From our survey

After you send the esketamine referral: a referrer FAQ

You documented the medication history, had the conversation, and sent the referral. Then the patient disappears from your view for weeks, and reappears with questions you may not be able to answer. What happened in between?

These answers walk referring clinicians through the esketamine pathway after the handoff, so expectations stay accurate and you stay useful to the patient. Where we cite survey numbers, they come from 443 adults we polled in ten Midwest states and are final after Pollfish's validation.

Why does it matter what happens after I refer?

Because patients will keep asking you. In our poll, 56 percent of respondents would begin with their primary doctor when pursuing ketamine or esketamine, and a doctor's recommendation would sway 74 percent. Their trust in you outlasts the referral. Patients will come back to you with questions about the process, costs, and side effects, often before they ask the treating clinic.

Who evaluates the patient?

Typically a psychiatrist or other prescriber affiliated with, or working at, a certified treatment site. Some certified centers accept referrals directly from primary care and do their own evaluation; others require a psychiatric evaluation first. The evaluation reviews the diagnosis, treatment history, cardiovascular and cerebrovascular risk, substance use history, and other factors relevant to safety and candidacy. The treating prescriber decides whether esketamine is appropriate.

How long until the first dose?

It varies with evaluation wait times, prior authorization, and site capacity. The prior authorization step is often the longest. Patients are generally willing to wait for coverage. In our poll, 51 percent would take an insured route with extra steps, 23 percent would pay cash to keep it simple, and 26 percent had not decided. Setting that expectation at referral helps patients not give up during the wait.

What if prior authorization is denied?

Denials often turn on documentation, such as missing doses or durations for prior antidepressant trials or absent symptom scores. The treating site can usually file an appeal or ask for a peer-to-peer call, and you may be asked for more chart records. A complete medication history at referral is the best prevention.

Does the patient stay on their oral antidepressant?

That depends on the indication and the treating prescriber's plan. Esketamine has been studied and labeled in combination with an oral antidepressant, and the current label also includes use on its own for treatment-resistant depression. Clarify with the treating clinician who manages the oral medication going forward, so the patient does not receive conflicting instructions.

What does a treatment session look like for the patient?

The patient arrives at the certified site, has blood pressure checked, and self-administers the nasal spray under direct observation. They then remain on site for a monitored observation period because of possible sedation, dissociation, and blood pressure elevation. A companion drives them home, because they may not drive themselves until the following day. Early treatment involves twice-weekly sessions, tapering afterward based on response.

What if the patient wanted treatment at home?

Some will. Our respondents' delivery preferences ran 44 percent for an in-person clinic, 22 percent for video care at home, and 23 percent for a clinic start with home care later. Esketamine never goes home, since certified sites administer every dose; Brain Recovery Centers explains how Spravato sessions are delivered in terms patients follow easily. Patients wanting home care may run into online services offering off-label ketamine, a different arrangement with much less supervision. Explaining this distinction clearly is one of the most useful things a referrer can do.

What should I receive back from the treating site?

Ask for it. Reasonable expectations include confirmation that the patient was evaluated, the treatment decision, any medication changes, and periodic updates on response. If you do not hear back, it is fair to request a note. Coordinated care avoids duplicated prescriptions and conflicting advice.

How is response measured?

Usually with standardized symptom scales, such as the PHQ-9 or clinician-rated measures, administered periodically. Treating clinicians adjust session frequency based on response, and they may stop treatment if it is not helping. Esketamine is not effective for everyone, and patients should hear that honestly.

Who handles side effects between sessions?

The treating site should be the first call for effects related to esketamine. For unrelated issues, and for ongoing primary care, the patient still comes to you. If blood pressure is a concern, coordinated monitoring between offices makes sense.

Does esketamine replace therapy?

No. Psychotherapy remains valuable and can be continued alongside. For patients who strongly prefer to avoid additional medication, which was important to 64 percent of our respondents, TMS or a structured psychotherapy may be options to discuss before or instead of esketamine.

What should I tell patients about cost?

That it depends on their plan. Esketamine may be covered under the medical or pharmacy benefit, and the observation visit is billed separately, so the treating site's billing staff should walk them through expected costs. Coverage is central to the decision for most people; 85 percent of our respondents named insurance as one of the two provider traits they would weigh most.

What if the patient stops showing up?

Missed sessions can reflect transportation problems, side effects, cost surprises, or worsening depression. Reaching out, or asking the treating site to, is appropriate. Transportation is a frequent barrier; Medicaid often covers non-emergency medical transportation, which may help.

Scope

This FAQ summarizes public information about the esketamine program and our survey findings. It is not prescribing guidance; refer to the current label and REMS materials. Suitability is a clinical decision made by the treating prescriber.

If a patient gets worse while waiting or mid-course, 988 is the number, by call or text; Suicide and Crisis Lifeline staff answer around the clock. Repeat it at every step of the handoff.

Methodology

Pollfish offered survey 395586438 to consumer-panel members, stopping on June 23, 2026, and received 443 completes, a sample of adults 18 through 64 in Wisconsin, Missouri, Oklahoma, Iowa, Illinois, Minnesota, Kansas, Ohio, Nebraska and Indiana. The data are final whole-sample shares. The publisher initiated the survey and covered its cost.