From our survey

How a depression referral moves from primary care to treatment

Most people picture getting new depression care as one decision. In practice it is a relay with several handoffs, and a family member who understands the handoffs can keep the baton from getting dropped.

This explainer walks through that relay as it usually runs for someone in the St. Louis area whose depression has outlasted standard medication, and it is written for the caregiver: the spouse, parent, sibling, or friend who is helping someone else through it.

Where most people say they would start

First, some context from our own research. In June 2026 we put a relay question to 443 Midwest adults across ten states: where would the pursuit of ketamine or esketamine treatment begin? A primary care office came first at 56 percent, then a psychiatrist at 23 percent, then a solo online search at 12 percent. Those are final figures.

Leg one: the primary care visit

The primary doctor's first job is to understand what is going on and what has already been tried. Expect a depression questionnaire, often the PHQ-9, which scores symptoms and gives everyone a baseline to measure against later. Expect questions about sleep, substance use, physical health, and safety.

Where you can help: Medication history is the heart of this visit. Clinicians usually reserve the label treatment-resistant for depression that has held on through two or more antidepressants, each one taken long enough, and at a high enough dose, to count. Your loved one may not remember names and dates when they are depressed. You might.

Leg two: adjust, or refer

The primary doctor has two broad options. They can adjust the current treatment themselves, or they can refer to psychiatry. For depression that has already survived several medication trials, a psychiatry referral is common.

This handoff stalls most often: referrals sit unscheduled, and a depressed person is poorly placed to chase them.

Where you can help: Ask at checkout who the referral went to, how to reach them, and roughly how long it usually takes. Put a reminder on your own calendar to follow up if nobody has called within that window.

Leg three: the psychiatric evaluation

A psychiatrist or psychiatric nurse practitioner will take a deeper history and discuss options. Those can include different medications or combinations, psychotherapy, TMS (a drug-free magnetic stimulation treatment), and for the right patient, esketamine.

Many people arrive at this appointment without ever having heard the relevant names; 73 percent of our respondents had never encountered Spravato, the esketamine nasal spray's brand name. That is fine. The clinician's job is to introduce options. The patient's job, with your help, is to describe their experience honestly.

Where you can help: Bring the same medication timeline. Encourage your loved one to ask, "Since the usual medicines have not worked, what else is on the table, and what fits me?"

Leg four: approval and paperwork

If esketamine is recommended, several things happen before the first dose. The treatment has to be given at a certified healthcare setting enrolled in the drug's federal safety program. The patient is enrolled too. And in most cases the insurer will want a prior authorization showing why this treatment is appropriate, typically documenting the medications already tried.

Insurance weighs heavily in how people think about this. When respondents named the two provider traits they cared about most, 85 percent included insurance coverage, and nearly two thirds, 65 percent, said coverage alone could make or break their willingness to start.

Where you can help: Call the insurer's member services line with your loved one on the phone, or with their permission, and ask whether the treatment and the specific treatment center are covered and what prior authorization requires.

Leg five: treatment sessions

At the certified site, the patient uses the esketamine spray while a clinician watches, then stays for observation because the medication can cause dissociation, dizziness, sedation, and a rise in blood pressure. Someone else drives until tomorrow. For families, Brain Recovery Centers keeps a page on what Spravato treatment sessions involve that families often find useful here.

Where you can help: This is the leg where caregivers matter most in practical terms. Someone has to drive them home. If sessions fall on a weekday, that may mean arranging time off, or lining up a rotation of drivers across family and friends. In the St. Louis region, it is also worth checking how far the certified site is from home, because a long drive twice a week in the early phase adds up.

Leg six: measuring and adjusting

Good care measures whether it is working. Expect the questionnaire from leg one to come back periodically, and expect the care team to adjust the plan based on the results. Improvement is not certain, and a clinician may recommend stopping or changing course.

Where you can help: Notice changes the patient might not report: more conversation at dinner, getting out of bed earlier, or the opposite. Your observations are data too.

Why this relay matters so much

In our poll, the recommendation most likely to get someone to try this care was their own doctor's, at 74 percent, with friends and family second at 18 percent. That is the relay in miniature: the family raises the question, the clinician carries it forward.

You do not decide what is right. You keep each handoff from slipping.

What this article is not

What you have read is general information plus poll results. It is no substitute for medical advice. Esketamine's FDA approval is for adults whose depression has not budged with other treatment, with every dose supervised at a certified site, while ketamine sold for home use through telehealth is a separate, looser practice. Suitability is always a clinician's call.

Should the person in your care speak of wanting to die, or should you fear they might act, use 988 this minute by call or text. Worried relatives get help from the Suicide and Crisis Lifeline too, at any hour.

Methodology

Figures are from Pollfish survey 395586438, answered by its consumer panel until June 23, 2026. We received 443 completes from residents of Indiana, Missouri, Iowa, Illinois, Wisconsin, Kansas, Minnesota, Nebraska, Oklahoma and Ohio, all between 18 and 64. Its totals have been validated. This research was ordered and financed by our publisher.