Spravato Treatment Form (current patients)

Spravato Treatment Form

Current Psychiatric Wellness clients receiving Spravato treatment.
Name*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Date
Email*
example@example.com
Gender: (Please select the gender you were assigned at birth for insurance purposes)*

MaleFemale
Today's Date:*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Spravato Healthcare Provider:*
By signing my initials beneath each of the following, I confirm that I understand and agree to these terms and conditions and consent to Spravato treatment. Please sign your initials below:*

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I understand that Spravato may impair my ability to drive safely, make legal decisions, or operate machinery. Please sign your initials below:*

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I agree to not drive a vehicle, make legal decisions, or operate machinery for 24 hours following the administration of Spravato. Please sign your initials below:*

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I acknowledge that it is my responsibility to arrange for a designated driver or alternative transportation to ensure my safe transportation after receiving Spravato treatment. Please sign your initials below:*

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I understand the importance of adhering to these precautions for my safety and the safety of others. Please sign your initials below:*

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I understand the risks include but are not limited to: dissociation, dizziness, nausea, sedation, vertigo, headache, dysgeusia, hypoesthesia, anxiety, lethargy, blood pressure increased, vomiting, insomnia, and diarrhea. Please sign your initials below:*

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I also understand that the potential side effects form Spravato nasal treatment may include: nasal discomfort, throat irritation, feeling drunk, dry mouth, hyperhidrosis, euphoric mood, dysarthria, tremor, oropharyngeal pain, mental impairment, constipation, pollakiuria, feeling abnormal, and tachycardia. Please sign your initials below:*

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I understand that good results are expected but not guaranteed. My depression may not improve with Spravato treatment even if I follow the complete treatment protocol. Please sign your initials below:*

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I understand that once Spravato is administered, I will need to keep talking and other noises to a minimum while in the treatment room. Please sign your initials below:*

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I understand that if I am more than 15 minutes late for a Spravato treatment, I will not be able to receive treatment that day. Please sign your initials below:*

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I understand that Spravato nasal treatment is not a substitute for continued behavioral medicine treatment. My psychiatrist or family doctor will determine if any oral medications or other treatments may be stopped if my depression improves. Please sign your initials below:*

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I understand that to achieve the desired results that a series of nasal treatments are needed, and it is my full intent to complete the course of treatment. Please sign your initials below:*

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I understand that I can revoke this consent at any time including during treatment. Please sign your initials below:*

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I understand that the duration of the treatment will be approximately two hours and I understand that it will be necessary for me to stay in the office for a while after the treatment ends, typically a few more hours. Please sign your initials below:*

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I understand that the use of Spravato for the treatment of Major Depression is Food and Drug Administration approved. Please sign your initials below:*

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I understand that Spravato nasal spray is indicated, in conjunction with an oral antidepressant, for the treatment of treatment-resistant depression in adults. Please sign your initials below:*

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Spravato is intended for patient administration under the direct observation of a healthcare provider, and patients are required to be monitored by a healthcare provider for at least 2 hours after administration. Spravato must never be dispensed directly to a patient for home use. Spravato is not approved as an anesthetic agent. The safety and effectiveness of Spravato as an anesthetic agent have not been established. Please sign your initials below:*

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I am agree that I have received and reviewed the pre-treatment instructions, post treatment instructions and that I can fully comply. Please sign your initials below:*

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I have been explained thoroughly about the use of Spravato for Major Depression and I had the opportunity to ask all of the relevant questions that I felt were necessary. Please sign your initials below:*

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I voluntarily request Psychiatric Wellness to administer Spravato for the treatment of my condition. Please sign your initials below:*

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By signing my name below, I hereby acknowledge and agree to the terms and conditions above. Please sign your full legal name below:*

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Because Spravato treatment is strictly regulated by FDA REMs guidelines there are certain rules that patients must follow to ensure our clinic remains compliant:

1. You must be monitored for the full two hours of your treatment sessions. This means you may not leave the monitoring room without asking for staff assistance and you must wait for them to come to you after pushing your call light versus getting up and leaving the room on your own. If you do not follow this rule you WILL NOT BE ALLOW TO CONTINUE TREATMENT with Spravato at our facility.

