Prepare
The patient blows their nose before the first device. Staff check the device and explain its use; it must not be primed.
LOW MOOD DISORDER CLINIC · GEELONG
When depression has not improved with usual treatment.
Treatment-resistant depression is a specific clinical diagnosis—not simply a difficult week or a period of feeling low. This page explains the supervised intranasal esketamine pathway so patients, families and referrers can understand what assessment and treatment involve.
Information only · Suitability can only be determined through specialist assessment
AT A GLANCE
Intranasal esketamine is a Schedule 8 prescription medicine registered in Australia for treatment-resistant major depressive disorder. It is self-administered by the patient in a clinical setting under direct healthcare supervision, followed by a period of observation.
UNDERSTANDING THE TREATMENT
What is intranasal esketamine?
Esketamine is one part of the ketamine molecule and acts on the brain’s glutamate system differently from conventional antidepressants. The registered nasal-spray medicine described on this page is Spravato® (esketamine hydrochloride). It is supplied in a single-use device and self-administered by the patient under the direct supervision of a trained healthcare professional; it is not taken home.
In Australia, its registered indication is treatment-resistant major depressive disorder in adults who have not responded adequately to at least two antidepressants, at adequate dose and duration, during the current moderate-to-severe depressive episode. The registered treatment is initiated together with a newly initiated oral antidepressant.
Important distinction: intranasal esketamine is
registered in Australia for treatment-resistant depression. It is
not registered specifically as a treatment for PTSD. A psychiatrist
must assess the diagnosis, treatment history, risks and available
options for each person.
Who may be considered?
An adult may be considered when a psychiatrist confirms a current moderate-to-severe major depressive episode and verifies that at least two previous antidepressant trials were adequate but did not produce sufficient improvement. Meeting these broad criteria does not automatically make treatment suitable.
Assessment also considers physical health, blood pressure, medications, substance use, pregnancy, previous treatment response, current risks, support and the person’s ability to attend repeated monitored appointments and travel home safely.
ABOUT THE MEDICINE
Spravato® in practical terms.
Spravato® is the Australian-registered brand of intranasal esketamine discussed on this page. It is a prescription-only, Schedule 8 controlled medicine. The decision to prescribe it—and the dose used at each appointment—belongs to the treating psychiatrist.
Active ingredient
Esketamine hydrochloride
Form
Single-use nasal spray device
Each device
28 mg esketamine · two sprays
Where it is used
Clinic or hospital under supervision
What is in the device?
Each device contains 32.3 mg esketamine hydrochloride, equivalent to 28 mg of esketamine, and delivers two sprays—one into each nostril. The inactive ingredients listed in the Australian Consumer Medicine Information are citric acid monohydrate, disodium edetate, sodium hydroxide and water for injections. The product does not contain preservatives, lactose, sucrose, gluten, tartrazine or other azo dyes.
How does it work?
Esketamine is an NMDA-receptor antagonist that acts on glutamate signalling in the brain. This is a different pathway from the main serotonin and noradrenaline mechanisms used by many conventional antidepressants. A different mechanism does not mean the medicine is suitable for everyone or that a particular outcome can be predicted.
How is a dose given?
A prescribed dose may require one, two or three single-use devices. The treating clinician determines the dose and provides the devices at the appointment.
Self-administer
With the head reclined, the patient gives one spray into each nostril while a healthcare professional directly supervises.
Rest between devices
When more than one device is prescribed, the patient rests in a semi-reclined position for five minutes between devices.
Remain for observation
The used devices stay at the clinic. Clinical observations and monitoring continue until the patient is considered stable.
Spravato® is never supplied for a patient to take home. The clinic
stores the medicine, provides it for supervised administration and
arranges disposal of each used device.
THE CLINICAL PATHWAY
Assessment comes first.
A request for information or referral is not approval for treatment. The pathway is deliberately structured so diagnosis, previous care, safety and practical suitability are reviewed before any treatment decision is made.
Referral and records
Relevant history, medication trials, diagnoses, investigations and treating-team information are gathered for review.
Psychiatrist assessment
A psychiatrist determines the diagnosis, confirms whether the registered criteria are met and weighs potential benefits, risks and alternatives.
Monitored treatment
If prescribed, dosing occurs in person with clinical observations, direct supervision and post-dose monitoring. Response and tolerability are reviewed over time.
Typical treatment phases
The registered schedule uses repeated appointments rather than a single treatment. The treating psychiatrist determines the actual dose, frequency and whether treatment should continue.
Weeks 1–4
Induction phase—usually two treatment sessions each week.
Weeks 5–8
Maintenance phase—usually one treatment session each week.
Week 9 onward
Frequency is individualised, commonly weekly or every two
weeks, using the least frequent schedule that maintains the
clinical response.
