Why "Depressed Enough" Is the Wrong Question for Spravato
A lot of people come to us already half-talked-out of the idea. They say some version of the same thing: "I'm still going to work. I'm functioning. I'm not sure I'm depressed enough for something like Spravato." The question underneath it is almost always – am I sick enough to qualify?
It's a question our Co-Founder and Chief Medical Officer, Dr. Ben Yudkoff, recently took up for fellow clinicians in an essay for Doximity's Op-Med. The answer is much the same whether you're a patient or a provider – "depressed enough" isn't really how eligibility works.
It's an understandable question. It's also the wrong measure. Esketamine (the active medication in Spravato) eligibility was never built around how bad a single day looks or how high your symptoms score on a given afternoon. It was built around something different: how many treatments have already been tried, and haven't worked.
What Actually Defines Spravato Eligibility
Spravato has two FDA-approved pathways, and neither one asks you to clear a "severity floor":
Notice what's missing from both: any requirement that you be at your worst. The criterion is treatment response, not severity.
Why Your Treatment History Matters More Than Severity
There's good evidence behind this framing. Roughly 1 in 3 people don't get enough relief from oral antidepressants alone, and even after trying a third oral antidepressant, about 86% still don't reach remission – a full lifting of symptoms (Spravato prescribing information). The odds of the next same-type medication working go down, not up.
The reason has to do with how these medications work:
So when two solid trials of the monoamine strategy haven't helped, a third or fourth version of that same strategy is statistically unlikely to. Matching the treatment to a patient's history, rather than just their symptom score, is the more personalized approach the evidence supports. And it's worth saying plainly – if those earlier medications didn't work, the treatments failed you. You didn't fail them.
How Insurance Affects Your Spravato Coverage
Here's the nuance that confuses people, because it's where "am I depressed enough" stops being entirely wrong. Clinically, eligibility is about treatment response. But insurers add their own requirements on top of the FDA criteria – often a documented depression-rating score at a moderate-to-severe threshold, along with a paper trail of the medications you've tried. So the real question is rarely "are you sick enough for the medicine." It's "does the documentation meet this particular plan's bar for authorization." That overlap is one of the most common places treatment gets delayed, and navigating it is part of what our team does for every patient. (See our guide to Spravato coverage and cost.)
So Who Is Actually a Candidate for Spravato?
In plain terms, Spravato may be worth exploring if:
Not everyone is a fit, and that matters too. Some people are better served by other options, and we're honest about that. (See who is not a good candidate for ketamine therapy.)
A Better Way to Think About Esketamine Eligibility
If you've been wondering whether you're "depressed enough," try a different question: have the treatments you've already tried done enough? If the answer is no, that – not the severity of any single day – is what makes a conversation about Spravato worth having. Our team can walk you through eligibility, the insurance side, and whether it's the right fit.
Are you a clinician? Dr. Yudkoff makes this same case for referring providers in his essay for Doximity's Op-Med: What I Tell Clinicians Who Ask if Their Patient Is 'Depressed Enough' for Esketamine.
This article is for general education and is not medical advice. Spravato is administered in a certified healthcare setting with monitoring. Talk with a qualified provider about your specific situation.
Take the first step today.
If you or someone you love is exhausted by depression that has not responded to conventional treatment, our team is ready to help you understand whether ketamine treatment or Spravato may be a fit. Book a free consultation. There is no pressure, and the information is yours to keep.
Available in Massachusetts and the greater Washington, DC and Maryland area.
Frequently Asked Questions
Do I have to be severely depressed to qualify for Spravato?
Clinically, no. Eligibility depends on whether enough other treatments have been tried without adequate relief, not on how severe your depression looks on a given day. Many insurers separately require a documented moderate-to-severe rating for authorization, which your care team helps you navigate.
How many antidepressants do I need to have tried before Spravato?
Generally at least two, each taken at an adequate dose for an adequate length of time during your current episode. A medication tried briefly or at too low a dose may not count toward that history, which is worth reviewing with a provider.
Can I qualify for Spravato if I'm still able to work and function day to day?
Yes. Functioning at work or in relationships does not disqualify you, since eligibility looks at your treatment history rather than how well you appear to be managing. Many people who qualify are still holding daily life together while carrying depression that has not responded to treatment.
Does insurance affect Spravato eligibility?
Yes. FDA criteria focus on treatment history, but insurers often add their own requirements, like a documented moderate-to-severe depression rating and a record of medications you have tried. Navigating that documentation is part of what your care team helps with before authorization.
