What does Spravato (esketamine) treat? Spravato is FDA-approved to treat adults with treatment resistant depression and depression with suicidal ideation. Treatment resistant depression is major depression that has not responded to at least two antidepressant medications.
How does Spravato work? Spravato is the S form of the molecule ketamine. At low doses, it is an NMDA receptor antagonist that acts on a pathway in the brain that affects glutamate. This mechanism is not fully understood but appears to stimulate neuron proliferation and increased connectivity between neurons in the brain. This leads to a “reboot” of the processes that have become ingrained and lead to depression symptoms.
How is Spravato (esketamine) different from ketamine? Ketamine is an anesthetic that has been used for decades. In recent years, it has been used to treat depression. It is administered by intravenous infusion or intramuscular injection. It is widely used and being extensively studied but is not currently FDA-approved for treatment of depression. SPRAVATO™ (esketamine) is a derivative of ketamine that is administered as a nasal spray. This allows for easier dosing and improved tolerance (especially if you hate needles!). It does not produce the same degree of nausea, dissociation and psychedelic effects that ketamine does, which makes it a good choice for those who prefer to avoid such experiences.
How often do I need treatment? Induction Phase: Weeks 1-4, administer twice per week. Day 1 starting dose: 56 mg (2 devices), subsequent doses: 56 mg or 85 mg (3 devices) Maintenance Phase: Weeks 5-8, administer once per week, 56 mg or 84 mg Week 9 and after, administer once per week or once every other week, 56 mg or 84 mg; dosing is individualized to the least frequent dosing to maintain response During weeks 1-4, your appointments will typically be scheduled on Monday and Wednesday or Tuesday and Thursday, but we will do our best to make a plan that works for you. For planning purposes, we try to schedule appointments in blocks of 4 or more weeks at a time.
How soon can I expect to see results? Esketamine is known for its rapid therapeutic effect, with results often seen as soon as 24 hours after the first dose. While some people may start to feel relief from symptoms within 1-2 days, more significant effects are usually seen within a week of beginning treatment. The positive effects of esketamine may be felt not only in terms of mood improvement but also changes in behavior, such as enhanced productivity and an increased interest in activities or conversations.
How long do the benefits of Spravato last? The effects of Esketamine are usually short-term and may last anywhere from several hours to a week or more. For some people, however, the benefits can last for around one month after starting treatment with Esketamine. It is best to think of esketamine as one piece of a larger treatment plan that includes other medications, psychotherapy, proper nutrition, consistent exercise, getting enough sleep, managing stress, and staying connected with friends and family.
What happens during a treatment session? You should plan to arrive 10-15 minutes before the start of treatment so you will be in a relaxed, restful state to begin treatment. You will empty your bladder and blow your nose prior to treatment. Staff will bring into one of our treatment rooms where you will settle into a comfortable reclining chair. You will gently inhale the medication through your nose. Depending on your dose, this will be repeated 2 or 3 times. Your blood pressure will be checked periodically. Two hours after the start of treatment, staff will make sure you are safe to leave. You may not stand up or walk around during the treatment or observation time as you could be dizzy or drowsy.
What should I bring to my appointment? Please bring music with headphones or earbuds, a neck pillow, blanket, eye mask, or anything else that will make you feel more comfortable. You are going to be here for 2 hours, so it’s important that you’re comfortable. We recommend not reading, watching videos, or looking at your phone during treatment as it is important to reduce visual stimulation during treatment. This is the perfect time to listen to guided meditation and other programs that promote positive mental images and relaxation.
What happens after treatment? Following administration of Spravato, you may be drowsy or have a feeling of dissociation. It is a requirement that you have someone drive you home after treatment and you should not drive for 24 hours. This must be with a trusted friend or loved one who can be relied on for help if needed. Leaving the clinic by taxi or public transportation is not an acceptable form of transportation. If your lived one waits at the office for you, we have a comfortable waiting room with Wi-Fi and complimentary coffee and tea available. If they do not stay at the office, it is important that they return on time to pick you up.
What are the side effects of Spravato? The most common side effects are feeling sleepy (sedation); feeling disconnected from yourself, your thoughts, feelings, and things around you (dissociation); dizziness; nausea; spinning sensation; increased urination; increased blood pressure. There is also a small risk of abuse and misuse of the medication; and increased suicidal thoughts and behavior. Keeping you safe during treatment is our highest priority. This is the reason we are REMS certified, monitor your comfort and symptoms during treatment, measure blood pressure periodically, and observe you for a total of 2 hours during treatment. It is important to know that most side effects are minor, occur only during the treatment session, and tend to improve with each session as your body gets use to the medication. Most people tolerate the medication so well that the observation period can be reduced from 2 hours to 1 hour after the first month of treatment.
Are there any medical conditions that make Spravato unsafe? Spravato cannot be given to patients who are allergic to esketamine, ketamine, or any of the ingredients in Spravato; if you have blood vessel disease such aneurysm in the brain, chest, abdominal aorta, arms, or legs; if you have an abnormal connection between your veins and arteries (arteriovenous malformation or AVM); or history of bleeding in the brain. Spravato should not be used if you are pregnant or breastfeeding.
What is REMS certification? REMS stands for Risk Evaluation and Mitigation Strategy. It is a process through which both the provider and patient are registered with the goal of monitoring use of Spravato and reducing the risk of serious adverse outcomes resulting from sedation and dissociation, and abuse and misuse of Spravato. Spravato is a class 3 (CIII) controlled substance that is only available through a restricted distribution program. The medication can only be delivered to a healthcare office and must be administered under direct observation of a healthcare provider. We will help you will register for the REMS program during your initial consultation visit if Spravato is an appropriate treatment for you. After that, the provider will submit reports to the REMS program verifying that Spravato was given and monitored as required by the FDA. You can learn more about REMS here.
Does insurance cover the cost of treatment? Several insurers cover the cost of Spravato treatment. Some insurance companies require documentation of two failed antidepressant trials and others require at least four antidepressants from two different categories (SSRI, SNRI, bupropion, mirtazapine) including augmentation (atypical antipsychotic, lithium, T3). Every policy is different, and we will help you navigate your plan’s requirements, so you know your coverage and out-of-pocket costs prior to starting treatment. Central Berkshire Psychiatric Services is a network provider for Blue Cross, Health New England commercial plans, Cigna, and Medicare. We are not provider for MassHealth or Medicaid including Health New England Be Healthy and Tufts Direct. Some other insurance plans may offer out of network benefits, but these vary widely and should be discussed with us on a case-by-case basis. Janssen, the maker of Spravato, also has programs in place that can help reduce your cost. The initial consultation process includes registering with the Spravato withMe program so a case coordinator can contact you to review your case in detail and walk you through the steps of signing up for programs that can help reduce your costs. Click here.
What if my insurance does not cover treatment? The cost for treatment paid for privately is $400 per session. The cost of medication is separate and will depend on your pharmacy benefit or current pricing if you buy the medication privately. We do not mark up the cost of medication so the cost will depend on the price from our specialty distributor at the time of purchase.
If I have Spravato with you, can you prescribe my other medications too? Esketamine alone is not a long-term solution for depression. It should be used in conjunction with traditional antidepressant medications and psychotherapy to provide the best results. In other words, Spravato is an addition to your current treatment, not a replacement. We will work with your current providers to coordinate your care, but you will continue working with them throughout your treatment with Spravato. We are a small practice and do not have the capacity to take on new patients for medication management. We are able to take new patients for esketamine treatment (and TMS) because of the shorter time frame of a given treatment course compared to ongoing medication management.
Central berkshire psychiatric services, PC 440 South Street Pittsfield, MA 01201