The Problem With 'Wait and See' in Depression Care
A new clinical commentary published in Psychiatric Times makes the case that treatment-resistant depression (TRD) outcomes improve significantly when clinicians stop waiting and start adjusting. The piece argues that systematic symptom measurement, faster dose optimization, and proactive side-effect management are the levers that move patients from partial response to full remission — and that too many providers are still pulling those levers too slowly.
The framing matters: TRD is defined not by a patient's biology alone, but by a history of inadequate response to at least two antidepressant trials. By the time someone carries that label, months or years have typically passed with little relief. The article's core argument is that the clinical culture of watching and waiting — giving a drug 6–8 weeks before reconsidering — extends suffering unnecessarily when better measurement and faster pivots are available.
Where Ketamine Sits in This Framework
Ketamine and its FDA-approved derivative esketamine (Spravato) are explicitly among the 'more efficacious treatments' this kind of guidance is designed to optimize. Both are now recognized first-line options for TRD in major clinical guidelines, and their speed advantage — meaningful antidepressant effects within hours to days rather than weeks — is precisely why the broader principle of faster titration and tighter monitoring applies so directly.
But speed of onset doesn't mean the work is done after one infusion or nasal spray session. The same logic the article applies to oral antidepressants holds here: response needs to be tracked with validated tools (like the PHQ-9 or MADRS), side effects need to be discussed openly at each visit, and maintenance schedules need to be adjusted based on how a patient is actually doing — not based on a default calendar.
For patients in IV ketamine programs specifically, this is where clinic-to-clinic variation shows up most clearly. Some programs use structured symptom scoring before and after each infusion and adjust the number or spacing of sessions accordingly. Others rely on informal check-ins. The Psychiatric Times piece implicitly supports the former approach: measurement-based care isn't just good practice in theory, it's the mechanism by which TRD patients actually reach remission faster.
Key Takeaway for Patients
If your ketamine provider isn't tracking your symptoms with a standardized scale at regular intervals, ask why. Measurement-based care — not gut feeling — is what the evidence supports for getting TRD patients to remission. You should know your scores, and your provider should be using them to make decisions about your treatment plan.
What This Means When You're Comparing Providers
For anyone currently evaluating ketamine clinics or esketamine programs, the principles in this article translate into concrete questions worth asking before you commit:
- How do you track my progress? Look for clinics that use validated depression rating scales — not just a verbal 'how are you feeling' at check-in.
- What's your protocol if I'm not responding after the induction series? A provider with a clear answer (adjusted dosing, extended series, referral for augmentation) is operating in line with measurement-based care. Vague reassurance is a yellow flag.
- How do you handle side effects? Dissociation, elevated blood pressure, and anxiety during infusions are common and manageable — but only if the clinic is actively monitoring and adjusting.
The Psychiatric Times piece is aimed at prescribers, but its underlying message is just as relevant for patients: the gap between partial response and remission in TRD is often closed not by switching to a different drug, but by doing the current treatment more systematically. That's as true for ketamine as it is for anything else in the TRD toolkit.
Source: Psychiatric Times — Optimizing the Use of More Efficacious Treatments in Treatment Resistant Depression (April 2026)
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