ON A TREATMENT DAY
Why monitoring matters.
Esketamine can temporarily affect blood pressure, alertness, perception, coordination and judgement. Each appointment therefore includes pre-dose checks, supervised self-administration and observation until the person is clinically stable. Post-dose monitoring lasts at least two hours and may be extended when clinically required.
Preparing for an appointment
Food: avoid eating for at least two hours before administration because nausea and vomiting can occur.
Fluids: avoid drinking liquids for at least 30 minutes beforehand.
Nasal medicines: steroid or decongestant nasal sprays should not be used during the hour before treatment.
Transport: arrange for another adult or an appropriate transport service to take you home. You cannot drive after treatment.
Before dosing
The clinical team reviews current health, medicines and any change in risk, and checks observations including blood pressure. Preparation instructions about food, fluids and nasal medicines are provided in advance.
During treatment
The nasal spray is self-administered under direct supervision. Staff remain available and monitor symptoms, blood pressure, alertness, breathing and general clinical stability.
Possible effects
Effects may include dissociation or altered perception, dizziness, nausea, sleepiness and a temporary rise in blood pressure. The full Consumer Medicine Information explains precautions, contraindications and less common risks.
Getting home
Patients cannot drive themselves home. Driving, operating machinery or undertaking hazardous activities must wait until the following day after a restful sleep and according to the treating team’s instructions.
When Spravato® must not be used
The Australian CMI states that it must not be used by someone who is allergic to esketamine, ketamine or an ingredient in the product; has or has had an aneurysm or bleeding in the brain; is pregnant; or is breastfeeding. A person who could become pregnant must discuss effective contraception during treatment and for six weeks after it ends.
Health conditions that need specific review
The psychiatrist needs a complete medical and psychiatric history. Particular review is required for uncontrolled cardiovascular disease or blood pressure, recent heart attack, abnormal heart rhythms, stroke or impaired blood supply to the brain, head injury or raised intracranial pressure, breathing problems, severe liver disease, untreated hyperthyroidism, psychosis, bipolar disorder or mania, and current or previous alcohol or other drug problems.
Medicines that cause sedation
Benzodiazepines, opioids, alcohol and other central nervous system depressants may increase sleepiness or breathing risk. The treating team needs an accurate list of all medicines and substances used.
Medicines that may affect blood pressure
Psychostimulants—including some ADHD medicines—and monoamine oxidase inhibitors can require closer blood-pressure review and monitoring.
TELL STAFF IMMEDIATELY
Symptoms needing urgent assessment
Chest pain, difficulty breathing or shortness of breath, a sudden severe headache, a change in vision, seizure, inability to stay awake, feeling as though you may faint, or suicidal thoughts and thoughts of self-harm require immediate clinical attention.
Treatment does not replace broader mental healthcare. Medication
management, psychological care, recovery planning, physical health
review and communication with the person’s usual clinicians may all
remain important.
COMMON QUESTIONS
Clear information before any decision.
Is esketamine the same as ketamine?
No. Esketamine is one component of the ketamine molecule. The registered treatment described on this page is a specific intranasal prescription medicine with its own indication, administration requirements and monitoring pathway.
What does dissociation mean?
Dissociation can feel like being disconnected from your body, thoughts, feelings, surroundings, space or time. Perception may temporarily feel altered. Staff monitor the intensity and duration of these effects and do not discharge a patient until they are considered clinically stable.
Can I take the nasal spray home?
No. Spravato® is stored by the healthcare service, supplied only for supervised self-administration at the treatment site and disposed of by the service after use.
Can I book an esketamine treatment directly?
No. Treatment cannot be selected or guaranteed through an online booking. The first steps are clinical record review and specialist psychiatric assessment. A psychiatrist decides whether this or another treatment pathway is appropriate.
Is it a treatment for PTSD?
Intranasal esketamine is not registered in Australia specifically for PTSD. People can have PTSD and depression at the same time, but diagnosis and treatment planning must be individualised by the treating psychiatrist.
Is the medicine covered by the PBS?
PBS subsidy may apply when the current restriction and prescribing requirements are met. Medicine, dispensing, psychiatric care and clinic monitoring can involve separate costs. Patients should receive an individual cost explanation before treatment begins.
Does everyone follow the same schedule?
No. The registered pathway provides a dosing framework, but the psychiatrist reviews response, side effects and ongoing need. Treatment may be adjusted, paused or ceased when clinically appropriate.
Read the official information
This overview does not replace the Consumer Medicine Information, Product Information or advice from a treating clinician.
Information reviewed 6 November 2026.
NEXT STEPS
Start with your treating clinician.
If you are seeking clinical advice, speak with your GP or treating psychiatrist. They can review your symptoms and treatment history and discuss whether specialist assessment is appropriate.
Ask an administrative question
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