Hearing that a medication did not do enough can feel like a closed door. In practice, it usually means your clinician now knows more about how your symptoms respond to treatment, and the next step is a matter of sorting through options rather than starting over. Clinicians use the term treatment-resistant depression for cases where earlier treatments have not brought enough relief. That label covers a wide range of people with very different histories, so the right next step depends on you as much as on the diagnosis.
What Usually Gets Reviewed Before Anything New
Before suggesting a change, clinicians usually review the earlier treatment. They look at how long each medication was used, the dose, and how steadily it was taken. They also consider whether something else may be muddying the picture, like anxiety, a thyroid issue, poor sleep, or alcohol or cannabis use. Sometimes the fix is minor, such as tweaking a dose or pairing the current drug with a second one. Other times the discussion shifts toward a different drug class or a procedure. The right route depends on your symptoms, medical background, daily routine, and whether the plan is workable over the long haul.
Plain Descriptions of the Main Next Steps
Transcranial magnetic stimulation, usually called TMS, uses a coil placed against the scalp to deliver short magnetic pulses to areas involved in mood regulation. You stay awake, sit in a reclining chair, and return for a series of sessions spread over several weeks. The schedule is the main demand. Scalp discomfort during sessions is a common complaint, and most people can drive themselves home afterward.
Ketamine, given by intravenous infusion in a clinic, works through a different mechanism and is usually given as a series rather than a single dose. Some people notice mood changes sooner than they expected, while others notice little. Effects during each session are short-lived, and the benefit may fade over time, which is why some plans include follow-up doses. You will need a ride home after each visit.
Spravato is a nasal form of esketamine, a relative of ketamine. It is given in clinic under the rules of its REMS program, which governs how doses are handled and observed. You typically remain in the office for a period after each dose before leaving, so plan for a longer visit than the dosing itself might suggest.
Questions Worth Bringing to Your Clinician
A short written list helps keep the conversation focused. Ask what the expected timeline looks like before you would notice a change, and ask what your clinician would consider a useful result, so you both know when to reassess. Ask which side effects are most common with each option and how they would be managed if they showed up. Ask about the time commitment, travel, and whether insurance covers the full course. Find out what happens if you need to pause, and whether the new option can be used alongside your current medication or would mean stopping it.
Tell your clinician everything you have tried before: the amounts taken, the duration of each course, and why you stopped any of them. Lacking that history, they may struggle to weigh the alternatives correctly. Should you sense pressure, say so and ask for additional time to think things over. A competent clinician will respect that request rather than treat it as resistance.
Keeping Your Own Goals in View
Treatment decisions are not only medical. Picture what a better week would look like for you. Maybe it means more energy at work, fewer hours lost to heavy low mood, steadier sleep, or simply being present for the people you care about. Those goals give you a practical yardstick for judging whether a treatment is worth the cost in time, money, and energy it asks for. Weighing those costs honestly is part of making a sound choice, not a sign that you are giving up.
No single option works for everyone, and results vary widely from person to person. A treatment that helps one patient may do little for another. Even so, a medication that has stalled is useful information, and real, evidence-based choices remain available. Working through them with your clinician one question at a time, and keeping your own goals in front of you, is a reasonable way to move forward.