Nasal Esketamine

Starting any medical treatment for the first time can leave you with questions, especially if you’re looking forward to the benefits it may bring. It’s no different when you’re preparing for your nasal esketamine treatment. Your previous mental health treatments may have consisted solely of taking antidepressants at home or visiting a therapist’s office for cognitive behavioral therapy (CBT), so nasal esketamine is probably a new treatment experience for you. If you're wondering what it's like to start nasal esketamine and get ready for your first session, keep reading. Getting Started with the Nasal Esketamine Treatment As with any new treatment, you’ll first talk to your primary care provider or psychiatrist about whether nasal esketamine is a good fit for you. Alternatively, you can schedule your esketamine nasal spray consultation with a treatment center (such as Greenbrook) that has certification by the FDA’s Risk Evaluation and Mitigation Strategy (REMS). At Greenbrook's REMS-certified nasal esketamine treatment centers, our Greenbrook-affiliated psychiatrists and psychiatric nurse practitioners will review your medical history and also conduct our own assessment to help determine whether nasal esketamine treatment is right for you. Certain conditions, including blood vessel disease and a history of psychosis, may make treatment a risk for you. Make sure you discuss all previous and present conditions with your doctor or nasal esketamine provider before beginning treatment. If the medication is deemed a good fit, you’ll receive your prescription from the Greenbrook-affiliated provider. Your Greenbrook Care Team will put together a personalized care plan for the weeks and months to follow. Keep in mind that you will need to take a standard (oral) antidepressant along with your nasal esketamine treatment. There are two important regulations to note when it comes to preparing for treatment: Each treatment is followed by a mandatory two-hour observation period. This means you will need to plan to stay at the center for at least two hours following your self-administration of the esketamine nasal spray. You cannot drive during the rest of the day after treatment and must arrange for transportation. These regulations are mandatory. It may be helpful to sit down and plan out several weeks’ worth of transportation once you know your treatment schedule. In addition, if you’re wondering what to bring for the treatment, we recommend entertainment such as an audiobook or playlist of favorite songs and a pair of headphones. You may want them during the two-hour observation period. What to Expect During Nasal Esketamine Treatment On the day of treatment, you’ll need to stop eating any food two hours before your appointment and stop drinking all fluids 30 minutes before you come in. Your Greenbrook Care Team will confirm that you are prepared for the two-hour observation period and that you have a ride home. You’ll get the opportunity to practice using a “trainer sprayer” that mimics the real nasal esketamine sprayer but does not release any medication. The Care Team will encourage you to use the restroom and set up your preferred environment in your private treatment bay or room. Some patients like reduced lighting, for example, while others don’t request light adjustments. You’ll complete a depression scale before each treatment session. Your Greenbrook provider will confirm that the dose kit is yours, show you how to administer it, and then hand it to you. Each sprayer contained 28mg of Spravato esketamine nasal spray. Patients usually start with two sprayers (56mg) and soon increase to 84mg (three sprayers) per treatment. But, your dosage maybe vary. Should you be left with a metallic taste by the spray, the Care Team will offer suckers to help make the flavor dissipate. After your dose, you’ll be encouraged to lie back in your comfortable recliner. While most patients enjoy a quiet setting, Greenbrook is prepared to accommodate patients with a more animated reaction to the medication. You may feel sleepy, dizzy, mildly dissociated, and/or nauseated during treatment. Greenbrook's Care Team is readily available if you need assistance. How to Prepare for after your Nasal Esketamine Treatment  Most side effects begin to wane in the second hour of observation, but if you’re wondering, “Is it safe to drive immediately after nasal esketamine treatment?” the answer is a resounding no. In addition to the mandatory ride home, you will need to block off time to rest and let side effects fully dissipate. This extended rest period is especially important in the first weeks of treatment when you’ll have treatment twice a week. Do not drive or operate machinery of any kind until the day after treatment. Just take it easy, relax, and take care of yourself. If you’re unsure what activities you can do or should avoid during this time, talk to your Care Team for more information. While side effects tend to dissipate completely after a good night’s sleep, many nasal esketamine patients begin feeling relief from depression symptoms within hours of their treatment. Other Tips in Preparing for Your Nasal Esketamine Treatment At Greenbrook, we make every effort to schedule your treatment in the afternoons or whenever it is most convenient for you. We encourage you to see each treatment session as an opportunity to relax and take care of your mental health. If you have any questions or concerns, talk to your doctor or the Greenbrook Care Team. At Greenbrook, we’ll help you feel at ease when preparing for each treatment session. Schedule A Free Consultation To get started with nasal esketamine, schedule your free consultation today.

