Andrew Paleno, PA-C, is a licensed and board-certified physician assistant at New Directions Mental Health’s Wexford – Stonewood clinic. With over seven years of psychiatric experience, including research on ketamine and difficult-to-treat depression, he now focuses on interventional services like Spravato® and TMS. In this interview, Andrew explains what sets Spravato® apart, how patients are supported before, during, and after treatment, and why individualized care matters at every stage.
What makes Spravato® different
What is Spravato®, and how did you get into this work?
Andrew: Spravato® is an FDA-approved treatment for what we would classify as treatment-resistant depression—which just means that someone has failed two or more antidepressant medications.
The mechanism is something that separates it from other things. While the mechanism is not fully understood, we believe that it works predominately on the glutamate system. When patients come to us asking, “What makes this so different?” or “What gives me hope when I’ve failed so many antidepressants?”—this is what we talk about.
I’ve been working in psychiatry for seven years and did research on ketamine before Spravato® was even FDA approved, so it’s kind of full circle now that I do this primarily.
Is there long-term data about Spravato®’s safety and effectiveness?
Yes. It’s been FDA-approved since 2019, and we now have six-year data showing that it’s safe and provides significant relief for a lot of people who have failed other antidepressants. Some research shows around approximately 65% reported significant relief in their symptoms.1
As people continue to fail antidepressants, statistically their chance of responding to the next one drops.
This gives people hope who are feeling pretty hopeless. We definitely see people have relief for the first time in their life.
Concerns around safety
What do people usually want to know before starting?
The most common themes are: what are the side effects? What are the safety issues? What’s the mechanism of action? And what does the logistics of treatment actually look like—how long is it? What does it feel like?
They’ll ask, “I’ve tried all these other medications, so what makes this different?” And I go over all that with them, including the numbers and the science, to help them understand that this really is something new.
What about safety concerns around ketamine itself?
Ketamine’s been used in medicine since the 1960s, commonly as an anesthetic. So it’s already been part of medicine for a long time.
The difference with Spravato® is that it’s esketamine—an isomer—and it’s a nasal spray. It has some similar characteristics to ketamine but is slightly different in formulation and how it’s administered.
Is there a risk for addiction?
I wouldn’t say there’s no potential for addiction, but it’s very low because of how closely we monitor it. You’re getting it in a controlled environment, and we screen people carefully. If someone’s actively struggling with substance use, they’re probably not the best candidate right now.
The way we administer and supervise Spravato® makes that risk extremely low.
Getting people ready to start
What kind of support do patients receive before their first session?
I spend a lot of time during intake going through everything: side effects, outcomes, what the day looks like. Walking through the possibilities helps people feel more confident. A lot of the unknowns can cause anxiety.
We also connect people with Spravato® With Me, a support program through the manufacturer. They provide extra resources and even a representative who can walk patients through questions. I’ve had patients speak highly of it. It’s not a replacement for what we do, but it adds another layer of support.
What treatment looks like—and how we stay with you
What should patients expect during the session itself?
Spravato® is administered as a nasal spray, and then patients stay with us for at least two hours. During that time, we monitor blood pressure and mental status, but we also just support them through the process.
Some people want to wear headphones and an eye mask. Others want to talk. It’s whatever feels right to them.
Can Spravato® bring up strong emotions or dissociation?
About a third of patients will experience dissociative side effects. They’re not necessarily negative, but they can be surprising or intense. Strong emotions can sometimes come with that.
What helps is preparing people for it ahead of time. That’s why we go over it thoroughly before their first session.
During treatment, we’re there with them. They’re not doing it alone.
Our staff is amazing—we have some of the best support people I’ve worked with.
Do you stay in touch with therapists or other providers during treatment?
Absolutely. We get a lot of internal referrals, so we’re often checking in with someone’s therapist or another provider here. But we’ve also built strong relationships with providers outside our organization.
If a patient is seeing someone externally, we’ll often collaborate, especially if there’s a significant change or update. We’ve developed good systems for keeping care teams informed.
Not sure if Spravato® is right for you?
What would you say to someone considering Spravato®?
If someone’s curious, the best next step is to schedule a consultation. That doesn’t mean they have to move forward with treatment. My goal during an intake is to provide as much information as possible so the patient can make an informed decision.
There’s a lot of information out there, but not all of it is accurate. I think it’s helpful to walk through their concerns, explain the evidence-based facts, and talk about whether they’re a good candidate.
Most of the time, people feel better after that conversation. Even if they’re not ready, they have a better understanding and can decide what to do next.
What would you say to someone worried about the cost of treatment?
One of the biggest concerns people have is cost. Ketamine historically hasn’t been the cheapest treatment, especially IV ketamine. Even when Spravato® was FDA-approved, there were concerns about affordability.
But the insurance coverage for Spravato® has gotten really good. We’re able to reach a lot of people, including underserved individuals, who are now able to get treatment.
Spravato® also has a really good program that helps cover the rest of the cost if insurance doesn’t cover everything. It’s very uncommon that we can’t treat someone due to cost.
If someone looked into Spravato® years ago and was told it wasn’t covered, should they check again?
Yes. I’ve had people who were assessed back in 2019 or 2020 and told their insurance wouldn’t cover it, and now it is. If that’s been a problem in the past, it’s worth rechecking. The coverage has definitely changed.
You don’t have to go through treatment alone.
Whether you’re exploring Spravato® for the first time or continuing a journey you’ve already started, our team is here to help. At New Directions Mental Health, you’ll be supported every step of the way—before, during, and after treatment.
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