About one in three people with major depressive disorder do not respond adequately to two or more antidepressant trials — a pattern clinicians call treatment-resistant depression (TRD) — and standard care guidelines were not designed for them. That does not mean recovery is out of reach. At Life Works Professional Counseling in Winchester, Virginia, we work with people who have tried the standard options and are still struggling.
What Makes Depression “Treatment-Resistant”
Major depressive disorder (MDD) is a clinical condition characterized by persistent low mood, loss of interest, changes in sleep and appetite, difficulty concentrating, and feelings of worthlessness or hopelessness (Mayo Clinic). Most people diagnosed with MDD are offered antidepressant medications — typically selective serotonin reuptake inhibitors (SSRIs), which work by increasing serotonin availability in the brain — as a first-line treatment. For many people, these medications help significantly. For others, they do not.
Treatment-resistant depression is generally defined as a major depressive episode that has not responded adequately to at least two antidepressant medications taken at appropriate doses for an adequate duration. This distinction matters because it signals that the biology driving the depression may involve pathways that standard medications do not directly address. Research has increasingly focused on the glutamate system — the brain’s primary excitatory neurotransmitter network — as a key factor in depression cases where serotonin-targeted treatment falls short (Nature).
Understanding this is not about labeling a person’s depression as uniquely difficult to treat. It is about recognizing that the same condition can have different underlying mechanisms in different people, and that mechanism shapes which treatment is most likely to help.
Treatment Options We Offer in Winchester
At Life Works, we offer several evidence-informed approaches for depression, including options specifically designed for cases where standard antidepressants have not provided adequate relief.
Individual Therapy and Medication Management
For many people, individual therapy — including talk therapy that examines thoughts, patterns, and lived experience — is an important part of treatment. We also offer medication management through our psychiatric nurse practitioner, Leslie Lartey, PMHNP-BC, FNP-BC. Medication management at Life Works involves careful evaluation of what you have tried, at what doses, and for how long, and it may include recommendations for different medication classes or augmentation strategies depending on your history.
Ketamine-Assisted Psychotherapy (KAP)
Ketamine-assisted psychotherapy (KAP) integrates ketamine — a medication that works through the brain’s glutamate system rather than the serotonin or norepinephrine pathways targeted by most antidepressants — with therapeutic support before, during, and after each medicine session. Clinical research supports ketamine’s effectiveness in producing rapid antidepressant effects, including in patients who have not responded to other medications (Nature). Studies show that ketamine may produce antidepressant effects within hours rather than the weeks required by traditional medications, suggesting it addresses different neurobiological targets.
At Life Works, KAP typically involves four to six ketamine sessions spaced over several weeks. Each medicine session runs approximately two to three hours from arrival to departure and moves through three phases: preparation, the medicine session itself, and integration. The same therapist stays with you throughout the entire process. We integrate KAP with evidence-based approaches including somatic work and talk therapy, because research supports combining psychotherapy with ketamine treatment as producing more meaningful and durable outcomes than ketamine alone.
KAP at Life Works is used off-label — meaning ketamine is not FDA-approved specifically for this application — and we are transparent about that. It is not appropriate for everyone. A thorough intake process helps us understand whether KAP is a reasonable fit given your history, current symptoms, and goals.
SPRAVATO® Treatment
SPRAVATO® (esketamine) is an FDA-approved nasal spray specifically indicated for treatment-resistant depression and for major depressive disorder with acute suicidal ideation or behavior (U.S. Food and Drug Administration). Unlike KAP, SPRAVATO® carries FDA approval for these specific indications and is available only through certified healthcare settings.
We are a SPRAVATO® certified provider. Treatment follows a structured protocol: during the induction phase (weeks one through four), sessions occur twice weekly; during the maintenance phase (weeks five through eight), once weekly; and from week nine onward, frequency is adjusted based on your individual needs and response. Each session requires a minimum two-hour observation period at our office. You will not be able to drive for 24 hours after a dose, and we ask that you avoid food for two hours and liquids for 30 minutes before each session.
SPRAVATO® is covered by several major insurance plans we accept, including Aetna, Cigna, Blue Cross Blue Shield, United Healthcare, and Sentara. We handle insurance paperwork on your behalf. If you are uncertain whether your plan covers SPRAVATO® treatment, we encourage you to contact us — our team will work through coverage questions with you before you commit to anything.
Two Barriers We Hear Often
“I’m not sure I can afford this.”