When can you start feeling better?

SPRAVATO® is self-administered at REMS-certified SPRAVATO® treatment centers under the supervision of a health care provider. REMS stands for Risk Evaluation and Mitigation Strategy. SPRAVATO® is a brand name for esketamine nasal spray , a Schedule III controlled substance derived from ketamine. This medication can cause brief sedation and dissociation in people who take it, and it has the potential to be abused. That’s why the esketamine nasal spray is only distributed to providers under the REMS program.

So many of us are used to those familiar names we associate with antidepressants: Zoloft®, Prozac®, Celexa, Paxil. The x’s and z’s roll off our tongues with little effort. These selective serotonin reuptake inhibitors (SSRIs) have been the most popular and commonly prescribed antidepressants since the late 1980s. Along with non-SSRIs like Wellbutrin and Cymbalta, these mostly oral antidepressants have served as the scaffolding for the nation’s mental health treatment for so long that the idea of taking psychedelics for depression and anxiety may feel absurd. But is it? In 2019, the Food and Drug Administration (FDA) approved nasal esketamine spray SPRAVATO® for treatment-resistant depression and then for major depressive disorder with acute suicidal ideation or behavior in 2020. Derived from ketamine , a dissociative anesthetic drug with hallucinogenic properties, this treatment is the closest the United States has come to implementing psychedelics for depression. Still, ketamine is more of a psychedelic-like medication, not a psychedelic in the same sense as psilocybin or LSD (lysergic acid diethylamide). Could those psychedelics eventually become the leading antidepressants? The Scientific Difference Between Psychedelics and Antidepressants Standard antidepressants, such as SSRIs, tricyclic and tetracyclic antidepressants, and monoamine oxidase inhibitors (MAOIs), all work to elevate the levels of monoamine neurotransmitters in the brain. Serotonin, dopamine, norepinephrine, and epinephrine (adrenaline) are all monoamines. They help regulate mood, emotion, the fight-or-flight response to fear, attention, memory, sleep, and function. According to the monoamine hypothesis, depression is a result of low monoamine levels in the central nervous system. Because standard antidepressants increase monoamines, they can help treat depression symptoms. Unfortunately, antidepressants can take weeks to kick in, and around one-third of people taking antidepressants will continue to experience symptoms during standard antidepressant treatment. Put simply, depression is a complex condition, and the monoamine hypothesis can’t explain every case. This is where psychoactive antidepressants come in. Ketamine and psychedelics for depression and anxiety have been shown to act more quickly to relieve symptoms of depression. Importantly, while ketamine is a dissociative drug, it is not a classic psychedelic like LSD or psilocybin. How do Psychedelics Work for Depression? In addition to elevating monoamine levels, ketamine and psychedelics for depression work by acting on amino acid neurotransmitters. They increase neuroplasticity by impacting the most prolific excitatory neurotransmitter, glutamate, which helps us perform cognitive functions pertaining to memory, learning, and thinking. Ketamine and psychoactive antidepressants also act on gamma-aminobutyric acid (GABA), an amino acid neurotransmitter that regulates brain activity and helps prevent issues with anxiety, depression, sleep, irritability, and concentration. Perhaps because of the way they impact the brain differently than standard antidepressants, psychedelics have been shown to have a more lasting effect. A study in the February 2022 issue of the Journal of Psychopharmacology reported that after two carefully controlled doses of psilocybin spaced two weeks apart, 75% of participants reported improved symptoms. Even more encouragingly, 58% of participants were still in remission from depression at the 12-month mark. Psilocybin has yet to gain FDA approval for treating depression, but this study highlights the important relationship between psychedelics and depression treatment. Unlike standard antidepressants, which must be taken every day and can come with side effects, psilocybin appears to relieve symptoms after one or two doses. With psilocybin and other psychedelics, as well as ketamine, side effects tend to last only during the treatment session and end shortly thereafter. A caveat is that due to the minuscule but worrisome risk of developing psychosis after taking dissociative or psychoactive medications, psychedelics and ketamine may not be appropriate for people with