IV Ketamine therapy remains the gold-standard of TRD treatment, however the FDA is expected to approve Johnson & Johnson’s esketamine nasal spray that will be marketed as Spravato. The drug is basically one half of the original ketamine molecule. The attempt was to split the drug to remove the psychedelic effects of the medicine. We understand that the concept of a transcendental experience is not part of mainstream Western medicine, but it is a part of our culture. We feel that the transcendental experiential effects of a ketamine infusion is an essential part of the treatment. The nasal delivery of the drug is certainly more desirable, however it may not be as effective, as dosing and absorption will be less precise. Studies are showing that this nasal spray form of the drug is not as potent as the IV form of Ketamine. The benefit of FDA approval of esketamine is that insurance companies may cover its higher cost, estimated to be $590-885 per dose. Spravato will not be dispensed to patients to take home like ketamine trouches. It will only be available in approved and certified treatment centers.