Seldom does the room where it takes place appear to be much. A reclining chair, a blood-pressure cuff, a box of tissues, a nurse who looks in every so often across two hours while the edges of the world go soft. This is how esketamine is administered: a nasal spray is used in a clinic under supervision, and the patient is kept motionless until the dissociation subsides before being permitted to drive home.
That tiny clinical scene has become something close to hope for the approximately one in three individuals whose depression does not improve after taking two or more antidepressants. In a field where people are accustomed to waiting six or eight weeks to feel any shift at all, esketamine, marketed under the brand name Spravato, acts on glutamate rather than serotonin and can move quickly, sometimes within a day.
Why, then, does your doctor hardly ever mention it?
A portion of the response is, to be honest, somewhat depressing and bureaucratic. After reviewing the data twice, NICE in England and Wales decided not to recommend the medication for NHS funding because the expense could not be balanced against an unclear long-term benefit. Before discounts, a single course costs about £10,500. Even after years of appeals from the Royal College of Psychiatrists and the manufacturer, that ruling remained in place. Scotland agreed. England declined. As a result, the same medication is accessible on one side of a line but not the other, creating an odd internal border.
Speaking with medical professionals gives me the impression that the silence isn’t actually due to medical professionals concealing a miracle. The majority of general practitioners are unable to prescribe it, even if they wish to. Esketamine is not part of the standard toolkit, which includes private providers, specialized clinics, supervised dosing, and monitoring. It’s not a secret that a family doctor works through a ten-minute appointment. They are operating within a system that silently shuts the door.
Even so, it’s difficult to ignore the discrepancy between what patients are actually offered and what the research indicates. American regulators went one step further than those in Britain, approving Spravato as a stand-alone treatment in early 2025 after first approving it as an add-on in 2019. This was the first nasal spray that was authorized to treat this type of depression on its own. It has now been administered to over 140,000 individuals worldwide.
It’s not unreasonable to exercise caution. The chemical cousin of esketamine, ketamine, has a long history of recreational abuse, and the trials had serious limitations, including short follow-up periods, small patient populations, and unanswered questions about what happens after treatment ends. It was appropriate for regulators to pose challenging queries. People will debate whether or not they asked them in the proper proportion for years to come.
The human math that lies beneath the spreadsheets is what remains while all of this is happening. Depression that is resistant to treatment is a serious issue. Longer episodes, increased anxiety, and more suicidal thoughts are all brought on by it. The gap between “approved” and “not cost-effective” can feel like the gap between a future and none to someone who has tried everything and seen no progress.
The medication was never marketed as a cure, and it isn’t one. However, it has altered the possibilities. It’s still unclear if the systems designed to deliver it will ever catch up.
Q: What is esketamine used for?
A: It treats depression that hasn’t improved after two or more antidepressants.
Q: How is it taken?
A: As a nasal spray, given in a clinic under supervision.
Q: Why won’t most GPs prescribe it?
A: It isn’t funded by the NHS in England and Wales.
Q: How fast does it work?
A: Some patients feel improvement within roughly 24 hours.
Q: Is it available anywhere in the UK?
A: Yes, Scotland’s medicines body accepted it back in 2020.