The Department of Veterans Affairs began administering esketamine, under the brand name Spravato, to eligible veterans within months of its 2019 FDA approval, calling it an expansion of options for veterans with treatment-resistant depression who hadn’t responded to anything else. But the schedule to receive the treatment is demanding, and not all VA facilities provide it.
Covered, but Not Automatic
VA coverage for the brand Spravato, the only FDA-approved nasal spray for adults with treatment-resistant depression, requires:
- Meeting the clinical definition of treatment-resistant depression
- Generally, a documented lack of response to at least two adequate antidepressant trials
- A formulary exception request that a VA provider has to submit and get approved before treatment can begin
Not every VA medical center offers Spravato on site. For veterans whose local facility doesn’t provide it, the only VA-covered path is a Community Care referral to a civilian provider, which the VA authorizes on a case-by-case basis when an in-network option isn’t available within a reasonable distance.
Read More: Defense Department Approves Spravato for Some Patients
That referral pathway is the part that changes the calculus. Steve Levine, M.D., chief patient officer at Compass Pathways, described the underlying treatment burden in an interview with Military.com. The company, with headquarters in London, is supplying its synthetic psilocybin formula for the VA PIVOT trial for treatment-resistant depression and comorbid PTSD.
Regarding the accessibility of Spravato:
“Patients need 25 to 50 treatments in a year — three-hour appointments they need to be driven to by a caregiver. It can take a couple of weeks before they know if it’s helping, and it’s not durable. They have to keep coming back,” Levine told Military.com.
When the Nearest Facility Is an Hour Away
Spravato’s FDA label requires twice-weekly dosing for the first four weeks, stepping down to weekly then every one to two weeks, with each visit requiring a minimum two-hour supervised observation period and a ride home, since patients can’t drive themselves. For a veteran whose home VA doesn’t offer the drug, that same schedule runs through a Community Care referral, meaning a civilian clinic that may be considerably farther from home than the VA facility they already know.
Read More: VA Says Veteran Trust Hit an All-Time High. Here’s What the Data Actually Shows.
For veterans in rural areas, where VA facility density is already thinner and where a meaningful share of the veteran population lives, that turns a demanding treatment schedule into a genuinely difficult logistical undertaking: eight round-trips in the first month alone to a clinic that isn’t necessarily close, each one requiring someone else to drive, on top of managing a condition that already makes sustained motivation and planning harder.
Levine, describing the broader access problem across the treatment-resistant depression population, put a number on how few people are actually getting through that process.
“There are 4 million adults in the U.S. with treatment-resistant depression,” Levine said. “Only about 100,000 of them are getting Spravato right now. Part of the reason relatively few people get Spravato is that there hasn’t been as much awareness of treatment-resistant depression as a subtype until recently — but it’s also the burden of treatment I mentioned.”
Why This Is Shaping What Comes Next
Compass and at least one other organization, the nonprofit Unosa Institute, are working on treatments for treatment-resistant depression with comorbid PTSD explicitly designed around a different model: fewer total sessions with a longer effect per treatment, rather than an indefinite twice-weekly-then-tapering schedule. Compass’s own Phase 3 data for its psilocybin candidate, still years from potential approval, has shown some patients maintaining response for six months after just one or two treatments.
None of that changes what’s available to veterans right now. For the moment, Spravato remains the only FDA-approved, VA-covered pharmacologic option beyond standard antidepressants, and getting it means clearing a formulary exception then potentially adding a Community Care referral and a longer drive on top of a schedule that already asks for a ride and three hours, twice a week, for a month, before tapering to something more sustainable months later.
The VA didn’t immediately reply to a query.
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