Esketamine (Spravato): Why It Is Not Available Through an Online Visit

What esketamine is

Esketamine is a nasal spray sold as Spravato. Chemically, it is one form of ketamine. The label calls it an NMDA receptor antagonist, a different kind of medicine from SSRIs and most other antidepressants.

This page explains what the FDA label, the FDA's REMS page and MedlinePlus say. It is general information, and it is here partly because people often search for this medicine online and deserve a straight answer about how it is given. See others on our list of medicines.

What it is approved for

The current FDA label lists two approved uses, both in adults:

• Treatment-resistant depression, either alone or with an oral antidepressant.
• Depressive symptoms in major depressive disorder with acute suicidal thoughts or behavior, along with an oral antidepressant.

Limits on what it can do

The label is direct about limits. It says the effectiveness of esketamine in preventing suicide or in reducing suicidal thoughts or behavior has not been demonstrated. It also says using it does not remove the need for hospital care when that is clinically needed, even if someone improves after a first dose.

It is not approved as an anesthetic and it is not approved for children or teens. This page describes only the label's approved uses.

How it works is also uncertain. The label says the way esketamine produces its antidepressant effect is unknown.

What a treatment session involves

You would spray the medicine yourself, while a healthcare provider watches, in a medical setting. Blood pressure is checked before and after. Then you stay for observation. The label says a provider must monitor you for at least 2 hours, including pulse oximetry to watch your breathing, and then assess when you are stable and ready to leave.

You cannot leave with the medicine. MedlinePlus says to plan for a caregiver or family member to drive you home. The label says not to drive or use machinery until the next day, after a restful sleep.

Tell your prescriber about other medicines, especially benzodiazepines, opioids and alcohol, which the label says may increase sedation.

Boxed warning and who should not take it

The boxed warning has several parts. Esketamine can cause sedation, including loss of consciousness in some people. It can cause dissociation, a feeling of being disconnected from yourself, your thoughts or your surroundings. It can cause respiratory depression, slowed or weak breathing, with rare reports of breathing stopping. It carries a potential for abuse and misuse. And antidepressants increased the risk of suicidal thoughts and behaviors in children, teens and young adults in short-term studies, so everyone taking one should be watched closely for worsening.

If you are in crisis or thinking about harming yourself, call or text 988, or call 911. Locascio Wellness does not provide emergency services. You can also see our crisis resources.

The label says esketamine must not be used by people with aneurysmal disease of the blood vessels, including in the chest, abdomen, brain or limbs; an arteriovenous malformation; a history of bleeding in the brain; or an allergy to esketamine, ketamine or its other ingredients.

Side effects and other warnings

In treatment-resistant depression, the most common side effects in the label are dissociation, dizziness, nausea, sedation, a spinning feeling, numbness, anxiety, lack of energy, raised blood pressure, vomiting, feeling drunk and headache. The list for people with acute suicidal thoughts is similar, and also includes a euphoric mood.

The label also warns about blood pressure increases that can be substantial after any dose, trouble with attention, judgment and thinking, and bladder symptoms, which it asks prescribers to monitor. Esketamine is a Schedule III controlled substance, and people with a history of drug or alcohol use disorder may be at greater risk of misuse. Tell your prescriber if you are pregnant, could become pregnant or are breastfeeding, because the label has specific warnings about this.

Why it cannot be managed online, in Pennsylvania, New York or elsewhere

Esketamine is not available through an online visit. Under the FDA's REMS, a safety program, it may be dispensed and given only in certified healthcare settings, which may not dispense it for use outside the setting. Outpatient settings must have a prescriber onsite during treatment and monitoring. Pharmacies must be certified too.

As of November 2026, a temporary federal rule (Federal Register, Fourth Temporary Extension) allows DEA-registered practitioners to prescribe Schedule II to V medicines by audio-video telemedicine without a prior in-person evaluation, under set conditions, through December 31, 2026. Rules may change after that date. That rule does not change where esketamine must be given: the REMS still applies.

This is not something an online visit can provide. A licensed psychiatrist on our team, a Doctor of Osteopathic Medicine (DO), treats depression by secure video for people physically located in Pennsylvania or New York during each visit. If depression has not improved with treatment so far, there are still options to talk through. Whether esketamine is an option for you is a decision for you and a prescriber connected to a certified setting. Ask us whether our psychiatrist can help with your wider depression care. See online depression treatment, psychiatry in New York or send us a medication question. Our therapists do not prescribe, and their depression therapy is for clients in Pennsylvania, West Virginia, Arizona, Colorado and Florida, not New York.