2. You must be on time for your treatments. If you are more than 15 minutes late you will be asked to reschedule your session and charged the late cancellation fee per clinic policy.

Because the treatment room is shared with other clients please be respectful of others.

1. Please refrain from talking or making unnecessary noise during your treatments. To get the most out of your treatment, we recommend using headphones or earbuds and listening to relaxing music. Please ask us if you would like suggestions for Spravato playlists. If you are consistently disruptive in the treatment room you will not be allowed to continue Spravato treatment at our clinic.

2. There is no smoking or vaping in the treatment room.

3. Please refrain from any strong odors in the treatment room. This means one must be bathed and free of strong body odors, fragrances or smoke smells.

Thank you so much for your understanding and cooperation with helping to keep our clinic in compliance and making the treatment setting pleasant for everyone.
By signing my name below, I hereby acknowledge and agree to the terms and conditions above. Please sign your full legal name below:*

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Frequently Asked Questions

(SPRAVATO FAQs)
FREQUENTLY ASKED QUESTIONS ABOUT SPRAVATO

IS SPRAVATO SAFE?

Spravato is a very safe depression medication in the hands of properly trained healthcare professionals. Its use as a treatment for depression, including treatment resistant depression, and other mental health conditions. The appropriate dosage is determined by your physician, below those necessary to induce general anesthesia. Spravato is also frequently used to treat patients with treatment resistant depression.

IS SPRAVATO A RECREATIONAL DRUG?

Spravato is esketamine, however ketamine has been abused as a recreational drug. Street drug use is in doses vastly higher than the sub-anesthetic doses used for the treatment of depression and other mental health conditions. As mentioned above, Spravato is used legally and safely and is a very safe medication in experienced hands. Incidentally, many of the drugs used in anesthesia practice have the potential for abuse, so Spravato is not unique in this respect. The key is administering the right dose to the right patient in the right setting.

IS INTRANASAL SPRAVATO THE ONLY WAY TO DELIVER SPRAVATO FOR TREATMENT RESISTANT DEPRESSION?

Spravato is only administered intranasally. Unfortunately, the effectiveness and predictability of response and the overwhelming majority of scientific studies of Spravato for depression and mental health conditions have been performed using intranasal Spravato. In short, intranasal Spravato is the gold standard route for Spravato administration.

CAN SPRAVATO HELP ME?

Research over the last 5-10 years has shown that intranasal administration of Spravato in sub- anesthetic doses remarkably benefits 70% of people suffering from severe depression. While the benefits can truly be remarkable, they often occur in ways that differ from some patients' expectations. That is, the changes produced by Spravato can be subtle, and while they occur quickly, they do not always manifest themselves immediately. This phenomenon stands in contrast to some patients' expectations of a benevolent "thunderbolt" response from Spravato treatment. With this in mind, we will work closely with you to identify and evaluate the benefits of Spravato as a depression medication.

WHAT SHOULD I EXPECT DURING MY FIRST INITIAL SPRAVATO VISIT?

After we have received your medical and psychiatric history and completed acknowledgement of ongoing care by a mental health professional or primary care doctor, we will schedule an initial consultation. At the initial consultation, we will discuss all your options regarding treatment for depression and assess if you are a good candidate for Spravato intranasal administrations, you are welcome to receive your first Spravato treatment once all insurance benefits and authorizations have been completed. You would also need to be enrolled in the Spravato REMS program. The logistics are as follows: we will apply monitors to enable us to record your heart rate and rhythm, blood pressure, and oxygen level continuously throughout the treatment, then we begin the intranasal administration while you are seated with your head at 45-degree incline. Afterwards, we will monitor you for approximately 120 minutes (2 hours) before you are released with a friend or relative who can drive you safely home. During the treatment, occasionally people experience nausea, mild non-threatening hallucinations, or dizziness. If you experience nausea, we are equipped to treat it with an anti-nausea medication. You will be awake during the treatment and able to interact with those around you. It is best to relax quietly or listen to relaxing music during the session. The effects of Spravato wear off quickly, although we ask that you refrain from driving until the day after the treatment.Please do not eat solid foods, milk, pulp-filled juices or soup for 4-hours prior to your appointment. Youmay have clear liquids such as water, Gatorade, apple juice, black coffee or tea up to two hours prior toyour appointment.

