Conditions · Treatment-Resistant Depression
Treatment-Resistant Depression treatment, has a next step here.
Treatment-resistant depression care in Coral Gables and Miami — re-evaluation first, then a real ladder: optimized medication, Spravato® and IV ketamine available now; TMS planned, with the waitlist open.
2-minute booking · benefits verified first · no referral needed
Home · Conditions · Treatment-Resistant Depression
Medically reviewed by Jay Borrego, DNP, PMHNP-BC, CRNA · Updated September 2026
Common signs
Sound familiar?
✓ Two or more antidepressants haven't brought remission
✓ Partial responses that fade
✓ Side effects that ended trials early
✓ Years of 'let's try another one'
✓ Told you're 'complicated' without a plan
Not a fit: uncontrolled blood pressure, aneurysmal vascular disease, pregnancy, active substance misuse — screened at evaluation.
How we evaluate it
Step one is never medication number six — it's a forensic re-evaluation: were doses adequate, durations real, diagnoses right? Thyroid, sleep apnea, ADHD, bipolar-spectrum and perimenopause all masquerade as resistance. Pharmacogenomic testing when it changes the choice.
How we evaluate it
When resistance is real, the ladder is real: augmentation strategies → structured therapy → Spravato® (FDA-approved for exactly this, often covered) → IV ketamine (55.4% response in the ELEKT-D trial) → TMS waitlist. Delivered by a clinician dual-trained in psychiatry and anesthesia, measured at every rung.
Cost & insurance
Evaluations and follow-ups bill to our participating plans or transparent self-pay. Benefits verified and your expected cost reviewed before your first visit.
What measured care looks like
PHQ-9 tracked at every visit
The Patient Health Questionnaire is scored before each appointment, so improvement — or its absence — is visible early and the plan changes when the data says to. Illustrative course shown; individual results vary
What's different here
The re-evaluation checklist
Before anyone says 'treatment-resistant,' we check: Were the antidepressant doses actually adequate? Were the trials long enough — 6 to 8 weeks at that dose? Was adherence real? Is the diagnosis right — bipolar spectrum, ADHD, thyroid disease, sleep apnea and perimenopause all masquerade as resistance? Is something else (alcohol, cannabis, a medication) working against the treatment? Pharmacogenomic testing when it would change the choice. Only then does the ladder start.
Available now: optimized medication, therapy, Spravato®, IV ketamine. TMS: planned, waitlist open.
Researching, not ready to book? Text us a question — a real person answers, no appointment, no pressure.
-Questions
Asked often. Answered clearly.
Psychiatric visits are billed to participating insurance plans or self-pay. Wellness programs use transparent flat self-pay pricing reviewed with you before enrollment — no surprise bills. Optional membership is $199 or $399 per month, published right on this page.
Dr. Borrego is a doctorate-prepared psychiatric nurse practitioner (DNP, PMHNP-BC) and certified registered nurse anesthetist (CRNA) — licensed in Florida to evaluate, diagnose, and prescribe for psychiatric conditions. The dual training in psychiatry and anesthesia is exactly what allows IV ketamine and Spravato® care to be delivered in-house by the same clinician who manages your psychiatric plan.
Start with a psychiatric evaluation if mental health is the main concern. Choose the $249 Precision Assessment if the picture is broader or unclear, or use the 2-minute fit assessment for a quick directional starting point.
Many psychiatry, therapy, and wellness services can be delivered by telehealth to eligible patients in Florida. IV ketamine, Spravato®, TMS, and IV lounge services require in-person care in Coral Gables.
Let’s Thrive provides outpatient care and is not an emergency service. If you are in suicidal crisis or emotional distress and need immediate support in the United States, call or text 988. For an immediate medical emergency, call 911.
Start here
Ready to feel like yourself again?
An advanced-care consult decides it — your history, your cardiovascular picture, your prior trials, your goals. We tell you the truth either way.
Booking a first visit commits you to nothing beyond it — benefits verified before you’re charged anything.
Prefer to talk first? Call (786) 933-9143