Spravato vs. Ketamine Nasal Spray: What's the Difference?

Spravato (esketamine) is the only ketamine-based nasal spray the FDA has approved to treat depression. Other products sold as "ketamine nasal spray" are compounded versions of ketamine itself. They are not FDA-approved, have not been reviewed for safety or effectiveness, and are often supplied for home use rather than given under the supervised monitoring Spravato requires. The two are often confused because they come from the same family of medications, but they differ in approval, oversight, where they are taken, and how insurance treats them.

Sacramento NeuroPsych Associates offers Spravato treatment in our Sacramento-area offices. We do not prescribe compounded ketamine sprays or provide IV ketamine infusions. This article explains the differences so you know what you are being offered, wherever you go.

Is Spravato the same as ketamine?

Not quite. Ketamine is a mixture of two mirror-image molecules. Esketamine, the active ingredient in Spravato, is one of those two (the "S" form) on its own. Both act on the brain's glutamate system, which is different from how most antidepressants work. In Spravato's clinical trials, improvement was measured within days rather than the weeks a typical oral antidepressant takes. That evidence is specific to Spravato's formulation and dosing, so a compounded spray should not be assumed to deliver the same benefit.

The bigger difference is regulatory. According to the Spravato prescribing information, Spravato is approved for two uses in adults:

• Treatment-resistant depression, on its own or together with an oral antidepressant. Treatment-resistant means at least two antidepressants have been tried without enough relief.
• Depressive symptoms in adults with major depressive disorder who have acute suicidal thoughts or behavior, together with an oral antidepressant. The label is clear that Spravato has not been shown to prevent suicide or reduce suicidal thoughts or behavior, and that hospitalization may still be necessary.

At Sacramento NeuroPsych Associates, Spravato is used together with an oral antidepressant, as our service page describes. Your provider decides what is appropriate for you.

Ketamine itself is FDA-approved only as an anesthetic given by injection. It is not approved for depression or any other psychiatric condition. Clinics that use it for depression are prescribing it off-label. For a plain-language explanation of how esketamine works and who is a candidate, see our article on ketamine nasal spray and what patients need to know.

What is a "ketamine nasal spray" if it isn't Spravato?

When you see ketamine nasal spray advertised online, it is almost always a compounded product. A compounding pharmacy mixes ketamine into a nasal spray (or a lozenge or tablet) for an individual prescription, often through a telehealth company that ships it to your home.

The FDA has issued two alerts about these products, one on compounded ketamine nasal sprays in February 2022 and a broader one on compounded ketamine products for psychiatric disorders in October 2023. Both are listed on the FDA's compounding risk alerts page. The agency's main points:

• Compounded drugs are not FDA-approved, so their safety, effectiveness, and quality have not been evaluated before they are sold.
• Ketamine's known risks include sedation, dissociation, increases in blood pressure, breathing problems, and the potential for misuse and abuse.
• Taking ketamine at home means a healthcare provider is not monitoring you while those effects happen.
• Dosing in a compounded spray does not translate to Spravato dosing. There is no data to convert one to the other.

None of this means a compounded product is automatically dangerous for every patient. It means you are relying on the compounder and the prescriber instead of an FDA review, and supervision arrangements vary. These products do not carry the on-site monitoring that Spravato's safety program requires.

How is Spravato given differently?

Spravato is available only through a safety program called a REMS (Risk Evaluation and Mitigation Strategy). The prescribing information requires that it be given in a certified healthcare setting and that patients be monitored by a healthcare provider for at least two hours after each dose. It cannot be dispensed for home use.

At Sacramento NeuroPsych Associates, a Spravato visit looks like this:

1. Check-in and blood pressure. Staff confirm you have a ride home and check your vital signs before dosing.
2. Self-administration under supervision. You use the nasal spray device yourself while staff observe.
3. At least two hours of monitoring. You rest in the office while staff watch for dissociation, sedation, blood pressure changes, and any trouble breathing.
4. Discharge with a driver. You leave once your provider confirms you are stable, and only with someone else driving. You should not drive or operate machinery until the next day, after a restful sleep.

Treatment is usually twice a week during the first month, then less often as your provider directs. Our article on Spravato side effects describes what the monitoring period is actually like.

Spravato vs. compounded ketamine nasal spray, side by side

FDA approval

• Spravato: approved for treatment-resistant depression and for depressive symptoms with acute suicidal thoughts or behavior in adults.
• Compounded ketamine spray: not FDA-approved for any psychiatric condition.

