Treatment-Resistant Depression Care in Chesapeake, VA

Understanding the term

What Treatment-Resistant Depression Actually Means

About a third of people treated for major depression do not reach remission after two adequate antidepressant trials. That group is what clinicians mean by treatment-resistant depression, or TRD. The label sounds final. It is not. It means the standard first moves did not work, and the plan needs to change.

Two words in that definition carry most of the weight: adequate dose and adequate duration. A surprising number of "failed" medications were never given a fair chance: stopped early because of a first-week side effect, kept at a starting dose for months, or taken inconsistently. One of the most useful things we do in an evaluation is reconstruct the real history of what was tried and how.

Before adding another medication

Is It Resistant, or Is It Something Else?

Before we call depression treatment-resistant, we look for the reasons it may not be depression alone. In our experience the most common are:

• Bipolar spectrum illness. Antidepressants alone work poorly, or make things worse, when the underlying condition is bipolar disorder. A careful history of energy, sleep, and mood episodes often changes the diagnosis.
• ADHD. Chronic underperformance, disorganization, and the demoralization that follows can look exactly like depression and will not lift until the attention problem is treated.
• Medical contributors. Thyroid disease, low vitamin D or B12, anemia, obstructive sleep apnea, and inflammatory conditions. We order labs when they have not been done.
• Substances. Alcohol is a depressant. Cannabis can blunt antidepressant response. Neither is a moral failing, but both change what will work.
• Trauma and personality factors that call for psychotherapy alongside medication rather than medication alone.

Only after that review do we treat the depression as truly resistant, and by then the plan is usually clearer.

The full menu

Evidence-Based Options When Standard Antidepressants Have Not Worked

Treatment-resistant depression has more options today than at any point in the history of psychiatry. At South Chesapeake Psychiatry and TRIP we offer or coordinate the following, roughly in the order they are usually considered:

• Optimization. Bringing the current medication to a full therapeutic dose for a full trial before declaring it a failure.
• Switching class. Moving from an SSRI to an SNRI, bupropion, mirtazapine, or a different mechanism entirely.
• Augmentation. Adding a second agent with strong evidence in TRD: aripiprazole, brexpiprazole, cariprazine, lithium, thyroid hormone, or bupropion combined with an SSRI.
• Newer mechanisms. Auvelity (dextromethorphan-bupropion), which acts on glutamate signaling and works faster than traditional antidepressants for some clients.
• SPRAVATO® (esketamine). The FDA-approved nasal spray for TRD, given in our REMS-certified clinic through TRIP and covered by most insurance plans with prior authorization. Since January 2025 it is approved both alongside an oral antidepressant and as a stand-alone treatment.
• Transcranial magnetic stimulation (TMS). A non-medication, non-invasive option we refer for and coordinate with local providers.
• Electroconvulsive therapy (ECT). Still the most effective treatment for the most severe depression, and we will say so and refer when it is the right choice.
• Psychotherapy. Particularly cognitive behavioral and behavioral activation approaches, in coordination with therapists in Hampton Roads.

How we work

What a Treatment-Resistant Depression Evaluation Looks Like Here

A new client begins with a 60-minute psychiatric evaluation with a board-certified psychiatric nurse practitioner. Bring every medication you have tried; if you do not remember doses, bring pharmacy printouts. We reconstruct the treatment history, review labs and order what is missing, revisit the diagnosis, and leave you with a written plan that includes what happens if the next step does not work either.

Justin Ray, MSN, PMHNP-BC, founded both South Chesapeake Psychiatry and TRIP, has treated serious mental illness for more than thirty years, and speaks nationally on psychopharmacology. Treatment-resistant depression is the reason TRIP exists. You can read more of his thinking in Exploring the Glutamate Pathway, Circuit Psychiatry: TMS, Theta-Burst, and TRD, and Immunopsychiatry and Inflammatory Depression.