- 21297 Foothill Blvd. Ste 203 Hayward, CA 94541-1554
- (415) 636-9700
- hello@exxceedwellness.com
Treatment-resistant depression (TRD) is depression that hasn’t adequately responded to at least two trials of antidepressants at adequate dose and duration. At Exxceed Wellness in Hayward, CA, TRD care includes two FDA-approved interventional treatments delivered in our clinic: Spravato (esketamine) and TMS therapy.
Treatment-resistant depression, sometimes called difficult-to-treat depression, is a clinical term used when a person with major depressive disorder has not had a meaningful response to at least two adequate trials of antidepressant medication. “Adequate” means a therapeutic dose, taken for a sufficient duration (typically six to eight weeks per trial), with sound adherence.
Estimates vary, but roughly one-third of people with major depressive disorder do not achieve full remission after their first antidepressant, and a significant subset continue to struggle even after multiple medication changes. TRD isn’t a rare edge case. It’s a well-recognized clinical category, and it has guideline-supported treatment options.
The word resistant can sound discouraging. Clinically, it simply describes how a depression has responded so far, not what’s possible going forward. Two FDA-approved interventional options exist specifically because researchers recognized that depression which doesn’t respond to oral antidepressants often does respond to treatments that work through different brain pathways. Many patients who reach a TRD diagnosis go on to achieve meaningful symptom relief with the right next step.
There is no single laboratory test for TRD. The diagnosis is clinical, based on a careful review of your medication history alongside a structured assessment of current depressive symptoms.
Our intake review covers your full medication history (including supplements and over-the-counter agents), prior psychotherapy, co-occurring conditions, sleep, substance use, and any medical conditions that can complicate depression treatment. The goal is to confirm whether interventional treatment is appropriate, rule out contributing factors that haven’t been addressed, and choose the next step that fits your specific picture.
SSRIs and SNRIs target the brain’s monoamine systems: serotonin, norepinephrine, sometimes dopamine. For many people, raising synaptic monoamine levels relieves depressive symptoms. For a substantial minority, it doesn’t, or it works for a while and then loses effect.
Researchers now understand that depression involves more than monoamine signaling. The glutamate system, the brain’s main excitatory neurotransmitter network, appears to play a central role in some forms of depression. So does cortical excitability in specific regions like the dorsolateral prefrontal cortex. Treatments that target these pathways are the basis of modern interventional care for TRD.
Spravato modulates the NMDA glutamate receptor, producing a different downstream effect on neuroplasticity than SSRIs do. This is why some patients who haven’t responded to multiple oral antidepressants do respond to Spravato.
Transcranial magnetic stimulation uses focused magnetic pulses to stimulate or modulate specific brain regions. It bypasses the medication pathway entirely, which is why it can help when oral antidepressants haven’t.
Spravato is an FDA-approved nasal spray for adults with treatment-resistant depression and for major depressive disorder with active suicidal ideation. It is the only nasal-spray esketamine approved for this use. At Exxceed Wellness, Spravato is delivered in-office under the federally required REMS program, with post-dose monitoring built into every appointment.
Learn more about Spravato treatment at our Hayward clinic ›
Transcranial magnetic stimulation is FDA-cleared for treatment-resistant depression. We offer the full protocol menu: standard 10Hz rTMS, iTBS / theta-burst (also known as Express TMS, with 3-minute sessions), and Deep TMS using the BrainsWay H-coil. Each protocol has different session length, indication scope, and candidacy considerations. Choosing the right one is part of the consultation.
Learn more about TMS therapy at our Hayward clinic ›
For some patients, TMS and Spravato are used in combination or in sequence. For example, beginning with TMS and adding Spravato if response is partial, or vice versa. Combination strategies are individualized and require careful medical oversight; we discuss these only when clinically appropriate.
Neither option is universally “better.” The right choice depends on your medication history, lifestyle, side-effect tolerability, insurance coverage, and clinical specifics that come up in the consultation. At a high level:
| Spravato (esketamine) | TMS therapy | |
|---|---|---|
| Mechanism | NMDA glutamate receptor modulation | Focused magnetic stimulation of specific cortical regions |
| Delivery | Nasal spray, in-clinic only (REMS) | Non-invasive, in-clinic only |
| Session length | About 2 hours (dose plus monitoring) | 3 to 37 minutes depending on protocol |
| Treatment course | Twice-weekly induction, then transition, then individualized maintenance | Daily 5x per week for about 6 weeks, then taper or maintenance |
| FDA approval scope | TRD; MDD with active suicidal ideation | TRD; OCD (Deep TMS); other indications by protocol |
| Driving day-of | Not allowed; designated driver required | Permitted |
| Common insurance coverage in California | Often covered for TRD with prior authorization | Often covered for TRD with documented antidepressant failures |
The right next step is best chosen during a consultation, where we can review your full medication history and current symptoms together.
Our practice is led by Nefretiri Abat, J.D., PMHNP-BC, a board-certified Psychiatric-Mental Health Nurse Practitioner with twenty years of clinical training and a Juris Doctor in addition to her psychiatric credentials. TRD treatment requires careful clinical judgment, transparent communication about candidacy, and ongoing monitoring; that’s the core of what we do.
In-office TRD treatment, both Spravato and TMS, is delivered at our Hayward clinic. Telehealth medication management is available for ongoing follow-up between sessions, and for patients across California who need pre-treatment evaluation before traveling to the clinic.
We also accept Stockton patients in person at our second location. For all other California residents, telehealth-based intake and ongoing medication oversight are available statewide.
Both Spravato and TMS are commonly covered by major California insurance plans for documented treatment-resistant depression, although coverage details vary by carrier and plan tier. Prior authorization is typically required for both.
If your plan isn’t listed, contact us. We can verify benefits and provide a superbill for out-of-network reimbursement. See our full fees and insurance page ›
The clinical definition is depression that hasn’t adequately responded to at least two antidepressant trials at adequate dose and duration. If multiple medications haven’t given you meaningful, sustained relief, that’s worth discussing with a psychiatric provider, not as a self-diagnosis but as the starting point of a clinical conversation.
The standard threshold is two adequate trials. “Adequate” means each medication was taken at a therapeutic dose for typically six to eight weeks. Some clinicians use stricter definitions; what matters most is reviewing the actual history rather than counting prescriptions.
There is no universal answer. Spravato may be a better fit when there’s active suicidal ideation, when oral medication has been a sticking point, or when the patient prefers a faster onset. TMS may be preferred when patients want to avoid sedation or driving restrictions, or when OCD also needs treatment (Deep TMS is FDA-cleared for OCD specifically). The clinical choice is made together during the consultation.
Both are commonly covered for TRD with prior authorization, though coverage and patient cost share vary by plan. We handle the prior auth process and verify benefits before treatment begins.
In some cases, yes, sequenced or combined under clinical supervision. Combination strategies are individualized and require careful oversight; they aren’t right for every patient.
Treatment-resistant doesn’t mean untreatable. If interventional options don’t produce adequate response, additional strategies remain: augmentation with other agents, ECT referral, ketamine clinical trials, comprehensive review for missed contributing factors. We don’t end the conversation when one treatment falls short.
No. You can schedule a consultation with our practice directly. We’ll request your medication history at intake.
Often yes. Both Spravato and TMS are commonly used alongside an oral antidepressant, not in place of one. Any changes to your medication regimen are made by your prescriber based on clinical response.
If standard antidepressants haven’t given you the relief you need, the next conversation is with a psychiatric provider who treats TRD specifically. We see patients in person at our Hayward and Stockton clinics, and via telehealth across California.
