Treatment-resistant depression
Treatment-resistant depression in Richmond — when medications haven't been enough.
If you've tried two or more antidepressants at adequate dose and duration and still aren't well, you're not out of options — and you don't need to wait months to find out what comes next.
Medically reviewed by C. Britt Beasley, MD · Last reviewed June 10, 2026
At Richmond Brain & Behavior, Dr. C. Britt Beasley personally evaluates treatment-resistant depression and directs the interventional options that may fit: Deep TMS (BrainsWay H1), Spravato (esketamine), and IV ketamine. The recommendation you get here isn't shaped by only having one tool in the room.
New patients are typically seen within days, not months. Request an evaluation or call (804) 476-8274.
The term
What treatment-resistant depression means
“Treatment-resistant depression” (TRD) is a clinical label, not a judgment. In practice it usually means major depressive disorder that hasn't responded adequately to at least two oral antidepressants tried at a sufficient dose for a sufficient length of time.
It does not mean:
- Your depression is untreatable
- Nothing will ever help
- You failed somehow
It means the standard first-line medication pathway hasn't gotten you well — and it's time to consider treatments that work through different mechanisms than the usual serotonin/norepinephrine antidepressants.
Depression that hasn't responded sits alongside other conditions we treat. When OCD is the primary problem rather than depression, see Deep TMS for OCD (H7 coil) separately.
When to look further
When to consider interventional options
Interventional psychiatry — magnetic stimulation and ketamine-family treatments — is generally worth discussing when:
- You've completed two or more adequate antidepressant trials without getting well
- Side effects or medical constraints have limited what oral medications you can use
- You've had partial response but remain significantly impaired
- You want a physician who can weigh more than one next-step option, not a clinic built around a single device or drug
Candidacy is a clinical judgment. The honest way to know is an evaluation: Dr. Beasley reviews your history, screens for safety, and tells you directly whether an interventional path — and which one — is appropriate. Find out if it's right for you.
Not interchangeable
Comparing Deep TMS, Spravato, and IV ketamine
These are not interchangeable. They differ in mechanism, regulatory status, schedule, and how they're typically paid for. Head-to-head evidence comparing all three is limited; the better fit usually comes down to your history, medical picture, and what you can realistically sustain.
| Topic | Deep TMS (BrainsWay H1) | Spravato (esketamine) | IV ketamine |
|---|---|---|---|
| What it is | Non-invasive magnetic stimulation of prefrontal cortex | Nasal-spray esketamine, supervised in office | Intravenous ketamine infusion |
| Regulatory status | FDA-cleared for MDD (major depressive disorder) | FDA-approved for TRD (with oral antidepressant) | Off-label for depression (FDA-approved as anesthetic) |
| Typical course | ~36 sessions over several weeks (often 5 days/week), then taper; theta-burst and accelerated schedules for some patients | Induction: twice weekly × 4 weeks, then weekly / spaced maintenance | Series of infusions; maintenance planned from the start |
| Session logistics | ~20 min; awake; can drive afterward | Self-administered spray + at least 2 hours monitoring; no driving that day | Infusion + monitoring; no driving; arrange a ride |
| Insurance framing | Many plans cover for TRD, usually with prior auth — we verify before you commit | Often covered via specialty pharmacy / prior auth — we verify benefits | Generally self-pay (off-label use) |
| Who often leans this way | Prefer a non-drug option; can attend frequent short visits; want to avoid controlled substances | Want an FDA-approved ketamine-family option with an insurance pathway | Need finer, weight-based dose control; insurance path not available or Spravato not appropriate |
Scroll sideways to compare all three.
Deep TMS uses focused magnetic pulses — no anesthesia, no systemic drug. You're awake; the most common early side effects are scalp discomfort or headache. Dr. Beasley treats with the BrainsWay H1 coil for depression (and the H7 for OCD on a separate indication). Details: Deep TMS in Richmond.