a family history of psychosis. How Ketamine is Similar to Psychedelics Like psychedelics, ketamine can cause dissociation and hallucinations, and the two types of medications work similarly to improve symptoms of depression. However, psilocybin, LSD, and other psychoactive antidepressants do this by completely overriding the brain’s inhibitory framework. Ketamine, on the other hand, relaxes it. The overriding is why classic psychedelics produce a much stronger and less relaxing “trip.” In studies on psychedelics and depression, patients go through much longer treatment sessions with psilocybin than with ketamine. The observation period after psilocybin treatment is six hours, for example, compared to the two-hour waiting period after ketamine treatment. However, psilocybin’s more intense nature may give it an edge over ketamine. When a patient undergoes FDA-approved nasal esketamine spray treatment, they start out with two treatment sessions a week for four weeks, followed by once-weekly sessions for another four weeks. After this, they may come in for nasal esketamine treatment once every week or two to maintain remission from depression. Psilocybin can be effective after far fewer doses, and its positive effects may last longer than nasal esketamine spray. The difficulty, of course, is that psilocybin and LSD are Schedule I controlled substances, meaning that they have a high potential for abuse, and the FDA currently does not recognize any medical benefits they may have. Ketamine, on the other hand, is a Schedule III controlled substance, which means it holds the potential for abuse but has recognized medical benefits. Psilocybin is also beginning to gain traction as a legitimate psychoactive antidepressant. The state of Oregon decriminalized psilocybin and approved its therapeutic use in 2020. Cities such as Denver, Colorado; Oakland and Santa Cruz, California; Washington, D.C.; and Somerville, Massachusetts have also decriminalized psilocybin. Psychedelics and Depression: A Promising Future Because they are fast-acting and long-lasting, psychedelics for depression may be a game-changer for mental health. However, FDA approval may not come until 2025 or later, and even then, the stigma of psychedelics may pose a roadblock to widespread psychoactive antidepressant treatment. While the future is promising, we are still in the experimental phase for psychedelics and depression. Even now, we lean on standard antidepressants as we explore new options. For example, nasal esketamine spray (SPRAVATO®) must be taken alongside an oral antidepressant. The good news is that nasal esketamine spray, which works similarly to psychedelics, is FDA approved, covered by insurance, and available at Greenbrook. We offer nasal esketamine spray consultations , along with transcranial magnetic stimulation (TMS) treatment for those who would rather not try nasal esketamine spray. Learn how TMS works here. To get started with nasal esketamine, schedule a free consultation with Greenbrook. We look forward to helping you find relief from depression.

Starting any medical treatment for the first time can leave you with questions, especially if you’re looking forward to the benefits it may bring. It’s no different when you’re preparing for esketamine nasal spray treatment. Your previous mental health treatments may have consisted solely of taking antidepressants at home or visiting a therapist’s office for cognitive behavioral therapy (CBT). What will it be like to add SPRAVATO® treatment to your treatment plan? Preparing for SPRAVATO® treatment, also called esketamine nasal spray , can help you feel more at ease and ready for what your first day of treatment will bring. Getting Started with the SPRAVATO® Treatment As with any new treatment, you’ll first talk to your primary care provider or psychiatrist about whether you’re a fit for esketamine nasal spray. Alternatively, you can schedule an esketamine nasal spray consultation with a treatment center that has certification by the FDA’s Risk Evaluation and Mitigation Strategy (REMS) for administering SPRAVATO® treatment. SPRAVATO® is FDA approved for treatment resistant depression (TRD) and major depressive disorder with suicidal ideation or behaviors (MDSI). Note that SPRAVATO® is not a replacement for hospitalization for those currently high at risk. At Greenbrook’s REMS-certified SPRAVATO® treatment centers, our Greenbrook-affiliated psychiatrists and psychiatric nurse practitioners will review your medical history and also conduct our own assessment to help determine whether nasal esketamine spray treatment is right for you. Certain conditions, including blood vessel disease and a history of psychosis, may make nasal esketamine