What hope feels like…
I have seen hundreds of patients with treatment-resistant depression at the Center for Anxiety and Depression—people who have been on countless medications with little to no benefit or intolerable side effects. I know how hopeless it can feel to suffer from depression for years and have doctors tell you there are no other options.
I’m here to tell you that is not my way.
I ran the TMS program as Director, providing Spravato, TMS, and Vagus Nerve Stimulators to patients like you or your family member. I prepared patients for these therapies by following my proprietary evidence-based treatment algorithm for treatment-resistant depression, developed in collaboration with Dr. Dave Dunner. I went to bat with insurance companies—submitting prior authorizations, appeals, and second appeals, writing letters of medical necessity, scheduling doc-to-doc interviews, and meeting with drug companies.
Although I am no longer providing these services directly, I know what steps to take and who to call to get you these services with relative ease.
So if you are suffering from treatment-resistant depression, I highly recommend an evaluation with me. We can then decide whether it makes sense for me to prepare you for one of these treatments with medication management or for me to refer you to a preferred provider on my referral list. I am also happy to advise your prescribing doctor, if you have one, on next steps for medication management.
⚡ Key Takeaways
- Expert-level evaluations from a Former TMS Program Director who has assessed hundreds of complex cases
- Proprietary treatment algorithm developed in collaboration with Dr. Dave Dunner
- Three treatment pathways assessed: TMS therapy, Spravato (esketamine), and Vagus Nerve Stimulation
- Preparation or referral: I can prepare you with medication management or refer you to preferred providers
- Prescriber consultation: I can advise your current doctor on next steps
- Insurance navigation expertise: Prior authorizations, appeals, and medical necessity letters
- Insurance accepted: Premera, Regence, Aetna, Cigna, First Choice, Lifewise, Medicare
What is Treatment-Resistant Depression?
Treatment-resistant depression (TRD) is depression that has not responded adequately to at least two different antidepressant medications from different drug classes, each taken at therapeutic doses for 6-8 weeks. Approximately 30% of people with major depression have TRD, which requires advanced treatments like TMS, Spravato, or VNS therapy.
TRD isn’t a personal failing or a sign that you’re “too depressed” to get better. It’s a clinical designation that means your brain chemistry responds differently to standard treatments.
💡 You Might Have TRD If…
You’ve tried multiple antidepressants (SSRIs, SNRIs, or others) without adequate relief. You’ve had partial responses that faded. You’ve stopped medications due to intolerable side effects. You’ve been told “we’ve run out of options” by previous providers.
Here’s the hopeful part: treatment-resistant doesn’t mean treatment-impossible. It means treatment-requiring-a-different-approach. The newer therapies I evaluate patients for work through completely different mechanisms than traditional antidepressants.
Why My Background Matters for Your Evaluation
Not all TRD evaluations are created equal. As Former TMS Program Director at the Center for Anxiety and Depression, I evaluated and treated hundreds of patients with treatment-resistant depression. I’ve seen the full spectrum: patients who responded dramatically, patients who needed protocol adjustments, patients who were better suited for other treatments.
I developed a proprietary evidence-based treatment algorithm for treatment-resistant depression in collaboration with Dr. Dave Dunner—a systematic approach that guides each step of the evaluation and treatment preparation process.
This experience matters because TRD evaluation isn’t just checking boxes on a form. It’s understanding nuances:
- Was your previous medication trial actually adequate, or were doses too low or duration too short?
- Are there medical factors (thyroid issues, sleep apnea, chronic pain) contributing to treatment resistance?
- Which of your specific symptoms and history patterns predict better response to TMS versus Spravato versus VNS?
- What are realistic expectations for your particular situation?
I also know how to navigate the insurance system. I’ve submitted countless prior authorizations, written appeals and second appeals, drafted letters of medical necessity, conducted doc-to-doc interviews, and worked directly with drug companies. I know what steps to take and who to call to help you access these treatments.
The Three Advanced Treatment Options I Evaluate For
TMS Therapy
- Magnetic pulses stimulate brain regions involved in mood
- 36 sessions over 7-9 weeks
- 19-minute sessions
- No anesthesia, no sedation
- 83% response rate, 62% remission
- Referral to preferred providers
Spravato (Esketamine)
- Nasal spray targeting glutamate/NMDA receptors
- Twice weekly initially, then maintenance
- 2-hour in-office monitoring (REMS required)
- May cause temporary dissociation, sedation
- No driving until next day
- Can work within 24-48 hours
- 69% response rate in trials
- Referral to preferred providers
VNS (Vagus Nerve Stimulation)
- Implanted device stimulates vagus nerve
- Surgical procedure required
- Long-term treatment option
- For severe, chronic TRD
- Gradual improvement over months
- Evaluation and neurosurgeon referral
Each treatment works through a different mechanism. TMS uses magnetic fields to directly stimulate underactive brain regions. Spravato works on glutamate pathways rather than serotonin. VNS modulates brain circuits through the vagus nerve. The right choice depends on your specific situation.
What Happens During an Evaluation
The evaluation appointment typically runs 60-90 minutes. Come prepared with a list of all psychiatric medications you’ve tried (names, doses, duration, why stopped). If you have records from previous providers, bring those too.
