmHg in diastolic pressure at least once during the first four weeks.
- Sedation and breathing: Sedation on a standardized alertness scale occurred in 48% to 61% of treated patients in trials, and loss of consciousness in 0.3% to 0.4%. Respiratory depression has been reported after approval, with rare reports of respiratory arrest, which is why pulse oximetry is part of monitoring.
- Dissociation: Dissociative or perceptual changes were measured in 61% to 84% of treated patients in trials. They were transient and occurred on the day of dosing.
- Abuse and misuse: Spravato is a Schedule III controlled substance with potential for abuse and misuse, so clinicians screen for risk and monitor throughout treatment.
All figures in the list come from the FDA labeling (Janssen Pharmaceuticals, Inc., 2025). For a deeper look at safety, read Is Spravato Safe? What Medical Monitoring Should Be in Place?
Tell your clinician before starting if you have:
- Aneurysmal vascular disease, an arteriovenous malformation, or a history of bleeding in the brain (these are contraindications)
- High blood pressure, a history of heart attack or stroke, heart valve disease or heart failure, or brain conditions involving increased pressure
- Liver problems or a history of psychosis
- A history of substance or alcohol use disorder
- Pregnancy or plans to become pregnant, or plans to breastfeed (breastfeeding is not recommended during treatment)
- Use of central nervous system depressants (such as benzodiazepines, opioids, or alcohol), psychostimulants, or monoamine oxidase inhibitors
Spravato is not approved for anyone under 18. Antidepressants can increase suicidal thoughts and actions in people 24 and younger, especially in the first few months of treatment or after dose changes. Tell your care team right away about any new or worsening mood changes, anxiety, agitation, or thoughts of suicide (Janssen Pharmaceuticals, Inc., 2025).
The REMS Requirement: Why Treatment Happens in a Certified Clinic
Spravato is available only through a restricted FDA program called the Spravato REMS (Risk Evaluation and Mitigation Strategy), because of the risks of serious outcomes from sedation, dissociation, respiratory depression, and abuse and misuse. Under the program, healthcare settings must be certified, patients treated in outpatient settings must be enrolled, doses are self-administered under direct observation, and patients are monitored for at least two hours afterward. Spravato must never be dispensed directly to a patient for home use (Janssen Pharmaceuticals, Inc., 2025; SPRAVATO REMS, n.d.).
Therapeutic Infusions is a REMS-certified Spravato center, so every step above takes place in a private treatment room with continuous medical supervision.
Frequently Asked Questions
Can I take Spravato at home?
No. Spravato is only given in a REMS-certified healthcare setting and must never be dispensed for home use (SPRAVATO REMS, n.d.).
Can I drive myself home or to work afterward?
No. Plan for someone to drive you home, and avoid driving or operating machinery until the next day after a restful sleep (Janssen Pharmaceuticals, Inc., 2025).
Will I need to stay on Spravato indefinitely?
Not necessarily. Your clinician evaluates your benefit at the end of induction and adjusts the frequency over time, aiming for the least frequent dosing that keeps you well (Janssen Pharmaceuticals, Inc., 2025). Whether to continue, space out, or stop is individualized, so decide it with your prescriber rather than on your own.
Do I still take my oral antidepressant?
It depends. For TRD, Spravato is FDA-approved either on its own or together with an oral antidepressant (Janssen Pharmaceuticals, Inc., 2025). Your prescriber decides what is right for you, so do not stop or change any medication without talking with them first.
What if Spravato doesn’t work for me?
Not everyone responds, which is why benefit is formally reassessed at the end of induction. If it is not helping, there are next steps to discuss. Read What If Spravato Doesn’t Work? Next-Step Options for Patients.
Scheduling Your Spravato Treatment at Therapeutic Infusions
A twice-weekly induction schedule can be hard to fit around work, school, and family. At Therapeutic Infusions, appointments are available seven days a week, up to 10 PM, and we offer immediate appointments that bypass standard three- to six-month psychiatric wait times. Ongoing psychiatric talk therapy and medication management, led by board-certified psychiatric nurse practitioners, are available alongside treatment. We serve patients from our Wilmington, Delaware headquarters and our Warrington, Pennsylvania campus, and we assist patients through insurance authorization.
Learn more about Spravato treatment, see our insurance information, or contact our team to schedule a consultation.
If you are in crisis or having thoughts of suicide, call or text 988 (the Suicide & Crisis Lifeline), or call 911 in an emergency.
References
Daly, E. J., Trivedi, M. H., Janik, A., Li, H., Zhang, Y., Li, X., Lane, R., Lim, P., Duca, A. R., Hough, D., Thase, M. E., Zajecka, J., Winokur, A., Divacka, I., Fagiolini, A., Cubała, W. J., Bitter, I., Blier, P., Shelton, R. C., . . . Singh, J. B. (2019). Efficacy of esketamine nasal spray plus oral antidepressant treatment for relapse prevention in patients with treatment-resistant depression: A randomized clinical trial. JAMA Psychiatry, 76(9), 893–903. https://doi.org/10.1001/jamapsychiatry.2019.1189
Janssen Pharmaceuticals, Inc. (2025). Spravato (esketamine) nasal spray, CIII: Full prescribing information and Medication Guide (Reference ID 5580441). U.S. Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/211243s019lbl.pdf
Popova, V., Daly, E. J., Trivedi, M., Cooper, K., Lane, R., Lim, P., Mazzucco, C., Hough, D., Thase, M. E., Shelton, R. C., Molero, P., Vieta, E., Bajbouj, M., Manji, H., Drevets, W. C., & Singh, J. B. (2019). Efficacy and safety of flexibly dosed esketamine nasal spray combined with a newly initiated oral antidepressant in treatment-resistant depression: A randomized double-blind active-controlled study. American Journal of Psychiatry, 176(6), 428–438. https://doi.org/10.1176/appi.ajp.2019.19020172
SPRAVATO REMS. (n.d.). What is the SPRAVATO® REMS (Risk Evaluation and Mitigation Strategy)? https://www.spravatorems.com/
Zaki, N., Chen, L. (N.), Lane, R., Doherty, T., Drevets, W. C., Morrison, R. L., Sanacora, G., Wilkinson, S. T., Popova, V., & Fu, D.-J. (2023). Long-term safety and maintenance of response with esketamine nasal spray in participants with treatment-resistant depression: Interim results of the SUSTAIN-3 study. Neuropsychopharmacology, 48(8), 1225–1233. https://doi.org/10.1038/s41386-023-01577-5
Leave a Reply