spray treatment a risk for you. Make sure you discuss all previous and present conditions with your doctor or nasal esketamine spray provider before beginning treatment. If the medication is deemed a good fit, you’ll receive a SPRAVATO® prescription from the Greenbrook-affiliated provider. Your Greenbrook Care Team will put together a personalized care plan for the weeks and months to follow. Keep in mind that you will need to take a standard antidepressant along with your SPRAVATO® treatment. There are two important regulations to note when it comes to preparing for SPRAVATO® treatment: Each SPRAVATO® treatment is followed by a mandatory two-hour observation period. This means you will need to plan to stay at the center for at least two hours following your self-administration of the esketamine nasal spray. You cannot drive during the rest of the day after treatment and must arrange for transportation. These regulations are mandatory. It may be helpful to sit down and plan out several weeks’ worth of transportation once you know your nasal esketamine spray treatment schedule. In addition, if you’re wondering what to bring for the nasal esketamine spray treatment, we recommend entertainment such as an audiobook or playlist of favorite songs and a pair of headphones. You may want them during the two-hour observation period. What to Expect During SPRAVATO® Treatment On the day of treatment, you’ll need to stop eating any food two hours before your appointment and stop drinking all fluids 30 minutes before you come in. Your Greenbrook Care Team will confirm that you are prepared for the two-hour observation period and that you have a ride home. You’ll get the opportunity to practice using a “trainer sprayer” that mimics the real SPRAVATO® sprayer but does not release any medication. The Care Team will encourage you to use the restroom and set up your preferred environment in your private treatment bay or room. Some patients like reduced lighting, for example, while others don’t request light adjustments. You’ll complete a depression scale before each nasal esketamine spray treatment. Your Greenbrook provider will confirm that the dose kit is yours, show you how to administer it, and then hand it to you. Each sprayer contained 28mg of esketamine nasal spray. Patients usually start with two sprayers (56mg) and soon increase to 84mg (three sprayers) per treatment. But, your dosage maybe vary. Should you be left with a metallic taste by the spray, the Care Team will offer suckers to help make the flavor dissipate. After your dose, you’ll be encouraged to lie back in your comfortable recliner. While most patients enjoy a quiet setting, Greenbrook is prepared to accommodate patients with a more animated reaction to the medication. You may feel sleepy, dizzy, mildly dissociated, and/or nauseated during treatment. Greenbrook’s Care Team is readily available if you need assistance. How to Prepare for After your SPRAVATO® Treatment Process Most side effects begin to wane in the second hour of observation, but if you’re wondering, “Is it safe to drive immediately after SPRAVATO® treatment?” the answer is a resounding no. In addition to the mandatory ride home, you will need to block off time to rest and let side effects fully dissipate. This extended rest period is especially important in the first weeks of treatment when you’ll be taking nasal esketamine spray treatment twice a week. Do not drive or operate machinery of any kind until the day after treatment. Just take it easy, relax, and take care of yourself. If you’re unsure what activities you can do or should avoid during this time, talk to your Care Team for more information. While side effects tend to dissipate completely after a good night’s sleep, many nasal esketamine spray treatment patients begin feeling relief from depression symptoms within hours of their nasal esketamine spray treatment. Other Tips in Preparing for Your SPRAVATO® Treatment At Greenbrook, we make every effort to schedule your treatment in the afternoons or whenever it is most convenient for you. We encourage you to see each nasal esketamine spray treatment session as an opportunity to relax and take care of your mental health. If you have any questions or concerns, talk to your doctor or the Greenbrook Care Team. At Greenbrook, we’ll help you feel at ease when preparing for your nasal esketamine spray treatment. Schedule A Free Consultation To get started with nasal esketamine spray treatment, we offer free consultations at Greenbrook . If your doctor thinks you should avoid nasal esketamine spray treatment, transcranial magnetic stimulation (TMS) is a drug-free, FDA-cleared option for you to consider. Learn more about how TMS works .

