High-Functioning Depression: The Hidden Signs When You Keep Showing Up
High functioning depression isn't a formal diagnosis, but it's real. Learn the hidden signs, how it overlaps with dysthymia, and when to get evaluated.
If you've tried antidepressants and still feel stuck, you may have heard about Spravato, an esketamine nasal spray for depression. Spravato esketamine for depression has drawn interest because it can improve symptoms quickly for some people with treatment-resistant depression. Here's a clear look at how it works, what treatment involves, and the questions to bring to your provider.
Our practice does not offer esketamine or ketamine treatment. This article is for education only. If you're interested in Spravato, ask your psychiatric provider whether it's appropriate for you and where it's available.
Key takeaways
- Spravato is the brand name for esketamine, a form of ketamine given as a nasal spray.
- Esketamine nasal spray is FDA-approved for adults with treatment-resistant depression, and for depressive symptoms in adults with major depression who are having acute suicidal thoughts or behavior.
- Some people notice improvement within hours, and a series of treatments over several weeks may lead to longer-lasting results.
- Feeling detached or dreamlike is a common short-term effect, which is why treatment happens under medical supervision.
- It's given only at certified treatment centers, with at least two hours of monitoring after each dose and no driving until the next day.
What is esketamine?
Esketamine is a form of ketamine, a medication first developed in the 1960s and approved by the FDA as an anesthetic in 1970. Researchers later found that ketamine could help with depression, including in people who hadn't improved with other treatments.
Esketamine is given as a nasal spray under the brand name Spravato. It's FDA-approved for treatment-resistant depression, which means depression that hasn't improved enough after trying standard treatments. Generic ketamine, by contrast, is not FDA-approved for depression and is used off-label. Our guide to ketamine for depression explains the differences in more detail.
How Spravato esketamine for depression works
Most antidepressants work on brain chemicals like serotonin. Esketamine works on a different system. It blocks NMDA receptors in the brain, which increases the availability of glutamate, one of the brain's main chemical messengers.
Researchers believe this helps the brain grow new connections between nerve cells, a process called neuroplasticity. Depression may weaken some of these connections, and rebuilding them could help explain why esketamine can work so quickly. Scientists are still studying exactly how it improves mood.
What a treatment session is like
Esketamine is given as a nasal spray in a medical setting, where the care team can adjust the amount and schedule for each person. You stay under medical supervision during and after each dose.
Safety requirements
Because of its side effects, Spravato is available only through an FDA safety program (called a REMS), and only at certified healthcare settings:
- You give yourself the spray under the direct supervision of a healthcare provider. It can't be taken home.
- You're monitored for at least two hours after each dose.
- You shouldn't drive or operate machinery until the next day, after a restful night's sleep, so you'll need a ride home.
- It's approved for adults only. It's often used together with an oral antidepressant, and in 2025 the FDA also approved it on its own for treatment-resistant depression.
The dissociative effect
Many people feel detached, dreamlike or disconnected from their surroundings after a dose. Some notice changes in how they see colors or a sense of floating. This feeling typically lasts about an hour.
The dissociative feeling isn't the goal of treatment. In fact, some recent research suggests the antidepressant effect may not depend on it. Instead, the brain's response to the medication may be what improves mood.
Other side effects
Other short-term effects can include dizziness and nausea. Less commonly, ketamine-type medications can raise blood pressure or slow breathing. These risks are part of why esketamine is only given with medical monitoring. Your provider can tell you which side effects to expect and how they'll be managed.
How long does esketamine last for depression?
Some people notice their mood improve within hours of a treatment. The benefit from a single dose may last up to about a week, though this varies a lot from person to person.
Receiving treatments over several weeks tends to lead to better, longer-lasting results than a single dose. Research suggests that dose and how often treatments are given both affect how long the antidepressant effect lasts.
Booster treatments
After an initial series, some people find their symptoms slowly return. When that happens, providers may recommend occasional "booster" treatments. How often depends on how you respond.
After treatment: ongoing care
Esketamine isn't a stand-alone fix. People usually continue their existing antidepressants during and after treatment, under their prescriber's direction. Regular follow-up with a mental health professional helps you track your progress and adjust your plan.
As with any medication, talk with your prescriber before starting, stopping or changing anything. Don't stop an antidepressant on your own because you're starting a new treatment.
Questions to ask your provider
If you're considering Spravato, these questions can guide the conversation:
- Do I meet the criteria for treatment-resistant depression?
- Is esketamine a safe option with my health history and current medications?
- What side effects should I expect, and how are they monitored?
- How often would I need treatments, and for how long?
- Where can I receive it, and is it covered by my insurance?
When depression treatment isn't working
If you're researching esketamine, you've likely already tried treatment and still aren't feeling better. That's frustrating, and it's more common than you might think. It doesn't mean you're out of options.
A fresh psychiatric evaluation can take a new look at your care. That might mean adjusting your medication plan or using GeneSight testing to see how your body may process certain medications. Our guide to what to do when antidepressants don't work is a good place to start.
If you're having thoughts of suicide, don't wait for a new treatment. Call or text 988, call 911 in an emergency, or visit our crisis resources page.
Frequently asked questions
What is the difference between Spravato and ketamine?
Spravato is esketamine, a form of ketamine given as a nasal spray. It's FDA-approved for treatment-resistant depression. Generic ketamine is approved as an anesthetic, and its use for depression is off-label.
How quickly does esketamine work?
Some people notice improvement within hours of a dose. A series of treatments over several weeks usually produces stronger, longer-lasting results. Response varies, and not everyone benefits.
Do I stop my antidepressant if I start Spravato?
People usually keep taking their existing antidepressant during esketamine treatment. Never stop or change a medication on your own. Your prescriber will tell you how esketamine fits with your current plan.
Who might be a candidate for esketamine?
Esketamine is generally considered for people whose depression hasn't improved enough with other treatments. Whether it's right for you depends on your health, history and current medications. Ask your psychiatric provider whether it's appropriate and where it's available.
Explore your depression treatment options
If depression treatment hasn't worked the way you hoped, our psychiatrist and psychiatric physician assistants can review your care, discuss your options, and help you decide whether a treatment like esketamine is worth asking about. We see patients in person in Chicago and by telehealth anywhere in Illinois. Request an appointment to talk through next steps.
