A habit of thought in primary care fits in one sentence: "If a patient wants something new, they will ask for it." It is a reasonable instinct, and according to a survey we paid for this summer, mostly wrong when the treatment is esketamine for depression.
We put the question to 443 adults in ten Midwest states: what would it take for them to try ketamine or esketamine therapy? Their answers undercut several beliefs that shape how primary care handles treatment-resistant depression. Here are five, each checked against the data. All numbers are final.
Myth 1: Patients who want it will bring it up
That assumes the patient knows the option exists, and most do not. In our sample, 73 percent met the name Spravato for the first time in our questionnaire; another 21 percent recognized the word without knowing what it was, and only 6 percent could describe it.
A patient cannot request what they cannot name. "Nothing has worked" does not mean they have ruled out newer options; often it means they have run out of the ideas they know. The gap between what exists and what they know is where your recommendation does its work.
Myth 2: Direct-to-consumer marketing has already done the persuading
With ads everywhere, it is easy to assume patients arrive pre-sold. For this treatment, in this sample, that picture does not hold. Asked which voice would most sway them, advertising drew 2 percent, podcast hosts 1 percent, and influencers with a service or first responder background 4 percent. The winner was not close: 74 percent picked their own doctor, and relatives or friends trailed far behind at 18 percent.
If ads were closing this decision, a clinic could skip the referral relationship. The data says the opposite: the physician is the decisive voice for roughly three people in four.
Awareness campaigns are not useless; they plant a name. The decision itself seems to wait for someone the patient already trusts to say the name back.
Myth 3: Patients go straight to psychiatry for this
Many primary care clinicians assume a treatment-resistant patient has already moved on to a psychiatrist. Asked where they would go first for this kind of treatment, respondents put primary care in front at 56 percent, psychiatrists and therapists at 23 percent, and web searches at 12, and 5 percent were at a total loss. In a room of twenty patients, that last group is one person who would simply stall. For most of the rest, your office is the front door, and where psychiatry is thin, as in much of the rural Midwest, it may be the only door for months.
Myth 4: This is a rare problem you will seldom see
Treatment-resistant depression is often framed as a specialty edge case. Asked about their lives, nearly three respondents in four (72 percent) had seen standard medication fail to relieve depression, anxiety, or PTSD, in themselves, someone close, or both; for 37 percent it was personal alone, and 13 percent reported both.
This was a general consumer panel, not a waiting room, so it is not a prevalence estimate; self-report is imprecise, and "did not help" is a patient's judgment, not a diagnosis. Still, the patient on your schedule this afternoon who says the medication "just isn't doing much" may be the typical case, not an outlier.
Myth 5: Patients mostly care about speed and novelty
Newer treatments are often sold on how fast they work, but respondents ranked differently. Among their top two provider factors, insurance landed on 85 percent of lists and proximity on 43 percent, while FDA approval trailed at 27 percent and quick results at 24. Asked separately, 59 percent called FDA approval deciding or a big factor, a bar insurance cleared for 65 percent.
For a referrer, that is practical. The patient does not need an exciting pitch. They need to hear that the treatment is approved, that it might be covered, and where the nearest certified site is.
What this means at the point of care
None of this argues for or against esketamine in any particular patient; suitability depends on history, diagnosis, contraindications, and the treating clinician's judgment. The survey only shows how people say they decide, and on that question the answer points at you.
- Know where the nearest certified Spravato center is. Esketamine is given under supervision in a certified setting with monitoring after each dose, and many Midwest counties lack one, so drive time belongs in the conversation.
- Name the option aloud when a patient reports an inadequate response to several antidepressants; given how few recognize it, that may be the first time they hear it.
- Separate esketamine from other ketamine offerings. Spravato's FDA approval covers treatment-resistant depression; clinic IV ketamine is an off-label use; at-home products are a looser category that patients who have seen headlines tend to blur together. A patient handout such as Brain Recovery Centers' Spravato overview can help keep them apart.
- Talk coverage early. With insurance at the top for so many respondents, prior authorization is part of the recommendation.
- Remember the payer mix: commercial insurance was named by 39 percent of respondents and Medicaid by 37, with Medicare at 23, so a referral list limited to commercial-only sites misses many patients.
A note on what we do not know
This article reports top-line answers only. It does not show how any subgroup, such as older patients or Medicaid members, answered, so do not read one into it. It also measures stated intention, which is related to, but not the same as, what moves people in an exam room. What it does show holds across several questions: awareness is low, described need is high, and the voice most people say they would follow belongs to their own physician.
If a patient, or anyone reading this, has thought about not being alive, the Lifeline picks up at 988, phone or text, around the clock. Sharing the number costs nothing and can matter enormously.
Methodology
We, the publisher, paid for this study and commissioned it. Pollfish fielded it through June 23, 2026, and 443 consenting adults completed it, each between the ages of 18 and 64 and living in one of ten Midwest states. Where a question allowed several answers, the tallies exceed 100. The numbers reflect the panel's final validation.