At our clinic, we are deeply committed toproviding effective, holistic, and patient‑centered care for those strugglingwith depression and other mental health challenges. That commitment extends tothe treatments we offer and, sometimes equally importantly, to treatments we choosenot to offer. One such example is Spravato (esketamine), the FDA‑approvednasal spray that has gained considerable attention in recent years as a noveloption for depression.
Although Spravato has proven benefits forsome, it also carries limitations which are both clinical and practical andmake it not an ideal choice for every patient. After careful review ofthe data, costs, and patient experience, our clinic has chosen not to prescribeSpravato. The reasons we’ve drawn this conclusion are explored in this article.
Spravato’s pricing structure is among themost significant concerns for both patients and the broader healthcare system.
A Spravato treatment session, typicallyincluding the medication, clinical administration, and mandatory observationperiod, can cost several thousand dollars per visit when billed to insurance.While actual allowed amounts vary widely by plan and setting, in somereal‑world billing examples insurers have paid thousands per treatment sessionafter hospital coding, with total series costs that can reach tens of thousandsof dollars over many weeks of therapy.
Even though Spravato is FDA‑approved andmany insurers will cover it with prior authorization, this doesn’t mean thecost disappears. In many cases:
● Patients still face highdeductibles, coinsurance, or copays before benefits apply.
● Insurers require documentation ofmultiple failed antidepressants before authorizing coverage.
● Healthcare systems - ultimatelypatients through their premiums - absorb enormous expenditures simply becausethis drug is reimbursed at a very high rate.
By contrast, off‑label racemic ketaminecontaining both R‑ and S‑ketamine molecules is typically much lessexpensive, even without insurance. Infusions, injections, or compounded oral ornasal routes are often billed in the low hundreds to low thousands per session.
These financial disparities are partlydue to Spravato’s proprietary status and lack of generic alternatives. Janssen,the manufacturer, holds exclusive rights to market Spravato (esketamine) andhas structured pricing accordingly. This in turn drives up insurer costs, whichcontributes to higher premiums and restricted formularies across mental healthmedications.
In short: Spravato’s cost to bothpatients and to the insurance system is disproportionate relative to what themedication delivers compared with alternative ketamine therapies.
Ketamine is a chiral molecule, meaning itexists as two mirror‑image forms: S‑ketamine (esketamine) and R‑ketamine(arketamine).
● In traditional clinical practice(including IV infusions and oral preparations) patients receive racemicketamine, which includes both enantiomers.
● Spravato, by contrast, containsonly the S‑ketamine (esketamine) enantiomer. There are important implicationshere:
Racemic ketamine may provide broaderpharmacologic activity because both enantiomers interact with NMDA receptorsand other central nervous system targets in ways that aren’t fully replicatedby esketamine alone. Some clinicians and preclinical research suggest that theR‑ketamine component may contribute uniquely to antidepressant effects,potentially enhancing the overall benefit of racemic ketamine. By removing theR‑ketamine component, Spravato delivers a reduced spectrum of pharmacologicactivity which, for some patients, may translate to lower efficacy.Observations from ketamine practitioners bear this out anecdotally: many reportpatients transitioning from Spravato to racemic ketamine with better outcomes.
Spravato is not simply “ketamine in anasal spray.” It’s a distinct compoundwith distinct effects. This matters when a clinic’s goal is to tailor treatmentto a patient’s biology and symptom profile.
While Spravato’s FDA approval is abenefit in terms of standardized safety data, it also imposes stringentrequirements:
● Patients must receive Spravatoonly in REMS‑certified facilities.
● Each session mandates observationfor at least two hours after dosing due to risks such as sedation anddissociation.
● The need for specializedcertification and extended clinical monitoring limits access and createsadministrative burdens that many practices (including ours) choose not to adoptbecause they detract from patient‑centered flexibility.
These controlled administrationrequirements, while intended to enhance safety, can make treatment feel rigidand prohibitive for patients whose lives and obligations make frequent clinicvisits challenging.
Spravato’s FDA approval stemmed fromrigorous clinical trials showing efficacy in treatment‑resistant depression.However, two important caveats apply:
● The long‑term effectiveness andsafety profile of Spravato remains less well established than many wouldassume; studies have focused on acute changes over weeks rather than sustainedfunctional recovery over years.
● Most comparative evidence suggeststhat racemic ketamine (especially when individualized in dose and route) oftenyields more robust and consistent results for many patients. Although directhead‑to‑head randomized trials are limited, convenience samples and providerexperience suggest notable differences in outcomes.
For these reasons, a one‑size‑fits‑allapproach with Spravato is not appropriate. We believe treatment decisionsshould be individualized, and we prioritize options that maximize thelikelihood of meaningful recovery while minimizing unnecessary cost or burden.
Finally, our clinic believes thatketamine or esketamine should never be standalone treatments. Mental healthcare is most effective when integrated with psychotherapy, lifestyleinterventions, and physical support systems. Some Spravato programs focus primarilyon medication delivery without robust integration or comprehensive care, whichrisks under‑serving patients’ broader needs.
In sum, our decision not toprescribe Spravato comes down to several core principles:
✔Value‑based care — avoiding disproportionate costburdens on patients and insurers.
✔ Clinicaleffectiveness— preferring options with broader pharmacologic activity and more flexibledosing.
✔ Patientaccessibility— reducing barriers to care such as strict REMS requirements and more frequentclinic visits.
✔ Holistictreatment — emphasizing integrated therapy overmedication alone.
Spravato remains a valid option for manyindividuals, and we support patients who access it through other providers whenappropriate. But in our practice, we have found alternative ketamine‑basedapproaches to be more aligned with our clinical goals and patient needs.
If you have questions about whichtreatment path is right for you, we’re always here to help you explore optionsthrough a free introductory call. [link here for “free introductory call”https://medicinewithin.com/start-here]
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