The Push to Get TRD Treatment Right—Faster
A new clinical commentary published in Psychiatric Times (April 2026) is drawing attention to a straightforward but underused idea in treatment-resistant depression (TRD) care: measure symptoms consistently, adjust doses quickly, and address side effects before they cause patients to quit. The piece argues that these three habits—collectively called measurement-based care—can meaningfully shorten the time it takes patients to reach remission.
For the estimated 30% of people with major depression who don't respond adequately to standard antidepressants, this kind of systematic approach matters enormously. TRD is defined by failing at least two adequate antidepressant trials, and it carries a disproportionate share of depression's total burden: higher rates of hospitalization, disability, and suicidality. Getting these patients to remission faster isn't just a clinical nicety—it's a public health priority.
The commentary doesn't single out one treatment over another, but it squarely addresses the newer, more efficacious options now available for TRD—a category that includes esketamine (Spravato) and IV ketamine, alongside treatments like transcranial magnetic stimulation (TMS) and lithium augmentation. The central message: even the best treatments underperform when clinicians aren't tracking outcomes rigorously or adjusting the regimen in response to real-time data.
Why This Is Especially Relevant to Ketamine Treatment
Ketamine and esketamine occupy a unique position in the TRD landscape. They work through a completely different mechanism than traditional antidepressants—targeting glutamate receptors rather than serotonin or norepinephrine—and they often produce rapid symptom relief within hours to days rather than weeks. That speed is one of ketamine's most important clinical advantages. But speed alone doesn't guarantee lasting remission.
The principles highlighted in this commentary map directly onto what separates good ketamine care from mediocre ketamine care:
- Symptom measurement: Reputable ketamine providers use validated rating scales (like the PHQ-9, MADRS, or QIDS) before, during, and after treatment series—not just informal check-ins. This creates an objective record of whether a patient is responding and how much.
- Dose optimization: IV ketamine dosing is not one-size-fits-all. Providers who track outcomes can identify when a patient needs a higher dose, a longer infusion, or a modified protocol. Without measurement, these decisions become guesswork.
- Side effect management: Ketamine's dissociative effects, nausea, and blood pressure changes are real, and they're the most common reasons patients drop out of treatment. Providers who anticipate and manage these proactively—with pre-medication, monitoring protocols, and clear patient communication—improve completion rates and outcomes.
In short, the clinical rigor described in this Psychiatric Times piece is exactly what patients should be looking for when they evaluate a ketamine clinic or psychiatrist.
Esketamine vs. IV Ketamine: Does This Change the Comparison?
One nuance worth unpacking: esketamine (Spravato) has a structural advantage when it comes to measurement-based care. Because it's administered in a certified healthcare setting under direct observation, with mandatory post-dose monitoring, there's a built-in framework for tracking patient response. The REMS program that governs Spravato requires providers to document each session—creating a paper trail that can support the kind of systematic care the commentary recommends.
IV ketamine, by contrast, is offered off-label and through a much wider variety of clinic types. Quality varies significantly. Some IV ketamine providers use rigorous symptom tracking and detailed intake and follow-up protocols. Others do not. This variability is one of the legitimate criticisms of the IV ketamine market, and it's why provider vetting matters so much for patients considering this route.
The takeaway isn't that one form is categorically better—IV ketamine remains the more flexible option, with dosing that can be more precisely titrated for individual patients. But the commentary's emphasis on structured, data-driven care is a useful lens through which to evaluate any provider, regardless of which form of ketamine they offer.
Key Takeaway for Patients
When evaluating a ketamine provider, ask specifically how they track your progress. Do they use standardized depression scales before and after each session? How do they decide when to adjust your dose or treatment schedule? What's their protocol for managing side effects like nausea or dissociation? Providers who can answer these questions clearly are practicing the kind of measurement-based care that research increasingly shows leads to better outcomes—and faster remission.
The Bigger Picture for TRD Care in 2026
The publication of this commentary reflects a broader shift happening in psychiatric practice. As newer, faster-acting treatments become more available—ketamine, esketamine, and emerging psychedelic-assisted therapies—the field is grappling with how to use them well, not just how to use them. Having access to an efficacious treatment is only half the equation. The other half is a clinical team that knows how to monitor response, adapt the approach, and keep patients engaged through side effects and setbacks.
For people navigating TRD, this is ultimately good news. It means the conversation is maturing. Clinicians are being pushed to move beyond trial-and-error prescribing toward something more intentional. And patients who know what good care looks like are better positioned to find it—and to advocate for it when it's missing.
Read the original commentary at Psychiatric Times.
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