If you practice primary care in St. Peters, a survey we commissioned this summer carries an uncomfortable implication for your schedule. For one emerging category of depression care, you are not one input among many. You are effectively the decision.
We fielded the study among 443 adults, 18 to 64, from ten Midwest states to learn how people decide about ketamine and esketamine therapy. The intent was commercial; the result reorganized what we thought we knew about where these decisions get made.
The headline number
When respondents were asked whose recommendation would actually make them try this treatment, 74 percent picked their own doctor. The rest of the field was thin: 18 percent a close friend or relative, 4 percent a public figure from the service or first responder world, an advertisement 2 percent, and a podcast host 1.
A separate item confirmed the direction: for a first stop, primary care physicians drew 56 percent and psychiatrists or other mental health clinicians 23 percent, while independent searching (12 percent), asking a friend (1 percent), and simply not knowing (5 percent) trailed. Final validation moved several figures by a point; the margin barely changed.
What that means in an exam room
Roughly three quarters of patients are waiting on a physician's opinion before they act, and slightly more than half intend to seek it from primary care rather than psychiatry. In practice, many patients who might be candidates for newer treatment-resistant depression options will never encounter them unless the topic surfaces in a fifteen-minute visit with their family doctor. That is a workload problem as much as a knowledge problem, and it is worth naming rather than assuming the referral ecosystem will solve it.
Patients do not know what to ask for
Awareness of the approved option is close to nil. Of the 443 people surveyed, 73 percent were meeting the name Spravato for the first time, 21 percent knew only its sound, and 6 percent understood it.
So the question will rarely arrive in clinical form. It arrives as "nothing is working," and translating that into a treatment-resistance workup falls to the clinician. The open-text item makes it vivid: 319 respondents typed what they would search for, and the replies were symptom language and appeals such as "best ways to handle depression," "how to help someone with depression," and "someone please help me."
The population carrying this is larger than the literature suggests
Across the sample, 72 percent had direct or family experience of depression, anxiety, or PTSD that persisted through standard medication; the split was 37 percent self, 22 percent other, and 13 percent both, with 28 percent reporting none.
This is self-report from a general-population panel, not a diagnostic instrument or a prevalence estimate. What it measures is expectation: most adults in your waiting room have already watched standard treatment fall short for someone, which is worth remembering when you propose a fourth SSRI.
Coverage governs whether a referral survives
Insurance led the provider criteria, chosen as a top-two factor by 85 percent of respondents, ahead of proximity (43 percent), FDA approval (27 percent), speed of results (24 percent), discretion (11), and service-member specialization (10). Insurance would be the deciding consideration for 22 percent and a heavy one for 43 percent, 65 percent in total. Between covered-with-hoops and self-pay-and-start-sooner, half chose the hoops; paying took 23 percent and indecision 26.
A referral into an out-of-network or cash-only setting is, for many patients, a referral that quietly dies between your office and theirs. Know which regional sites participate with which plans before the name goes on paper. For a patient-facing explanation of one certified program, Brain Recovery Centers maintains a Spravato information page you can share.
The payer mix is not what most clinics plan around
Counting all coverage respondents selected, commercial insurance came to 39 percent and Medicaid to 37, while TRICARE held 5, Medicare 23, and the uninsured 9; 2 percent declined to answer. Medicaid running nearly level with commercial coverage in a general-population sample is the finding most likely to be missed by anyone building referrals around commercial plans. For a St. Peters practice, knowing which nearby certified sites take Missouri Medicaid changes what you can realistically offer a meaningful share of your panel.
Patients are cautious, not opposed
Respondents' first reactions to ketamine treatment for depression or PTSD broke down as skeptical 21 percent, hopeful or curious 18, cautious but open 34, negative 9, and unaware 18. Slightly more than half were receptive; firm opposition stayed in single digits. Skepticism at that level usually reflects missing information, and the information patients want is about legitimacy: FDA approval was decisive or major for 59 percent and somewhat important for 27 percent.
On alternatives, half of respondents wanted to avoid medication even though TMS was unfamiliar to them, and 13 percent knew TMS and placed great weight on avoiding medication. Roughly 64 percent care about drug-free approaches, while only about 25 percent recognize the most established one.
Five practical implications
- Expect the topic in symptom language, and treat "nothing has worked" as a prompt to review the adequacy of prior trials.
- Document dose and duration for each prior antidepressant; prior authorization turns on it, and rebuilding it later costs staff time.
- Keep a short, current list of certified esketamine sites within a reasonable drive, noting which plans each accepts, Medicaid included.
- Name the treatment under discussion. Supervised esketamine at a certified site and at-home ketamine from a direct-to-consumer prescriber are not interchangeable, and patients conflate them constantly.
- When you decline to recommend something, the alternative for many patients is not another clinician. It is searching alone, where the least regulated options are easiest to find.
Nothing here is clinical guidance or a recommendation about any therapy; treatment selection belongs to the treating clinician and the patient.
A closing note for any patient reading over a clinician's shoulder: if suicidal thoughts have entered the picture, reach out today rather than waiting for an appointment. A trained counselor answers 988 by phone or text at every hour, free of charge.
Methodology
As this site's publisher, we commissioned and funded the study; we have a commercial interest in the category and publish the results in full regardless. Pollfish administered it on its consumer panel; after the June 23, 2026 close, the sample stood at 443 consenting members of the public, 18 to 64, living in ten Midwest states. Items that allowed multiple responses sum past 100, since each share is out of all respondents. Values follow the panel's data validation.