You’ll leave knowing whether you’re a candidate for TMS, Spravato, VNS, or a combination approach. We’ll then decide together on the best path forward—whether that’s me preparing you through medication management, referring you to a preferred provider on my list, or advising your current prescribing doctor on next steps.
Who Typically Qualifies
TMS Candidates
Adults and adolescents 15+ who have failed at least one antidepressant. No metal implants in head. No history of seizures. Available for daily treatments for 7-9 weeks.
Spravato Candidates
Adults with TRD who have failed at least two antidepressants. Must remain at office for 2-hour monitoring. No uncontrolled hypertension. No active substance use disorder.
VNS Candidates
Adults with chronic, severe TRD who have failed multiple medication trials and at least one adequate course of TMS or ECT. Willing to undergo surgical implantation.
May Need Different Approach
If your depression is newly diagnosed, mild, or hasn’t yet tried adequate medication trials, we may recommend optimizing standard treatments first before advancing to these options.
Important: Insurance typically requires documentation of previous treatment failures before approving TMS or Spravato. Part of the evaluation involves ensuring your history meets insurance criteria. With my experience navigating prior authorizations and appeals, I can help guide this process.
Insurance & Payment
The TRD evaluation is billed as a psychiatric diagnostic evaluation, which is covered by most insurance plans I accept.
💰 Self-Pay Option
Initial TRD evaluation: $750 (cash pay). This comprehensive assessment includes full medication history review, candidacy determination for all three treatments, and a detailed treatment plan with next steps. Follow-up appointments are $275 for 30 minutes.
Your Provider
Cara J. Erkut, M.D.
I’m a board-certified psychiatrist with specific expertise in treatment-resistant depression. As Former TMS Program Director at the Center for Anxiety and Depression, I evaluated and treated hundreds of patients who hadn’t responded to traditional antidepressants. I developed a proprietary evidence-based treatment algorithm for TRD in collaboration with Dr. Dave Dunner. I trained at Mayo Medical School and completed my psychiatry residency at the University of Washington, where I served as Chief Resident. I’m also a certified psychoanalyst and Clinical Instructor at UW Harborview.
Frequently Asked Questions
Treatment-resistant depression is typically defined as depression that hasn’t adequately responded to at least two different antidepressant medications taken at appropriate doses for adequate duration. Some definitions require failure of three or more medications. About 30% of people with depression have TRD.
Candidacy depends on your specific history, medication trials, medical conditions, and treatment goals. A comprehensive evaluation examines all these factors to determine which treatments you may qualify for and which would be most appropriate for your situation. I assess for all three options during a single evaluation.
I no longer provide these treatments directly. However, I can prepare you for these treatments through medication management, or refer you to preferred providers on my referral list who I trust to deliver excellent care. I can also advise your current prescribing doctor on next steps if you prefer to stay with your existing provider.
Yes. The evaluation is billed as a psychiatric diagnostic evaluation, which is covered by most insurance plans. I accept Premera, Regence, Aetna, Cigna, First Choice, Lifewise, and Medicare. Cash pay is $750 for the comprehensive initial evaluation.
Running a TMS program means I saw hundreds of cases and understand the nuances of who responds well to these treatments. I developed a proprietary evidence-based treatment algorithm for TRD in collaboration with Dr. Dave Dunner. I also know how to navigate insurance—I’ve submitted prior authorizations, appeals, second appeals, written letters of medical necessity, conducted doc-to-doc interviews, and worked directly with drug companies. This experience helps me guide you to the right treatment with relative ease.
Bring a list of all psychiatric medications you’ve tried, including names, doses, how long you took them, and why they were stopped. If you have records from previous psychiatrists or therapists, those are helpful. Also bring your insurance card and a list of current medications.
Spravato works on glutamate pathways and NMDA receptors, which can cause temporary dissociation (feeling disconnected or “floaty”), dizziness, nausea, and sedation during the 2-hour in-office monitoring period. These effects typically resolve within 1-2 hours. Due to REMS (Risk Evaluation and Mitigation Strategy) requirements, you cannot drive or operate heavy machinery until the following day after each treatment. You’ll need someone to drive you home after every session.
Serving the Seattle Metro Area
This is what hope feels like.
Schedule a comprehensive TRD evaluation to find out if TMS, Spravato, or VNS could help you.
BOOK A CONSULTATIONOr call (206) 312-8457
Sources & References
- Sackeim HA, et al. (2020). Clinical outcomes in a large registry of patients with major depressive disorder treated with Transcranial Magnetic Stimulation. J Affect Disord. 277:65-74. [83% response rate, 62% remission]
- Daly EJ, et al. (2019). Efficacy of Esketamine Nasal Spray Plus Oral Antidepressant Treatment for Relapse Prevention in Patients With Treatment-Resistant Depression. JAMA Psychiatry. 76(9):893-903. [69% Spravato response]
- Rush AJ, et al. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. Am J Psychiatry. 163(11):1905-1917. [30% TRD prevalence data]
- FDA. Spravato (esketamine) REMS Program. spravatorems.com
- Neuronetics, Inc. (2024). NeuroStar TMS Clinical Outcomes Data. Data on file.
Are you a psychiatric practice looking to add TMS, Spravato, or other advanced depression treatments? Staffingly provides virtual medical assistants trained in TMS scheduling, Spravato REMS coordination, prior authorization support, and patient response tracking.