HOW MANY INTRANASAL ADMINISTRATIONS DO I NEED?

The standard Spravato protocol for depression that has resulted from scientific trials and clinical experience around the U.S. is about 2 times per week for the first 4 weeks, and then weekly for 2 - 4 weeks and then maintenance. It has been shown that serial intranasal administrations are more effective than single intranasal administrations, and many patients who respond to Spravato treatment require maintenance intranasal administrations on an ongoing basis following the initial series. The frequency of these maintenance intranasal administrations varies greatly from person to person. It is important to note that Spravato intranasal administrations should not be viewed as a cure for depression, but rather a depression treatment that is a piece of a multi-modal approach that may include ongoing mental health therapy or other depression medication.

CAN I CONTINUE TO TAKE MY REGULAR MEDICATIONS?

Yes, you should not stop your antidepressant medications in order to receive Spravato. It is essential that we review your current medication list prior to beginning Spravato treatments.

IS SPRAVATO ADDICTING?

Spravato is not physically addicting but it could be psychologically addicting in those using it recreationally at much higher doses and in far greater frequencies than we will use. There is potential for abuse and misuse. Consider the risks and benefits of using Spravato prior to use in patients at higher risk of abuse. All patients will be monitored for signs and symptoms of abuse and misuse.
Please sign full signature:*

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OTHER SPRAVATO FAQs

Is there a difference between Spravato Nasal Spray and Ketamine Infusions?
Spravato (esketamine) is the s-enantiomer of racemic ketamine. There are no head-to-head studies comparing esketamine and ketamine infusion. Spravato (esketamine) is delivered in a nasal spray form and ketamine is delivered intravenously.

Are there Samples of Spravato?
There are no samples of Spravato available—in accordance with federal guidelines, which prohibit the distribution of samples of class III medications.

How much does Spravato Cost?
The cost of Spravato is dependent on your insurance plan.

Can Spravato be taken with other medications for depression?
Spravato should be administered in conjunction with an oral antidepressant (AD). The new open-label oral AD initiated during Study 1 (short-term) was an SSRI in 32% of patients and an SNRI in 68% of patients.

What if a patient misses a dose of Spravato?
If a patient misses treatment session, and depression symptoms worsen, consider returning your patient to previous dosing schedule (i.e., every 2 weeks to once weekly, once or twice per week), per clinical judgement.

Can I pick up Spravato and self-administer at home?
No, under the REMS, Spravato must be administered in a certified healthcare setting. Due to the possibility of delayed or prolonged sedation or dissociation in some cases, patients should be monitored by a healthcare professional for at least 2 hours following each treatment session, or until the clinician determines the patient is safe to leave.
Signature:*

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The second page of this MUST be filled out and sent in through the mail, text or email.

Our address is:
1491 S Sunnylane Rd,
Del City, ok 73115

You can text it to: 405-437-0205

You can email it to: kylie@psychiatricwellness.org

Please complete page 2 of Spravato Enrollment Form in the next step. Again, this MUST be filled out to continue.

Spravato REMs <--- FORM that MUST be filled out - PAGE 2 ONLY
Should be Empty:

Spravato Treatment Form

Patient Health Questionnaire (PHQ-9)

Generalized Anxiety Disorder Screener (GAD-7)

Columbia-Suicide Severity Rating Scale (C-SSRS)

Frequently Asked Questions