Referral Form for Spravato®, Repetitive Transcranial Magnetic Stimulation, and Ketamine

If you are a healthcare provider referring a patient for treatment, please complete the referral form here.

Eligibility Criteria for Spravato® (Esketamine) Treatment

Patients seeking treatment with Spravato® must meet specific criteria as per FDA guidelines and clinical best practices. Below are the key eligibility requirements:

1. Diagnosis

• Treatment-Resistant Depression (TRD): Patients must have a confirmed diagnosis of Major Depressive Disorder (MDD) and have not responded adequately to at least two different antidepressant medications at therapeutic doses during their current episode of depression.

• Major Depressive Disorder with Acute Suicidal Ideation or Behavior (MDD with SI): Patients experiencing significant suicidal thoughts or behaviors in the context of MDD may also be eligible.

3. Exclusions for Spravato® and Repetitive Transcranial Magnetic Stimulation

Spravato® may not be suitable for individuals with:

• A history of hypersensitivity to esketamine or ketamine.

• A history of aneurysm

  • Those pregnant or trying to become pregnant, or breastfeeding

Repetitive Transcranial Magnetic Stimulation may not be suitable for individuals with:

Presence of metallic implants in or near the head (excluding the mouth)

  • Examples: cochlear implants, aneurysm clips, deep brain stimulators, electrodes, or metallic fragments.

  • These could interact dangerously with the magnetic field.

Implanted electronic devices

  • Examples: pacemakers, cardioverter defibrillators (ICDs), or other neurostimulators that may be affected by magnetic pulses.

History of epilepsy or increased seizure risk (except where rTMS is specifically indicated for seizure treatment under strict monitoring)

  • rTMS can theoretically trigger seizures.

Pregnancy (usually considered an exclusion unless benefits outweigh risks and used in specialized settings)

Severe or unstable medical or neurological conditions that could increase risk

  • Examples: brain tumors, recent stroke, or intracranial hemorrhage.

Any condition that prevents safe placement of the coil

  • Severe cranial deformity or skin lesions over the target area.

Inability to cooperate or remain still during treatment

  • Severe agitation, movement disorders, or cognitive impairment preventing compliance.

Important note: Relative contraindications (like taking medications that lower seizure threshold) require careful risk assessment but are not absolute exclusions.

*** Please note that Aether Interventional Psychiatry does not provide general psychiatric care for patients who are not enrolled in our Treatment Resistant Psychiatric Disorder Program.

How to Submit

• Download the referral form here.

• Complete the form with detailed information about the patient’s history and previous treatments.

• Email the completed form to info@aetherpsychiatricconsultants.com or fax it to 800-280-6196.

What to Expect After Submission

• Referral Forms: Once we receive your referral form, we’ll review it and contact both the referring provider and the patient to schedule the initial consultation.

If you have questions or need assistance with determining eligibility, please don’t hesitate to contact us at info@aetherpsychiatricconsultants.com or call 828-424-5512. We’re here to support you every step of the way!