Spravato is FDA-approved esketamine for adults with treatment-resistant depression, given with an oral antidepressant, only in a certified setting under a REMS program. It acts through the glutamate/NMDA system — a different mechanism from oral antidepressants. Monitoring for at least two hours after each dose is required. Details: Spravato in Richmond.
IV ketamine is the full ketamine molecule given intravenously. Using it for depression is off-label. That has two practical consequences worth stating plainly: insurance generally does not cover it, and the treatment does not carry the FDA's review of that specific antidepressant use. The practical advantage of the infusion route is controlled, weight-based dosing. Details: IV ketamine in Richmond.
We offer all three under physician direction. Which — if any — fits you is the evaluation, not a webpage.
Candidacy
Who this is for — and who it may not be for
Often appropriate to discuss if
- You meet a clinical picture of treatment-resistant depression (typically two or more adequate antidepressant trials)
- You can commit to the visit schedule for the option under consideration
- You want a board-certified psychiatrist directing the plan — not a technician-only protocol
Situations that need careful screening
- Certain implanted metal or electronic devices near the head (TMS safety screen)
- Significant uncontrolled cardiovascular disease, active psychosis, or pregnancy (ketamine-family and TMS decisions both require individualized judgment)
- Primary OCD rather than depression — H7 Deep TMS for OCD may be the more relevant interventional path
- Active substance-use concerns — still discussable; Dr. Beasley is board-certified in addiction medicine and treats both conditions in one practice
There is no online checklist that replaces an evaluation. If something is unsafe or simply not the right next step, you will be told that directly.
The path
What to expect: evaluation, then a plan
- 1
Request a time
Use the request form or call (804) 476-8274. The office emails back promptly to confirm. Most new patients are seen within days.
- 2
Evaluation with Dr. Beasley
History of medications tried, response and side effects, medical and psychiatric screening, and a plain discussion of which options (if any) fit. Bring a medication list if you have one.
- 3
Coverage and cost, before you commit
Before you commit to a course, we frame insurance vs. self-pay honestly: TMS and Spravato often have a prior-auth pathway; IV ketamine is typically self-pay. See insurance for how the practice approaches coverage generally. We do not invent carrier lists on this page — tell us your plan and we'll verify.
- 4
Treatment plan
If you proceed, Dr. Beasley sets the protocol, reviews response over time, and adjusts. A trained clinical team may deliver sessions; the physician directs the course.
- 5
Ongoing care
Maintenance (especially for Spravato or a ketamine series) is planned deliberately. Interventional treatment here sits inside a serious psychiatry practice, not a stand-alone procedure mill.
Payment
Insurance and self-pay — framed honestly
- Deep TMS: Many insurers cover courses for treatment-resistant depression (and, increasingly, OCD), usually with prior authorization. Rules vary by plan. We review your specific coverage before you start.
- Spravato: Often covered for TRD through a specialty-pharmacy model, typically with prior authorization. We coordinate access and verify benefits; we don't publish list prices on the website.
- IV ketamine: Because the antidepressant use is off-label, infusions are generally self-pay. If cost is a deciding factor, say so early — it legitimately changes which option is more realistic.
No carrier names are listed here by design. Coverage is plan- and indication-specific. Ask when you request an appointment; we'll confirm what applies to you. More on logistics: Insurance · FAQ · About.
Questions
Common questions
What counts as treatment-resistant depression?
Do I need to fail every medication before trying TMS, Spravato, or ketamine?
Which is better — Deep TMS, Spravato, or IV ketamine?
Is IV ketamine FDA-approved for depression?
Can I drive after treatment?
How soon can I be seen?
Will I see Dr. Beasley or a technician?
Is this a cure for depression?
Now accepting new patients
Find out which option — if any — fits.
Request an evaluation. Dr. Beasley will review your history, screen for safety, and tell you honestly whether Deep TMS, Spravato, IV ketamine, or none of the above is the right next step. New patients are typically seen within days.
Richmond Brain & Behavior
3111 Northside Avenue, Suite 200B
Richmond, VA 23228
Monday – Friday, 9am – 5pm
office@beasley.healthcare