Who Qualifies for Spravato?

The approved labeling defines two adult indications:

• Treatment-resistant depression in adults, as monotherapy or in conjunction with an oral antidepressant. [FDA label]
• Depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior, in conjunction with an oral antidepressant. [FDA label]

The labeling adds that the effectiveness of Spravato in preventing suicide or in reducing suicidal ideation or behavior has not been demonstrated, and that its use does not preclude the need for hospitalization when hospitalization is clinically warranted.

Two details in that definition do most of the work. “Adequate dose and duration” means a medication taken long enough and at a high enough dose to give it a fair trial — stopping after a week, or never reaching a therapeutic dose, is generally not counted as a completed trial. “Current episode” means the trials that count are usually the ones during this period of depression, not medications tried years ago.

There is no single universally agreed definition of treatment resistance across all of psychiatry. Clinicians and insurers may apply slightly different thresholds, which is one reason a clinician reviews the actual history rather than a count.

Because prior antidepressant trials are central both to the indication and to most coverage decisions, they usually need to be documented rather than recalled approximately. Useful details for each medication include:

• the name of the medication;
• the highest daily dose reached;
• roughly when it was started and stopped;
• how long it was taken at that dose;
• why it was stopped — inadequate benefit, side effects, or another reason.

Pharmacy records, a prescriber’s notes, or a patient portal medication history are often the easiest way to reconstruct this. The same information is typically requested during prior authorization.

When Spravato was first approved in 2019, the treatment-resistant depression indication required use together with an oral antidepressant. On January 17, 2025, the FDA approved a supplement expanding that indication to include monotherapy, so the current labeling reads “as monotherapy or in conjunction with an oral antidepressant.” [FDA approval letter]

Older material online — including clinic websites and articles written before 2025 — often still states that an oral antidepressant is mandatory. For treatment-resistant depression, that is no longer what the label says.

Which approach fits an individual patient is a clinical decision. Being eligible for monotherapy under the label does not mean stopping an existing antidepressant is advisable; antidepressants are generally not stopped abruptly, and any change should be made with the prescribing clinician.

The second indication is different in population, in regimen, and in what the evidence supports. It covers depressive symptoms in adults with major depressive disorder who have acute suicidal ideation or behavior, and the labeling specifies use in conjunction with an oral antidepressant. [FDA label] The studies supporting it evaluated rapid reduction of depressive symptoms in patients assessed to be at imminent risk for suicide, alongside comprehensive standard of care. [J Clin Psychiatry]

Three points from the labeling should be read together with that indication:

• Effectiveness in preventing suicide or in reducing suicidal ideation or behavior has not been demonstrated.
• Use of Spravato does not preclude the need for hospitalization if clinically warranted, even if symptoms improve.
• The regimen studied for this indication was 84 mg twice per week for four weeks, and use beyond four weeks has not been systematically evaluated.

This indication is not an alternative to emergency care. Someone in immediate danger needs an emergency department or 911, not an outpatient appointment.

A clinician evaluating a patient for Spravato is answering several questions at once: whether the diagnosis and history match a labeled indication, whether any contraindication exists, whether blood pressure and cardiovascular status make monitored dosing appropriate, and whether other medications or substance use change the risk picture. [FDA label]

What Innerbloom Medical specifically does

At Innerbloom Medical, that evaluation begins with a free physician intake with Dr. Andrew Zabel, a board-certified Emergency Medicine physician, who reviews your history and discusses treatment options. This is a clinic process, distinct from the FDA and REMS requirements described above. An intake does not commit you to treatment and is not itself a determination of eligibility.

The prescribing information lists three contraindications — situations in which Spravato should not be used: [FDA label]

• Aneurysmal vascular disease, including of the thoracic and abdominal aorta, intracranial vessels, and peripheral arterial vessels, or arteriovenous malformation.
• History of intracerebral hemorrhage.
• Hypersensitivity to esketamine, ketamine, or any of the excipients.

Beyond those, the labeling describes precautions rather than absolute bars, including blood pressure elevations, sedation and dissociation, respiratory depression, abuse and misuse potential, cognitive effects, urinary tract symptoms, and embryo-fetal considerations. These are covered in Spravato safety, warnings, and contraindications.

FDA labeling describes what a medication is approved to treat. An insurance policy describes what that plan will pay for. They are written by different organizations for different purposes, and they do not always line up.

Insurers commonly add requirements such as:

• a specific number of documented, adequately dosed antidepressant trials;
• specific diagnosis codes on the claim;
• documentation of the current episode and symptom severity;
• administration in a certified setting, billed a particular way;
• an authorization valid for a fixed period, requiring renewal to continue.

Because plans differ, no clinic can tell you in advance what your plan will require or approve. See does insurance cover Spravato for how coverage is usually structured.

The list below is educational only. It is not a screening tool, not a diagnostic instrument, and not a determination that you do or do not qualify for Spravato. Checking every item does not mean you are eligible; checking none does not mean you are not. Only a clinician who has evaluated you can make that judgment.

Again: this checklist is educational. It does not determine eligibility, and nothing on this page should be used in place of an evaluation by a clinician.

Spravato’s labeling covers adults with treatment-resistant depression, with or without an oral antidepressant, and adults with major depressive disorder and acute suicidal ideation or behavior, with an oral antidepressant. Treatment-resistant depression generally refers to inadequate response to at least two adequate antidepressant trials in the current episode.

Three questions decide whether treatment actually starts: does the FDA indication apply, does medical screening find a contraindication or a precaution that changes the plan, and does the insurer approve coverage. These are answered separately, and only the first is settled by the label.