Depression
Depression that has not lifted yet
If two antidepressants have already failed you, that is a clinical category with its own treatments, not a sign that you are beyond help. It is called treatment-resistant depression, and it is most of what we do.
- Two trials
- is the usual threshold for treatment-resistant depression
- Days
- rather than weeks, for how quickly some options act
- Often covered
- Spravato® has a pathway on most major plans
01What we mean by treatment-resistant
A specific thing, with specific options
Treatment-resistant depression usually means major depressive disorder that has not responded adequately to at least two antidepressants taken at a proper dose for a proper length of time. It is common. It is not a verdict on you, and it is not a sign that you tried badly.
What it does mean is that a third antidepressant from the same family is less likely to be the answer. The treatments that tend to help at this point work on a different system in the brain, and several of them act far faster than the six to eight weeks an oral antidepressant needs.
Which one is right depends on your history, your insurance, and how much therapy you want built around the treatment. That is a conversation with a physician.
Treatment-resistant depression usually means major depressive disorder that has not responded adequately to at least two antidepressants taken at a proper dose for a proper length of time. It is common. It is not a verdict on you, and it is not a sign that you tried badly.
What it does mean is that a third antidepressant from the same family is less likely to be the answer. The treatments that tend to help at this point work on a different system in the brain, and several of them act far faster than the six to eight weeks an oral antidepressant needs.
Which one is right depends on your history, your insurance, and how much therapy you want built around the treatment. That is a conversation with a physician.
02What we offer
The routes open to you, in the order we would suggest them
Which of these is right depends on your history and what you have already tried. That is decided in a consultation with a physician.
- 01Spravato® (esketamine)FDA-approved specifically for treatment-resistant depression, given in our REMS-certified clinic, and often covered by insurance. The most direct route if you meet the criteria.
- 02Ketamine-assisted psychotherapyKetamine paired with a therapist who prepares you, stays with you, and helps you process it afterward. Self-pay, but more flexible in dose and depth than Spravato®.
- 03Psychiatry & medication managementA full psychiatric evaluation and a considered look at what you have already taken. Sometimes the answer is a medication change rather than a new modality.
- 04PsychotherapyOn its own or alongside treatment. Depression that has lasted years usually has psychological weight that medicine alone does not lift.
03The evidence
What the research shows
FDA approved
Esketamine for treatment-resistant depression
Randomized trials in adults whose depression had not responded to at least two antidepressants supported approval in 2019, with improvement measured in days rather than weeks.
Am J Psychiatry 2019
Meta-analysis
Ketamine in real-world practice
Pooled real-world data found rapid, meaningful relief in depression that had not responded to other treatments.
J Psychiatr Res 2022
72 studies
Ketamine paired with psychotherapy
A systematic review of studies combining ketamine with therapy found stronger engagement, greater symptom reduction, and longer-lasting gains than psychotherapy alone.
Clin Psychol Rev 2025
A third antidepressant is not the only thing left to try.
04Is this for you
Where this helps, and where it does not
Yes
Often a good fit
- Two or more antidepressants have not worked well enough
- You have been depressed for months or years rather than weeks
- You are functioning, but at a cost that is getting harder to pay
- Therapy has helped somewhat but has plateaued
- You want something that acts faster than another six-week medication trial
No
Not the right tool
- You have not yet tried a first-line antidepressant or a course of therapy — those come first
- You are in immediate danger. Call or text 988, or 911 if you are unsafe right now
- Active, untreated psychosis or mania, which needs a different kind of care first
- A single session that fixes it — none of this works that way
Eligibility is decided in a medical consultation. If a treatment is not right for you — including when the right answer is staying with your current prescriber — that is what we will recommend.
05Common questions
How is this different from what my psychiatrist has already tried?
Most first-line antidepressants act on serotonin, norepinephrine, or dopamine. Esketamine and ketamine act primarily on the glutamate system, a different mechanism altogether. That is why they can work for people whom the first family of medicines did not help, and why the response often shows up in days rather than the six to eight weeks an SSRI typically needs.
Do I have to stop my current antidepressant?
Usually not, and you should not stop anything without talking to the prescriber who started it. In January 2025 the FDA approved Spravato® as a standalone treatment, so it no longer has to be combined with an oral antidepressant, but many insurance policies still expect one. Your full medication list is reviewed at intake and any changes are made deliberately, in coordination with whoever is currently prescribing for you.
How quickly would I know if it is working?
Faster than with an oral antidepressant. Trials of esketamine measured meaningful change within days to a couple of weeks. The decision to continue is based on how you actually respond over the first few weeks rather than on any single session.
What if it does not work?
Then we tell you, and we adjust or stop. A proportion of people in every trial did not respond, and whether you are one of them is not knowable in advance — which is exactly why the first weeks are treated as a trial, with progress measured.
Is any of this covered by insurance?
Spravato® is, on most major plans, provided you meet the criteria — typically documentation that two antidepressants did not work well enough. Psychiatry and psychotherapy are covered on many plans. Ketamine therapy is self-pay because it is prescribed off-label. We verify all of it before you commit.
Spravato® is a registered trademark of Janssen Pharmaceuticals, Inc.