If you’re planning to try SPRAVATO® for treatment-resistant depression (TRD), knowing the typical SPRAVATO® treatment schedule can help you figure out how to adjust your daily life to accommodate treatment. SPRAVATO® is the brand name for esketamine nasal spray, and it’s one form of ketamine. Like ketamine, esketamine can cause you to feel dissociated, sleepy, and dizzy in the hours after you receive a dose. You’ll need a ride home–and probably a long nap!–after each visit to your local Greenbrook location . At Greenbrook, we work with you to map out an esketamine nasal spray treatment schedule that works for you. Your SPRAVATO® Treatment is Unique to You SPRAVATO® treatment is usually the most time-intensive during the first four weeks. Whether your provider refers you to Greenbrook or you come to us on your own, your Greenbrook psychiatrist or psychiatric nurse practitioner will review your medical history and evaluate your symptoms. If our provider believes esketamine nasal spray is a good fit, they will build an esketamine nasal spray treatment schedule and dosage plan based on your needs. If you’re wondering, “How long will I have to take SPRAVATO®?,” the answer is that your treatment duration will depend on how much the symptoms are improving as you progress. After the first month of SPRAVATO® treatment, your Greenbrook provider will evaluate how well it is working and determine if any dosage adjustments are needed. How Often Can you Expect to Take SPRAVATO®? During a typical SPRAVATO® treatment schedule, you’ll take two doses a week for four weeks. Before each treatment, your provider will give you a depression scale to fill out. This helps them—and you!—understand how the treatment is working throughout your esketamine nasal spray treatment schedule. Your provider will then confirm that the dose kit belongs to you and show you how to self-administer the sprayer. Each sprayer contains two sprays for a total of 28 mg of esketamine nasal spray. Your prescription can vary depending on which of the two FDA-approved indications you’re taking it for: treatment-resistant depression (TRD) or major depressive disorder with acute suicidal ideation or behavior (MDD). If you’re being treated for TRD, you will self-administer medication from two sprayers for a total of 56 mg. After the first treatment, you will take 56 or 84 mg of SPRAVATO®two times per week for the first four weeks of your SPRAVATO® treatment schedule. In weeks five through eight, you’ll take either 56 or 84 mg weekly. By the ninth week and beyond, your Greenbrook provider will evaluate whether you need a 56 or 84 mg dose once a week or once every two weeks. Your total esketamine nasal spray treatment duration after this point will vary based on your symptoms and response to treatment. Those being treated for MDD will self-administer 84 mg of medication on their first day of treatment. Patients will continue taking an 84 mg dose twice a week for the first four weeks. After this, a Greenbrook provider will work with the patient to determine the next steps. Some people continue taking 84 mg of SPRAVATO® while others go down to 56 mg. It’s important to note that esketamine nasal spray is not a substitute for hospitalization related to suicide.  How to Speak to Your Doctor About SPRAVATO® While you don’t need a doctor’s referral to begin a SPRAVATO® treatment schedule, we encourage you to speak with your provider about whether the treatment is right for you. It can feel awkward to bring up medication, but you and your doctor are a team. Together, you’re working to figure out how best to manage symptoms of depression. Ask them if they think esketamine nasal spray could benefit you . During this conversation, discuss any history of alcohol or substance abuse and tell your provider whether you are pregnant or plan to become pregnant. SPRAVATO® should not be taken if you are pregnant or breastfeeding. Other health conditions, such as blood vessel disease, a ketamine allergy, or a history of psychosis, can make taking SPRAVATO® dangerous for you. Your doctor will go over your current and past medications and conditions to determine if esketamine nasal spray is right for you. If your doctor doesn’t think esketamine nasal spray is a good idea based on your medical history, FDA-cleared transcranial magnetic stimulation (TMS) may be an option. Learn more about how TMS works . Questions You Should Ask Your Doctor About SPRAVATO® At Greenbrook, our providers are always prepared to answer any questions about esketamine nasal spray. We recommend asking the following questions: How can I know if esketamine nasal spray is working? What do I do if I don’t feel esketamine nasal spray is working? If you struggle with side effects or feel that esketamine nasal spray isn’t working, your doctor may adjust your dosage or esketamine nasal spray treatment schedule. Please share your questions and concerns with the provider who cares for you at Greenbrook—they’re here to help. Schedule A Free Consultation If you have tried at least two antidepressants without success, you may qualify for esketamine nasal spray. Thanks to its FDA approval, SPRAVATO® treatment at certified centers is covered by insurance. At Greenbrook, we’ll handle the paperwork so that you can focus on your treatment. We offer esketamine nasal spray consultations to help you get started. Schedule your free consultation today.

