How to choose a depression provider - and what to do when meds are not enough

By the STL Depression Clinics Editorial TeamIndependent, medically reviewed for accuracy

Finding help for depression is hard when you already feel drained. This is a short, practical guide to picking a provider in the St. Louis area, the questions worth asking, and the options that exist when a first or second antidepressant has not worked.

Start with how you feel, not a diagnosis

Most people do not begin by searching for a specific treatment. They search for the feeling: I can't get out of bed, nothing brings me joy anymore, my medication stopped working. All of those are valid reasons to reach out. You do not need to have it figured out before you call. A good provider expects you to arrive with symptoms, not a plan.

Match the provider to what you need

Different providers do different jobs, and the right starting point depends on your situation:

• Primary care doctor. A reasonable first stop for milder or first-time depression. Many people are prescribed their first antidepressant here.
• Therapist or counselor. For talk therapy such as cognitive behavioral therapy. Often used alongside medication.
• Psychiatrist. A physician who specializes in mental health medication and complex cases.
• Specialty or interventional clinic. Focused on treatment-resistant depression, offering options like TMS and Spravato when standard medications have not worked.

If you have already tried a couple of medications without relief, a specialty clinic may save you time. You can browse local and regional options in our provider directory.

Questions worth asking before your first visit

• Do you treat depression that has not responded to medication?
• What treatments do you offer - therapy, medication, TMS, Spravato?
• Do you take my insurance or MO HealthNet? What will a visit cost?
• How soon can I be seen, and is there a waitlist?
• Will I see the same clinician each time?

There are no wrong questions. A clinic that answers plainly and patiently is showing you how they will treat you as a patient.

The role of your own doctor

For many people, the thing that finally tips them toward trying something new is a recommendation from a clinician they already trust. If you have a doctor you see regularly, tell them your antidepressant is not helping and ask directly what else is available. They can refer you, and a referral often makes the next appointment easier to get and easier to trust.

Red flags to avoid

• Any promise of a guaranteed cure or a miracle result. Responsible clinicians talk in terms of likelihood and follow-up, not guarantees.
• Pressure to pay large sums up front for long treatment packages before an evaluation.
• No physician involvement in treatments that require medical supervision.
• Vague answers about credentials, monitoring, or what happens if a treatment does not work.

When medication is not enough

If two antidepressants have not worked, that does not mean you are out of options - it means it is reasonable to look beyond standard prescriptions. Two commonly discussed choices are:

• TMS (transcranial magnetic stimulation), a non-drug, in-office treatment that uses magnetic pulses to stimulate areas of the brain involved in mood. It does not require sedation, and you drive yourself home.
• Spravato (esketamine), an FDA-approved nasal spray for treatment-resistant depression, given and monitored in a certified clinic. See our Spravato guide for details.

Neither is a cure, and both work best as part of ongoing, supervised care. But for people who felt like they had tried everything, having a clear next step can matter a great deal.