When you start looking for help, the words can pile up fast: counseling, psychiatry, IOP, TMS, esketamine. This page walks through the main categories so you can figure out roughly where you fit before you ever pick up the phone. None of this is a substitute for a real evaluation, but it should make that first call feel less overwhelming.
Talk therapy (counseling and psychotherapy)
Therapy means working with a licensed professional - a counselor, social worker or psychologist - to understand and change patterns of thinking, feeling and behavior. Approaches like cognitive behavioral therapy (CBT) have strong evidence for depression, anxiety and trauma. Therapy can be the whole treatment for milder symptoms, or one piece of a larger plan. It does not involve medication, and most community mental health centers in Missouri offer it on a sliding scale.
Psychiatry and medication
A psychiatrist is a medical doctor who can diagnose mental health conditions and prescribe medication, such as antidepressants. Nurse practitioners and some primary care doctors also prescribe these medications. For many people, an antidepressant plus therapy is the standard first step for moderate to severe depression. Finding the right medication and dose can take a few tries, which is normal, not a sign that nothing will work.
Intensive outpatient and partial hospitalization
Between weekly therapy and a hospital stay there is a middle tier. Intensive outpatient programs (IOP) and partial hospitalization programs (PHP) offer several hours of structured treatment a day, several days a week, while you still live at home. These can help during a rough stretch, after a hospitalization, or when weekly appointments are not enough.
When antidepressants have not worked
Sometimes the standard steps do not do the job. When someone has tried two or more antidepressants at an adequate dose and length without meaningful relief, clinicians often call it treatment-resistant depression. It is common, and importantly, it does not mean you are out of options. It usually means it is time to look beyond the usual medications.
TMS (transcranial magnetic stimulation)
TMS is an FDA-approved, non-invasive treatment that uses magnetic pulses to stimulate areas of the brain involved in mood. You are awake the whole time, it does not require anesthesia, and sessions are done in a series over several weeks. It is used mainly for depression that has not responded to medication, and it is increasingly covered by insurance for that purpose.
Spravato (esketamine)
Spravato is an FDA-approved nasal spray, derived from ketamine, for adults with treatment-resistant depression and for depressive symptoms with suicidal thoughts. Because of how it works, it is only given in a certified, monitored medical setting where staff watch you for a couple of hours after each dose. It is not something you take home. When it is a good fit, some people notice change faster than with traditional antidepressants, though results vary from person to person.
How to figure out your next step
- If you have never been evaluated, start with a therapist or your primary care doctor and be honest about how bad it has been.
- If you are on a medication that partly helps, tell the prescriber - a dose change or add-on may be all you need.
- If you have tried two or more medications without relief, ask specifically about TMS and Spravato, and whether you are a candidate.
- Always ask about insurance, including MO HealthNet, and wait times before you commit.