It is the third patient after lunch. She did not come in with this question, but she read something on her phone in the waiting room, and now she wants to know whether the ketamine thing is real or one of those internet treatments. She is looking at you. There are nine minutes left in the visit.
These are the questions referring clinicians in St. Charles County actually ask about esketamine. Patient-side figures come from a poll we ran of 443 adults in the Midwest (details at the end); they are final and describe the public, not physicians.
What exactly is Spravato, and how is it regulated?
Spravato is esketamine, the S-enantiomer of ketamine, delivered as a nasal spray at certified sites under a restricted distribution program. Adults with treatment-resistant depression are its core approved population. The patient sprays it under direct observation, and it is never handed over to take home, so there is nothing to fill at the pharmacy in O'Fallon. A second labeled use covers adult major depression with acute suicidal ideation or behavior, with the explicit caveat that it does not replace hospitalization when that is indicated. The label has been revised since approval, so check the current insert, not a summary like this.
How is it different from IV ketamine in a clinic, and from the lozenges people order online?
Regulatory status is the difference, and it is not subtle. Esketamine is approved for this indication and comes with a mandated safety program that dictates setting, observation, and documentation. Clinic-infused generic ketamine for depression is off label: legal, widely offered, backed by real research, but without approval for this use or a standard protocol binding one clinic to the next. Oral or sublingual ketamine from a telehealth service is the loosest of the three, with the thinnest evidence and usually nobody in the room. Three things, one word, and your patient cannot be expected to sort them.
Do my patients already know it exists?
Almost certainly not. In our survey, 73 percent said the name Spravato was new to them, 21 percent knew the sound of it but not the substance, and 6 percent could explain it. When 319 respondents typed what they would put into a search bar, they wrote symptoms and pleas, such as "therapist near me," "depression medicine alternatives," "help with depression." Essentially no one typed a drug name. She will not ask for esketamine. She will ask whether anything is left.
Who is even a candidate, and who decides?
The treating center decides; you are not expected to pre-qualify anyone. Broadly, the studied population was adults with major depressive disorder who had not responded to adequate trials of at least two antidepressants in the current episode. Intake screening follows the hemodynamic and sedative profile: vascular history, prior intracranial hemorrhage, blood pressure control, pregnancy and lactation, substance use, and whether the patient can meet the observation requirement.
What does the visit look like for the patient?
Plan on half a day, not a lunch break, and tell patients that up front. After the self-administered dose comes a monitoring period with blood pressure checks while the sedative and dissociative effects rise and fade. Per the label, patients may not drive or run machinery before the following day and a night's sleep, so every dosing day needs a ride. Dosing starts more frequently and steps down to maintenance per the label and the treating clinician. For a patient driving in from Wentzville or St. Peters, logistics are a clinical variable. Ask about the ride at referral; that is where these quietly fail.
Who pays, and does coverage really decide this?
For most people it does, and the survey is blunt. Of the respondents, 85 percent named coverage as a first- or second-place criterion; nearness came next at 43 percent; FDA approval (27), results speed (24), discretion (11), and a service-member focus (10) trailed. Insurance would make or break the decision for 65 percent. Payer answers, multi-select, put commercial at 39 percent and Medicaid, a close runner-up, at 37; Medicare was 23, TRICARE 5, and 9 percent were uninsured. Before telling a patient it is covered, ask the center which plans it takes, MO HealthNet included, and how long prior authorization runs. For a patient-facing summary of the visits and the paperwork, Brain Recovery Centers keeps an overview of Spravato treatment you can share.
Where do patients in St. Charles County actually start?
They start with you. Given a list of first stops, 56 percent of our respondents picked their primary doctor. A psychiatrist or therapist was the choice for 23 percent and a web search for 12, with 5 percent unsure and 1 percent planning to ask a friend. And when we asked what would persuade them, 74 percent chose their own doctor's word, against 2 percent for an ad. There is no consumer-awareness path around the exam room.
What do I document and send with a referral?
Send enough history that intake need not rebuild it: each antidepressant this episode with dose, duration, and reason stopped; augmentation; current medications, especially anything affecting blood pressure; a baseline score if you use one; psychiatric, substance, cardiovascular, and neurologic history; and whether the patient has transportation on dosing days.
Is there a drug-free option they will ask about?
They will ask for the idea without the name. Across our sample, 64 percent valued a drug-free option, while just 25 percent recognized TMS by name. Half the sample, 51 percent, wanted drug-free care without knowing TMS existed. The patient who says she is tired of pills is often describing transcranial magnetic stimulation without the word for it.
What if the patient is in crisis today?
Crisis care comes first. Acute suicidality is an emergency evaluation, not a scheduling problem, and the acute indication in the esketamine label does not change that.
Say the number out loud before she leaves the room. Dialing or texting 988 anywhere in the U.S. brings a live Lifeline counselor, day or night. Saying it beats printing it on the after-visit summary, because the patient who needs it is rarely the one reading the handout.
Methodology
This publisher commissioned the consumer survey and covered its cost. On the Pollfish consumer panel it gathered 443 finished responses by June 23, 2026, from people 18 to 64 in ten Midwest and Plains states, Missouri included. It is a general-population sample, not a patient panel, and it measures awareness and preference, not clinical outcomes. On select-all questions the percentages sum past 100. We report the final, validated figures.