When do you refer patients with difficult-to-treat depression for consideration of TMS or esketamine?

We typically tend to refer patients with Treatment-resistant depression (TRD), which is defined as failure to respond to two or more adequate trials of antidepressant medications. An adequate trial is determined by both dose and duration and generally requires at least 4 weeks of treatment at a dose...

In my small private practice, where we offer both TMS and Spravato, the conversation about TMS typically begins once a patient meets criteria for severe depression with two failed trials from different medication classes at an adequate dose and duration, or when medications were not tolerated due to...