Treatment-Resistant Depression

Depression can be profoundly disruptive - emotionally, cognitively, physically, and socially. For many people, evidence-based treatment leads to meaningful improvement over time. But some individuals follow a careful course of therapy and medication and still don’t experience adequate relief. When symptoms persist despite appropriate care, it can feel discouraging, and it often signals the need for a more precise, integrated treatment strategy.

At The Grove Comprehensive Psychiatry and Wellness in Mesa, AZ, we approach treatment-resistant depression (TRD) with a clinician led, integrative framework that prioritizes diagnostic depth, thoughtful pacing, and safety. For carefully selected patients, Transcranial Magnetic Stimulation (TMS) and ketamine infusion therapy may be one part of a broader plan.
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What Is Treatment-Resistant Depression?

TRD typically refers to depression that has not improved adequately after at least two well-conducted antidepressant trials (appropriate dose and duration). Sometimes the term also applies when evidence-based psychotherapy has not led to meaningful change.

Clinically, TRD often signals a need to revisit key questions:

• Are we treating the right diagnosis (including bipolar spectrum conditions, trauma-related patterns, or significant anxiety)?

• Are medical factors contributing (sleep disorders, thyroid issues, chronic pain, medication side effects)?

• Were prior treatments truly adequate and well-matched to the presentation
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Why Depression May Not Respond

When depression persists, there are usually contributing factors - often overlapping:

• Diagnostic complexity: depression with anxiety, trauma, neurodevelopmental differences, or bipolar-spectrum features

• Physiological drivers: sleep disruption, endocrine issues, inflammation, pain conditions, hormonal shifts

• Treatment variables: insufficient dose/duration, side-effect limitations, inconsistent adherence, or therapy that wasn’t matched to readiness or clinical context
  
  

This is why TRD care benefits from a nuanced evaluation rather than simply adding another medication or technique.
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A Clinician-Led, Integrative TRD Approach

At The Grove Comprehensive Psychiatry and Wellness, assessment is designed to clarify the full clinical picture rather than rushing toward a single intervention. We begin with diagnostic clarification and careful screening for comorbid conditions that can shape how depression presents and how it responds to treatment.

We also review prior medication and therapy trials in detail, including whether each treatment was tried at an appropriate dose and for a sufficient duration, how well it was tolerated, and what the response pattern looked like over time. This helps distinguish a true lack of response from trials that were limited by side effects, timing, or incomplete fit.

Because sleep and daily functioning are often central to both the experience and persistence of depression, we assess sleep quality, energy, cognition, and the practical impact symptoms are having on work, school, relationships, and self-care. We then consider which psychotherapy approaches may be most appropriate, along with pacing that matches readiness and supports sustained engagement.

When symptoms include hopelessness or suicidal thinking, safety planning is addressed directly and thoughtfully as part of care. Our goal is not intensity for its own sake, but precision - the right interventions, in the right sequence, at a sustainable pace.
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How TMS Can Support Treatment-Resistant Depression

Transcranial Magnetic Stimulation (TMS) is a non-invasive, FDA-cleared treatment for depression that uses focused magnetic pulses to stimulate areas of the brain involved in mood regulation. Because it targets neural activity directly, TMS can be a strong option for people who haven’t had adequate relief with medication and therapy, or who prefer an approach with minimal systemic side effects.

At The Grove Comprehensive Psychiatry and Wellness, we deliver TMS using advanced technology, including the Magstim Horizon 3.0 system. This platform supports precise, consistent stimulation and allows our team to customize treatment to each patient’s needs and response over time. Sessions are performed in an outpatient setting, require no anesthesia, and most patients return to normal activities immediately afterward.

In addition to standard TMS schedules, we can offer accelerated treatment protocols for appropriate candidates. These protocols are designed to deliver the full course of care in a condensed timeframe - as little as 1-2 weeks, compared to the traditional six-week model. This may be especially helpful for patients who need faster scheduling flexibility, are traveling from out of town, or want a more intensive treatment cadence under close clinical supervision.

As with any advanced treatment, we begin with a comprehensive evaluation to confirm candidacy, review medical and psychiatric history, and ensure TMS is a safe fit. From there, we create a personalized plan that may include standard or accelerated scheduling, with ongoing monitoring to track progress and optimize outcomes.
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Where Ketamine Infusion Therapy May Fit

Ketamine, used in carefully monitored, lower-dose psychiatric settings, may help some individuals with TRD through mechanisms different from standard antidepressants.

At The Grove Comprehensive Psychiatry and Wellness, ketamine is never framed as a standalone solution. A responsible plan includes:

• Careful screening (psychiatric and medical history, medication review, safety considerations)

• Thoughtful pacing based on readiness and stability

• Monitoring and follow-up focused on sustained symptom change, not just short-term effects

• Integration with psychotherapy and ongoing psychiatric care to support longer-term improvement
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Because ketamine can affect perception and physiology, quality care requires appropriate monitoring, clear protocols, and psychiatric integration. Setting and follow-through matter - especially for individuals with comorbid anxiety, trauma histories, or medical complexity.
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