Have you ever thought about how long a medication stays in your system after you take it? Most medications must be taken regularly because they don’t last forever in our bodies. Oral antidepressants, for example, must be taken every day. Ketamine therapy, on the other hand, is given less often than once per day, whether it is ketamine given through an intravenous injection (IV) or in the form of esketamine nasal spray. The benefits of either ketamine-based treatment usually stick with you in-between doses, even though the medication is no longer in your system for much of that time. Ketamine is eliminated from your body in two phases. The first phase is called the redistribution phase. During that phase, the amount of ketamine in your bloodstream rapidly decreases over the first 45 minutes or so. After that, the remaining ketamine in your body is eliminated more slowly, with a half-life of around 2.5 or 3 hours. That means half of it is eliminated in each half-life. After a few half-lives (say, 12 hours) practically all of it is gone. Does Ketamine Show Up on Drug Test? Ketamine does show up on drug tests. That said, many standard drug panels do not screen for ketamine. If you’re trying to determine, “How long does ketamine stay in your system?” note that the body metabolizes it within a day or two. It’s the metabolic process that leaves behind metabolites. TTraces of these metabolites can show up on drug tests days and even months after a ketamine dose. Employers and other organizations who may require a drug test often use five-panel tests that can detect amphetamine, cocaine, opiates, phencyclidine (PCP), and tetrahydrocannabinol (THC). Others may use seven-panel drug tests that screen for the five previously mentioned drugs with the addition of benzodiazepine and barbiturates. Expanded test panels can detect eight to 12 drugs, including all of the aforementioned substances along with ecstasy (MDMA), hydrocodone (Vicodin), oxycodone (OxyContin), methadone, methaqualone, and propoxyphene. Ketamine doesn’t show up on this list because it’s not standard practice to test for it, even in a 12-panel drug test. However, a drug test that does detect ketamine can be ordered. Ketamine can show up in saliva samples for up to 24 hours, in blood samples for up to 72 hours, and in urine samples for as many as two weeks. A hair test can detect ketamine for a month or longer. If you find yourself facing a ketamine drug test and are undergoing ketamine IV therapy or esketamine nasal spray treatment, talk to your provider. They can give you advice on how to handle the situation. How Long Do Ketamine Effects Last? Ketamine side effects only last during the time the medication is in your system. The more potent side effects, such as dissociation, sedation, and nausea, usually dissipate within one to four hours. Drowsiness can persist for around seven to 12 hours, which is why many providers may recommend going home and resting for the remainder of the day following ketamine or esketamine therapy. If you are still feeling side effects the day after treatment, contact your provider for assistance. Fortunately, the positive effects ketamine and esketamine can have on depression symptoms last longer than any side effects. Ketamine IV therapy patients may receive treatment twice a week for four weeks, with maintenance doses every two to six weeks thereafter. Patients taking esketamine nasal spray for treatment resistant depression (TRD) or major depressive disorder with suicidal ideation (MDSI) also start out with two treatments a week for four weeks. This is often followed by one treatment a week for four additional weeks and maintenance treatments every week or two after that. In short, once you enter the maintenance phase of ketamine treatment, you may only have to come in one or two times a month to continue experiencing the positive effects of ketamine . Is Ketamine Therapy for Everyone? No. If you have a history of psychosis or have family members with a history of psychosis, ketamine therapy may not be for you. Blood vessel and cardiovascular diseases can make ketamine treatment risky, too. Anyone who is pregnant or breastfeeding, or is planning to breastfeed or become pregnant, should avoid taking any form of ketamine. Ask your doctor if ketamine IV therapy or esketamine nasal spray may be right for you. Keep in mind that ketamine IV therapy is not FDA-approved for treating depression or any mental health conditions, which means insurance does not cover it. Esketamine nasal spray, on the other hand, is covered by insurance because it is FDA-approved for hard-to-treat depression, and for depression with suicidal thoughts. . If you don’t qualify for esketamine nasal spray, transcranial magnetic stimulation (TMS) may be an option. TMS is a medication-free, FDA-cleared depression treatment that uses gentle magnetic pulses to stimulate areas of the brain. Learn more about how long TMS therapy lasts after each treatment and how TMS works . At Greenbrook TMS, we offer TMS and esketamine nasal spray treatment in a clean, comfortable environment. Schedule a free consultation today to find out if you may benefit from TMS or esketamine nasal spray treatment.