Who Is Eligible for Spravato Treatment?

Who is eligible for Spravato treatment? Spravato is FDA-approved for adults with treatment-resistant depression and major depressive disorder with acute suicidal ideation. But having one of these conditions doesn't automatically mean you're a good candidate. Certain medical conditions and other factors may be contraindications to Spravato, which is why a thorough clinical evaluation is required before treatment.

Quick answers

• You may qualify for Spravato if you have treatment-resistant depression or major depressive disorder with suicidal thoughts or behaviors.
• Spravato isn't right for everyone. Certain medical conditions — including some vascular, liver, and cardiovascular disorders — as well as pregnancy and breastfeeding, may affect eligibility.
• The only way to know if you're a candidate is through an evaluation at a Spravato-certified clinic.

What conditions qualify someone for Spravato?

Spravato is FDA-approved for two specific groups. People with: 

Treatment-resistant depression

Spravato is approved for adults with treatment-resistant depression (TRD), typically defined as not responding to at least two antidepressants from different medication classes after an adequate trial (though insurers may have additional requirements), according to a review published in Cureus.

The tricky part is defining an "adequate trial." According to board-certified adult psychiatrist MaryEllen Eller, MD, that means taking a medication at a therapeutic dose for long enough to fairly assess whether it works. For example, someone taking a low dose of Zoloft for months may not meet that standard if they never reached an effective treatment dose, she explains.

Another frustration: trying multiple medications from the same class (such as several SSRIs) may still count as only one trial for insurance purposes, says Dr. Eller. However, a medication you had to stop because of intolerable side effects may still qualify, she adds.

Major depressive disorder with suicidality

Spravato is also approved for adults with major depressive disorder and acute suicidal thoughts or behavior, per the FDA. Unlike treatment-resistant depression, eligibility doesn't typically require prior antidepressant or therapy failures, says Dr. Eller.

“Since no other intervention at this time is specifically approved for depression with suicidal thoughts, insurers who cover FDA-approved interventions will cover Spravato in this situation even if you have never taken an oral antidepressant medication or engaged in psychotherapy,” she explains.

What disqualifies someone from Spravato?

According to the FDA, Spravato is not appropriate for people with certain conditions, including:

• uncontrolled hypertension
• aneurysmal vascular disease
• arteriovenous malformations
• history of intracerebral hemorrhage
• severe liver disease
• pregnancy
• breastfeeding
• an allergy to ketamine or esketamine

Other health issues — such as uncontrolled high blood pressure, sleep apnea, COPD, or a history of hallucinations or substance use disorder — may require extra evaluation and monitoring. A “small risk is not a zero risk, so any intervention that poses a chance of worsening your overall health picture [needs to be assessed]," says Dr. Eller. To help manage these risks, Spravato is administered only through treatment sites enrolled in the Risk Evaluation and Mitigation Strategy (REMS) program, which helps ensure patient safety, per the FDA. 

Non-medical factors matter, too. Some people find the dissociative experience unsettling or anxiety-provoking, says Dr. Eller.

If you're unsure whether Spravato is a fit, talk with a qualified provider. And if it isn't the right option, other evidence-based treatments are available.

How do you find out if you're a good candidate for Spravato?

A Spravato evaluation includes more than a psychiatric assessment. Your provider will review your antidepressant treatment history and screen for any medical conditions that could increase risk.

Come prepared with a list of medications you've tried, including doses and when you started and stopped them. “If we have that information from the initial consult, we can lay a roadmap much more effectively of what the next steps are likely going to look like,” says Dr. Eller.

Insurance requirements can also affect esketamine eligibility. “The more information I have, the stronger I can advocate with your insurance company,” she says.

“At Radial, we are committed to advocating on behalf of our clients to ensure that cost and insurance coverage limitations do not prevent people from accessing effective treatment,” adds Dr. Eller.

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