Cost is a real consideration, and we think it is important to address it honestly. SPRAVATO® carries meaningful insurance coverage through the plans listed above, and we handle prior authorization and verification before treatment begins. For KAP and other services, while many insurance plans do not yet cover KAP, we provide documentation that some clients may be able to submit for out-of-network reimbursement, and FSA and HSA funds may also apply. We also accept CareCredit, which offers financing options that allow you to pay over time. Our team discusses all of this with you before you make any decisions — we want cost to be a factor you understand clearly, not one that quietly prevents you from getting care.
“I’ve already tried so many things. I’m not sure there’s anything left.”
This is one of the most common things we hear from people who reach out after years of trying different treatments. The honest answer is that TRD research has expanded significantly, and the range of available options is genuinely broader than it was even a few years ago. Most people we work with have not exhausted every approach that exists. We do not make outcome promises — results vary by individual, and no ethical provider guarantees specific results — but we do take your history seriously and use it to inform what we recommend rather than defaulting to a standard protocol.
Frequently Asked Questions
How do I know if what I have is treatment-resistant depression?
The clinical definition is typically two or more antidepressant trials at adequate doses and duration without sufficient response. If you have been told your depression is treatment-resistant, or if you simply feel like nothing has worked, a clinical evaluation is the right place to start. We can review your treatment history and help clarify where you actually stand.
Is SPRAVATO® the same as ketamine?
SPRAVATO® contains esketamine, which is a component of ketamine, but the two treatments are distinct in their formulation, administration, and approval status. SPRAVATO® is an FDA-approved nasal spray administered in a certified clinical setting; KAP uses ketamine delivered in a therapeutic context as an off-label treatment. Your history, symptoms, and insurance coverage all factor into which option may be worth exploring with your provider.
Do I have to stop my current antidepressants to try these treatments?
That depends on your individual situation and is a clinical decision, not a blanket policy. Some people continue existing medications alongside KAP or SPRAVATO®; others adjust under medical supervision. We review your full medication history before making any recommendations, and any changes to existing medications are handled thoughtfully and collaboratively.
What does the first appointment look like?
We start with a conversation — your history, what you have tried, how you have responded, and what you are hoping for. This is not a checklist intake. It is the foundation of understanding what direction makes the most sense for you, and it shapes every recommendation that follows.
How long does treatment take?
There is no single answer. SPRAVATO® follows a defined protocol with a structured induction and maintenance schedule. KAP typically involves four to six medicine sessions over several weeks, plus preparation and integration work. Individual therapy and medication management timelines vary based on your needs and response. We discuss realistic expectations at the outset rather than offering timelines that may not apply to your situation.
Key Takeaways
- Treatment-resistant depression (TRD) is a clinical designation — typically defined as inadequate response to two or more antidepressants — not a permanent verdict on whether recovery is possible.
- Standard antidepressants primarily target serotonin and norepinephrine; TRD often involves the glutamate system, which is the target of both KAP and SPRAVATO®.
- SPRAVATO® is FDA-approved for TRD and is covered by several major insurance plans; KAP is an off-label treatment with meaningful research support.
- Cost and prior treatment failure are real barriers — and both are worth discussing directly with our team before ruling out options.
- Results vary by individual, and treatment planning should be based on your specific history, not a one-size-fits-all protocol.
If your depression has not responded to antidepressants, your treatment history is information — not a ceiling on what is possible. At Life Works Professional Counseling in Winchester, we take that history seriously and use it to think carefully about what the right next step might be for you specifically. To request a consultation, contact us at 434-577-8171 or reach out through our website. We will give you a straight answer about what your options look like.
References
- Mayo Clinic. Symptoms and causes of depression. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007
- Nature. Ketamine’s effectiveness for depression. https://www.nature.com/articles/s41398-021-01327-5
- U.S. Food and Drug Administration. FDA approves new nasal spray medication for treatment-resistant depression, available only through certified healthcare settings. https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified
The information in this blog is for educational purposes only and does not constitute medical advice. The treatments described, including Ketamine-Assisted Psychotherapy and SPRAVATO®, may not be appropriate for every individual and should only be pursued under the guidance of a qualified mental health or medical provider who is familiar with your full history. Individual results vary. If you are experiencing a mental health crisis or thoughts of self-harm, please call or text 988 to reach the Suicide and Crisis Lifeline or go to your nearest emergency room.