Primary care clinicians in St. Peters have likely seen this visit more times than they could count. The patient on their second or third antidepressant says it is "maybe a little better," and the appointment slot is already half gone.
We commissioned a survey that puts a number on how widespread that experience is outside the clinic walls. It is larger than we expected, and it has direct implications for how referrers identify, document, and route patients whose depression has not responded to first-line care.
The study
We ran it with Pollfish, fielding it to that company's consumer panel; 443 interviews came back complete before the June 23, 2026 cutoff. Respondents were 18 to 64 and spread over ten Midwest states, Missouri included. This was a general-population sample, not a clinical one, and the question below relies on self-report rather than diagnosis. All figures are top-line and come from the validated final panel data.
The headline figure
The key item asked respondents whether standard medication had left depression, anxiety, or PTSD unresolved, in themselves, in someone they love, or in both. The results:
- Personally: 37 percent
- Someone close, not the respondent: 22 percent
- The respondent and someone close: 13 percent
- No experience of it: 28 percent
So 72 percent reported some direct exposure, and 50 percent, summing the first and third rows, reported it as their own experience.
A clinical reader will rightly note that "did not help" is broader than treatment-resistant depression as usually defined. Some of those respondents had inadequate trials, stopped early for tolerability, or have conditions other than major depression. We are not claiming a prevalence estimate for TRD. What we are claiming is narrower and still useful: half of ordinary adults in this region describe a personal history in which standard medication fell short. Many of them are presumably sitting in primary care exam rooms.
What they do and do not know
The same respondents were largely unaware of next-line options. When asked about Spravato, esketamine given as a nasal spray and approved by the FDA in adult treatment-resistant depression, 73 percent had never heard the name. A further 21 percent recognized it without knowing what it was. TMS was familiar to about one respondent in four.
For a referrer, the practical meaning is that patients are unlikely to raise these options themselves. If the conversation about what comes after two failed trials is going to happen, it will almost always need to start on your side of the desk.
Where they would go, and whom they would believe
As a first stop for this kind of treatment, 56 percent picked their PCP, 23 percent a psychiatrist, and 12 percent an online search. Only 1 percent would start by asking a friend.
Their own doctor was the most persuasive recommender for 74 percent, friends or family for 18 percent. Advertising drew 2 percent.
That makes primary care both the first stop and the most persuasive voice. It is an unusual amount of leverage, and it runs in both directions. A PCP who does not bring up next-step options is, in effect, the main reason a patient never hears about them.
How they describe the problem
An open-text item collected 319 descriptions of what respondents would search for when seeking help. The answers were symptoms and requests, not treatments: "ptsd help," "depression medicine alternatives," and even "someone please help me." Nobody framed it as a question about a drug.
Clinically, that suggests patients will present with how they feel and a vague sense that the medication is not enough. The work of translating that into "two adequate trials, insufficient response, consider escalation" falls on the clinician.
What would make them accept a referral
Coverage dominated. Among respondents weighing a provider, 85 percent put insurance in the top two and 43 percent put proximity there. FDA approval counted as deciding or big for 59 percent. Just over half preferred covered care with more administrative hoops over simpler self-pay, and 23 percent preferred self-pay.
The payer mix reported by respondents is worth noting for referral planning: commercial led (39 percent), Medicaid was close behind (37 percent), and Medicare (23 percent), no insurance (9 percent), and TRICARE (5 percent) followed. A referral network that only takes commercial plans will not serve a large share of this population.
Implications for a St. Peters practice
- Ask about response routinely. A brief structured check, such as a repeated PHQ-9, at each medication follow-up makes nonresponse visible before the patient gives up.
- Document trials as you go. Record each drug, its dose and duration, the response, and why it stopped. Payers usually want that before approving escalation, and reconstructing it later is painful.
- Name the category. Saying "this may be treatment-resistant depression, and there are further options" changes how a patient understands their situation.
- Know two or three receiving sites. Psychiatry, a TMS provider, and a certified esketamine treatment center within reasonable driving distance of St. Charles County, with a sense of which payers each accepts. A patient-facing Spravato overview can help those conversations.
- Keep the distinction clear. Esketamine is FDA-approved, delivered under a REMS program in certified settings with post-dose monitoring. Off-label ketamine, especially at-home programs, is a different category. Patients will conflate them unless someone separates the two.
Limitations
This is market research, not epidemiology. The sample was drawn from a consumer panel and is not weighted to match census demographics. Self-reported medication response is imprecise. This piece sticks to whole-sample figures and makes no claim about how any subgroup answered. The figures above should be read as directional signals from a regional general-population sample.
Even with those caveats, a result where most respondents report personal contact with stalled depression treatment, and almost none know what comes next, is a strong prompt to look harder at the patients already on your schedule.
Patients who disclose suicidal thoughts between visits should know the Suicide and Crisis Lifeline, which answers 988 calls and texts through the night as well as the day; veterans can press 1 on connecting. Putting that number on after-visit summaries costs nothing and may matter a great deal.
Methodology
Survey vendor: Pollfish, consumer panel. Sample: 443 adults, 18 to 64, living in Kansas, Ohio, Iowa, Missouri, Minnesota, Wisconsin, Indiana, Nebraska, Oklahoma, or Illinois. Fieldwork ended June 23, 2026. We report top-line percentages; multi-select items may sum above the sample, and all results come from the final validated file. The study was paid for, and commissioned, by our publisher. This article is not clinical guidance.