Where it is taken

• Spravato: in a REMS-certified office, with at least two hours of monitoring.
• Compounded ketamine spray: usually at home, with no in-person monitoring.

Who prescribes and oversees it

• Spravato: given under healthcare-provider supervision at a REMS-certified treatment center, with outpatients enrolled in the program.
• Compounded ketamine spray: any licensed prescriber, often through a telehealth service.

Safety data

• Spravato: reviewed by the FDA in clinical trials, with a boxed warning and ongoing safety reporting.
• Compounded ketamine spray: no FDA review of safety, effectiveness, or quality.

Insurance

• Spravato: many plans cover it when medical criteria are met and prior authorization is obtained. Coverage depends on your benefits.
• Compounded ketamine spray: usually self-pay.

Controlled substance

• Both are Schedule III controlled substances with potential for misuse. Spravato's REMS adds monitoring for signs of abuse before and during treatment.

What about IV ketamine infusions?

IV ketamine is a third option you may see advertised. It is ketamine given through a vein in a clinic, usually over 40 minutes or so, with monitoring during the infusion. Like compounded sprays, it is an off-label use that is not FDA-approved for depression, and it is typically paid out of pocket. Sacramento NeuroPsych Associates does not provide IV ketamine. If you are weighing it against Spravato, the questions to ask are the same: who is monitoring you, what happens if your blood pressure rises, and what the plan is after the initial course.

Which one does insurance cover?

Spravato is the one with an insurance pathway. Many plans cover it when medical criteria are met, and plans that cover it typically require prior authorization. That means the plan reviews records showing your diagnosis and the antidepressants you have already tried, then decides whether you meet its criteria. Coverage and authorization requirements depend on your plan and benefits.

Sacramento NeuroPsych Associates accepts many plans, including Aetna, Anthem Blue Cross, Blue Shield of California, Cigna Behavioral Health, Medicare, Medi-Cal, and United Healthcare. The full list is on our insurance page. Accepting your plan does not mean Spravato is covered for you; that depends on your benefits and the authorization decision. Copays, coinsurance, and deductibles still apply after approval. Our article on Spravato treatment cost walks through the billing questions to ask.

Compounded ketamine is rarely covered because insurers generally do not pay for non-FDA-approved compounded products used off-label.

Spravato in the Sacramento area

Dr. Manish Aggarwal, co-founder of Sacramento NeuroPsych Associates, provides Spravato alongside psychiatric evaluation and medication management for patients across Folsom, Rocklin, and the greater Sacramento region. A psychiatric evaluation comes first. It confirms your diagnosis, reviews the antidepressants you have tried, and checks for conditions that would make Spravato unsafe. If you plan to use insurance, our team can help verify your benefits before treatment begins. Our article on who qualifies for Spravato covers that evaluation in more detail.

Because every session includes at least two hours in the office and a ride home, patients usually pick the office closest to home or work. When you call, ask which office schedules Spravato and what days are available.

If you are in crisis or thinking about harming yourself, call or text 988 (Suicide and Crisis Lifeline) or call 911.

Frequently asked questions

Can I take Spravato at home?

No. The REMS program requires Spravato to be given in a certified healthcare setting with at least two hours of monitoring. It is never dispensed for home use, which is one of the clearest ways to tell it apart from a compounded ketamine spray.

Is Spravato stronger than a compounded ketamine spray?

They are not directly comparable. The FDA notes there is no data to convert a compounded ketamine dose to a Spravato dose. If you have used a compounded product and are considering Spravato, tell your provider what you took and how often so they can plan safely.

Does Sacramento NeuroPsych Associates offer compounded ketamine or IV ketamine?

No. We offer Spravato (esketamine) through the REMS program, along with TMS therapy and medication management for depression.

Why isn't ketamine nasal spray FDA-approved if esketamine is?

A manufacturer ran the large clinical trials needed to get esketamine approved for depression and agreed to the REMS safety program. No company has done the same for a ketamine nasal spray, so it remains an off-label, compounded product.

Can I switch from a compounded ketamine spray to Spravato?

Possibly, but it is a clinical decision. You would still need to meet the criteria for treatment-resistant depression and pass a safety screening, and if you use insurance, your plan's coverage requirements and any authorization must be checked. Bring your records so your provider has the full picture.

Take the next step

If you have been searching for ketamine nasal spray because antidepressants have not helped, the FDA-approved option is Spravato, given under supervision in a certified office. Schedule a psychiatric evaluation or call us at (916) 473-2235 to find out whether Spravato is appropriate for you and what your insurance requires.