Referral Form for Spravato® Treatment

If you’re a psychiatrist referring a patient for Spravato® (esketamine) treatment, please complete the referral form here.

Eligibility Criteria for Spravato® (Esketamine) Treatment

Patients seeking treatment with Spravato® must meet specific criteria as per FDA guidelines and clinical best practices. Below are the key eligibility requirements:

1. Diagnosis

• Treatment-Resistant Depression (TRD): Patients must have a confirmed diagnosis of Major Depressive Disorder (MDD) and have not responded adequately to at least two different antidepressant medications at therapeutic doses during their current episode of depression.

• Major Depressive Disorder with Acute Suicidal Ideation or Behavior (MDD with SI): Patients experiencing significant suicidal thoughts or behaviors in the context of MDD may also be eligible.

2. Current Treatment

• Patients must currently be on at least one oral antidepressant to be used alongside Spravato®. This ensures continued support for depression management and adherence to evidence-based treatment protocols.

3. Exclusions

Spravato® may not be suitable for individuals with:

• A history of hypersensitivity to esketamine or ketamine.

• A history of aneurysm

4. Comprehensive Psychiatric Care

• Patients must have an outside psychiatrist or mental health provider managing their ongoing medication regimen.

• Self-referrals are considered on a case-by-case basis; however, the patient will still need to establish care with a psychiatrist for medication management to ensure safe and effective treatment continuity.

How to Submit:

• Download the referral form here.

• Complete the form with detailed information about the patient’s history and previous treatments.

• Email the completed form to info@aetherpsychiatricconsultants.com or fax it to 828-377-7125.

What to Expect After Submission

• Referral Forms: Once we receive your referral form, we’ll review it and contact both the referring provider and the patient to schedule the initial consultation.

If you have questions or need assistance with determining eligibility, please don’t hesitate to contact us at info@aetherpsychiatricconsultants.com or call 828-424-5512. We’re here to support you every step of the way!