Depression Relief: Finding the Right Dosage for Esketamine Nasal Spray

If your depression hasn’t responded to traditional treatments, you might be considering esketamine nasal spray (Spravato®). At Holistic Behavioral & TMS Therapy in Aurora and Chicago, Illinois, and Las Vegas, Nevada, we understand that dosing can raise a lot of questions. We’re here to walk you through what determines your dose, how we adjust it, and what signs suggest you might need a change.

Our team — including Lawrence Abah, PMHNP-BC — offers compassionate expertise in this FDA-approved treatment. You receive individualized care in-person or via telehealth, so your treatment fits your life.

What is esketamine, and how is dosing set?

Esketamine is a fast-acting NMDA receptor antagonist approved for treatment-resistant depression (TRD) and major depressive disorder (MDD) with suicidal ideation. Unlike typical antidepressants that can take weeks to work, esketamine can reduce symptoms within hours — when used as directed by a provider.

For TRD, dosing involves two phases:

• Induction (weeks 1-4): Twice-weekly doses of 56 mg or 84 mg
• Maintenance (weeks 5-8): Once-weekly doses of 56 mg or 84 mg
• Long-term tapering (week 9+): Every one to two weeks

For MDD with suicidal ideation, treatment typically begins with 84 mg twice a week for four weeks. If needed, we can lower this to 56 mg, based on how well you tolerate it.

Does everyone start at the same dose?

Not always. We typically begin with 56 mg, especially in TRD cases, to evaluate tolerability. Depending on how your body reacts to that initial dose — and how much symptom relief you experience — we may increase to 84 mg. Some clinical studies allowed dose adjustments to improve comfort based on the patient's response.

What factors determine the dose that’s ‘just right’?

We consider:

• How severe your depression symptoms are
• How well you tolerated earlier doses
• Changes in your mood or side effects like sedation or elevation in blood pressure

We might increase to 84 mg if you’re tolerating treatment well but still feeling depressed. If side effects are an issue, we may lower your dose or adjust frequency.

How do we know when to adjust?

We regularly monitor:

• Your symptom relief: are depressive feelings improving?
• Tolerability: are you experiencing nausea, sedation, dizziness, dissociation, or increased blood pressure?

If symptoms persist or side effects cause concern, we may adjust up or down, but only in line with FDA-approved dosing guidelines.

What else matters during treatment?

Before dosing, it’s best to:

• Avoid food for two hours and liquids for 30 minutes before administration
• Use nasal sprays or decongestants at least one hour beforehand if needed

We also monitor you in the clinic for at least two hours afterward, checking for sedation, dissociation, and blood pressure changes — essential for your safety and optimal outcomes.

Esketamine is a powerful medicine that requires careful dosing. We personalize each treatment plan, monitor response, and support you through the process, whether in-office or via telehealth. Call or schedule an appointment online today to learn more about Spravato.