The 'Good Enough' Problem in Depression Care
A clinician perspective published this week in Psychiatric Times is pushing back on a quiet but pervasive standard in depression treatment: settling for outcomes that are merely "less bad." The piece calls on prescribers to pursue aggressive, remission-focused care for patients with treatment-resistant depression (TRD) — a population that has historically been managed with incremental adjustments, augmentation strategies, and a resigned acceptance that some patients will simply never fully recover.
This framing matters. Treatment-resistant depression — typically defined as depression that has failed to respond to at least two adequate antidepressant trials — affects an estimated 30% of people diagnosed with major depressive disorder. For years, the clinical conversation around this group has centered on harm reduction and symptom management rather than the goal of full functional remission. The Psychiatric Times commentary challenges that default posture directly, arguing that patient priorities and quality of life must anchor treatment decisions, even when the path forward is complex.
What 'Aggressive Care' Actually Looks Like
The piece outlines several treatment avenues that clinicians should consider more readily when first- and second-line antidepressants fall short. These include pharmacological augmentation strategies, psychotherapy combinations, neuromodulation approaches like transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT), and — critically — rapid-acting interventions including ketamine and its FDA-approved derivative, esketamine (Spravato).
What unites these options under the "aggressive care" banner isn't necessarily their intensity but their orientation: each is evaluated not by whether it reduces symptoms somewhat, but by whether it moves the patient toward remission. This is a meaningful philosophical shift in how clinicians are being asked to define success.
The commentary also emphasizes balancing side effect burden with patient priorities — an important nuance. Aggressive does not mean indiscriminate. A patient who values cognitive clarity may weigh ECT differently than one for whom rapid relief from suicidal ideation is the paramount concern. Individualized goal-setting, the authors suggest, should drive protocol design rather than the other way around.
From a ketamine standpoint, this framing is directly relevant. Ketamine infusion therapy and intranasal esketamine occupy a distinctive niche in the TRD landscape precisely because they operate outside the monoamine pathways that standard antidepressants target. For patients who have exhausted SSRIs, SNRIs, and augmentation agents, ketamine represents not a last resort so much as a mechanistically distinct option — one with a growing evidence base for producing rapid, meaningful relief even in highly refractory cases.
Key Takeaway for Patients
If you've been told that your depression is "managed" but you still don't feel like yourself, that may not be good enough. Current clinical guidance increasingly supports pursuing true remission — not just reduced symptoms. Ask your provider about whether all appropriate options, including ketamine-based therapies, have been considered as part of your treatment plan.
Why This Shift in Clinical Culture Matters
The significance of commentary like this extends beyond individual treatment decisions. It reflects a broader maturation in how psychiatry conceptualizes TRD — and a growing impatience with the gatekeeping that has historically delayed access to effective interventions.
For too long, the standard pathway for a TRD patient looked something like this: try a second antidepressant, add a mood stabilizer or atypical antipsychotic, refer to therapy, and wait. Ketamine — despite its impressive response rates in clinical research, including studies showing 50–70% response rates in TRD patients who had failed multiple prior treatments — was often positioned as an extreme measure reserved for crisis-level presentations. That calculus is beginning to change.
Part of what's driving this shift is outcomes data. Studies consistently show that partial remission in depression carries its own risks: higher rates of relapse, continued functional impairment, and — critically — increased suicide risk compared to full remission. The argument for pushing harder toward complete recovery isn't just quality-of-life idealism; it's evidence-based risk reduction.
At the same time, access and infrastructure remain real barriers. Ketamine infusion therapy is not yet universally covered by insurance, and esketamine, while FDA-approved, requires administration in a certified healthcare setting. For many patients navigating TRD, the challenge isn't awareness of options — it's finding clinicians equipped to offer them and systems that can support ongoing treatment.
What Patients and Families Should Know
If you or someone you care for has been living with depression that hasn't responded adequately to standard antidepressants, 2026 is a genuinely better moment to revisit the treatment landscape than it was even three years ago. The evidence supporting ketamine-based interventions has grown substantially, clinical guidelines are evolving, and the number of certified ketamine providers has expanded across the country.
The core message of the Psychiatric Times piece — that aiming for full remission is both appropriate and achievable for most TRD patients — aligns closely with the patient-centered philosophy that underlies evidence-based ketamine care. Settling for "less bad" is no longer a clinically defensible endpoint when better options exist.
You can read the original commentary at Psychiatric Times.
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