When a new report quantified the cost of treatment-resistant depression, it confirmed what many clinicians already suspected: a patient with treatment-resistant depression (TRD) costs Medicare about $46,000 a year. That is roughly 21%—about $8,000 more annually—than a patient whose depression is well controlled, according to an analysis by Health Management Associates (HMA) reported by Fierce Healthcare.
Most of that gap comes from hospitalizations and higher prescription costs. In plain terms, the system keeps paying for crises while underfunding the treatments that might prevent them.
For people living with depression that hasn’t responded to standard care—and for the families and clinicians supporting them—this is more than a budget line. It points to a hard question: why does coverage so often favor acute, downstream interventions over the upstream care that could change the path? This article looks at what the numbers say, what effective TRD treatment can look like, and why getting people to the right care sooner is both better medicine and better policy.
What the new report actually found
Treatment-resistant depression is generally defined as depression that hasn’t responded adequately to two or more medication trials. It is common: TRD affects nearly one in three people with major depressive disorder, according to HMA’s report.
The Medicare analysis found a clear pattern in where the extra spending goes:
- Hospitalizations. TRD patients had greater inpatient spending—a sign of more frequent acute and crisis care.
- Prescriptions. Medication costs were higher, reflecting the long cycle of trials many people go through.
- Outpatient and physician visits. Spending here was also higher, pointing to more intensive ongoing management.
The report also looked at people already receiving advanced treatments. Those undergoing transcranial magnetic stimulation (TMS) cost nearly $29,000 more than patients with controlled depression, and those undergoing electroconvulsive therapy (ECT) cost $48,000 more, per the analysis. These figures reflect how hard TRD can be to treat once it sets in.
The burden reaches beyond claims data. HMA’s report notes that families and caregivers often provide more than 23 hours of care each week, carrying real financial and emotional strain along the way.
Why a system pays more by treating less
There is a logic problem buried in these numbers. The costliest part of TRD is not the treatment that works. It is the care that happens when nothing has worked yet—the emergency visits, the inpatient stays, the years of medication trials that don’t land.
When effective treatment arrives late, the condition has more time to deepen. Depression is also linked to other serious health problems, which can compound both the human and financial cost over time.
This is the part worth sitting with: a system can spend heavily on a person for years and still leave them unwell, because the spending flows toward managing crises rather than resolving the underlying condition. Reaching people sooner, with treatment that can actually shift their trajectory, is where the math—and the medicine—start to align.
What effective TRD treatment can look like
Two approaches have strong evidence for depression that hasn’t responded to standard care. Neither is a cure, and neither is right for everyone. But both can interrupt the cycle that drives so much of the cost and suffering.
IV ketamine
IV ketamine—ketamine delivered as a controlled intravenous infusion—is widely regarded as the most well-studied and clinically supported form of ketamine therapy for TRD. A meta-analysis of 79 studies covering 2,665 patients reported significant and meaningful effects on both response and remission, with repeated treatments offering more durable benefit than a single infusion.
Other research has compared delivery methods directly. One meta-analysis found IV ketamine had a higher response rate (rate ratio 3.01) and remission rate (3.70) than intranasal esketamine, though head-to-head randomized trials are still limited.
Part of IV ketamine’s appeal for clinicians is precision. Because the infusion is delivered slowly and monitored in real time, a physician can adjust, slow, or pause dosing minute by minute based on how a person responds. That level of control is one reason IV administration remains the clinical standard for TRD. At-home or intranasal options can be less predictable and are not the default approach.
During treatment, some people experience dissociation—a temporary, altered sense of self or surroundings. In a supervised clinical setting, this is expected and monitored, not a cause for alarm.
Accelerated TMS
TMS uses targeted magnetic pulses to stimulate areas of the brain involved in mood regulation. Standard TMS courses run daily for several weeks. Accelerated protocols condense that into a much shorter window.
The most studied accelerated approach, Stanford’s SAINT protocol, brought rapid remission to nearly 80% of participants with severe depression in a controlled study, with remission typically occurring within days and the main side effects being temporary fatigue and headaches. Our own accelerated TMS protocol can be completed in a single day—a meaningful difference for people who cannot step away from work or family for weeks of daily sessions.
The coverage gap
Here is the tension the report makes hard to ignore. IV ketamine and accelerated TMS are among the more effective tools for TRD, yet neither is currently covered by insurance in most cases. Meanwhile, the system continues to absorb the far greater cost of hospitalizations and crisis care.
This is not a knock on any single payer or provider. It reflects how coverage policies have lagged behind the evidence. But the gap has real consequences: people who might benefit from effective treatment face out-of-pocket costs, while the system keeps paying for the downstream care that those treatments could help reduce.
The economic case is becoming difficult to set aside. Effective treatment is not only good medicine. It is sound policy.
What matters most when choosing care
Whatever the modality, the fundamentals of safe, effective treatment stay the same. If you are exploring options for yourself or someone you love, these are worth looking for:
- Medical screening before treatment. A thorough evaluation should review your cardiovascular history, current medications, and mental health history. Certain conditions may call for additional evaluation or a different approach.
- Physician-led oversight and monitoring. Your care team should monitor you throughout each session and be able to adjust treatment in real time.
- Preparation and integration support. Integration—the work of making sense of an experience and applying it to daily life—is part of what helps results last. Medicine is a catalyst, not a cure-all.
- A calm, supportive setting. The environment where you receive care contributes to both safety and the quality of the experience.
These standards matter as much for someone searching for the best ketamine infusion clinic in Miami as for someone in any other city. The right questions are the same everywhere.
How Nushama approaches TRD
At Nushama, care is built around the understanding that medicine alone is not enough. For people living with TRD, we offer medically supervised IV ketamine infusions and FDA-approved Spravato (esketamine) administration, alongside accelerated TMS. A comprehensive psychiatric assessment helps determine which approach may fit your needs and history.
Every journey includes preparation before treatment and integration afterward, supported by physicians and clinicians who stay close throughout. The goal is not a single good session. It is durable change you can carry forward.
If you are weighing your options, our care team can help you understand what to expect and whether this path could support your recovery. Speak with our care team to talk through your situation at your own pace.
Frequently asked questions
What is treatment-resistant depression?
Treatment-resistant depression is generally defined as depression that hasn’t responded adequately to two or more antidepressant trials at appropriate doses. A clinician can help determine whether this describes your experience and what options may help.
Why is TRD so costly?
Much of the cost comes from hospitalizations, repeated medication trials, and ongoing acute care—expenses that tend to accumulate when a condition isn’t adequately treated upstream. The Medicare analysis found TRD patients cost about $46,000 a year, roughly $8,000 more than patients with controlled depression.
Is IV ketamine covered by insurance?
In most cases, IV ketamine for depression is not currently covered by insurance, and the same is often true of accelerated TMS. Coverage varies, so it is worth asking a provider’s care team directly about costs and any payment options.
Is IV ketamine better than at-home or intranasal options?
IV ketamine allows real-time dose adjustments and has the strongest published evidence base for TRD, which is why it is often considered the clinical standard. At-home or intranasal options can be less predictable. The right choice depends on your history and a clinician’s assessment.
What is integration, and why does it matter?
Integration is the process of reflecting on a treatment experience and applying its insights to everyday life, often with the support of a therapist or coach. It helps translate the biological window ketamine can open into lasting change.
