Questions Missouri clinicians can ask when a patient is stuck

Patients rarely say "my treatment has failed." They say "I'm hanging in there," or "about the same," or nothing at all. The clinician's questions decide whether nonresponse surfaces in the visit or stays hidden for another three months.

This is a question script for Missouri clinicians caring for adults with depression, and for those with PTSD, where the same pattern of partial or absent response is common. It is organized by what you are trying to learn, with suggested wording and the reason behind it.

Why ask more deliberately

Our commissioned survey reached 443 adults in the Midwest, Missourians included, and 72 percent of them had seen standard medication fall short against depression, anxiety, or PTSD, in themselves or in someone close. For 37 percent it was personal, for 13 percent it was both personal and someone close, and 22 percent had seen it only in someone they care about. Only 28 percent said it had not touched them.

These answers are self-reported and top-line, and they are final. They are not a diagnosis count. But they point to a large pool of people who believe their treatment did not work, many of whom have not said so to a clinician in so many words.

Patients look to you to open the door. Their own doctor's recommendation was the strongest persuader for 74 percent of respondents, while 56 percent would bring the question to primary care before anyone else.

Measuring response

"On a scale of zero to ten, where ten is how you felt before this all started, where are you today?"

A simple anchor gives patients permission to say "four" instead of "fine." Pair it with a validated measure such as the PHQ-9 for depression or the PCL-5 for PTSD, repeated at each follow-up.

"What would be different in your week if this medication were really working?"

This surfaces the gap between partial and full response in the patient's own terms.

Checking the trial itself

"Some people skip doses or stop because of how a medication makes them feel. That is really common. Has that happened with this one?"

Normalizing nonadherence gets more honest answers than "Are you taking it every day?"

"What side effects have you noticed, even ones that seem minor?"

Sexual side effects, weight change, and emotional blunting are often underreported unless asked directly.

Looking for what else is going on

"Have there been times when you felt the opposite of depressed, like you needed much less sleep and had a lot of energy for days?"

Screening for bipolar features before escalating antidepressant treatment is essential.

"Have you been through something frightening or violent that still comes back to you, in memories, dreams, or feeling on edge?"

Trauma is frequently the undiagnosed driver when depression does not respond. For PTSD, first-line care usually centers on trauma-focused psychotherapies, and certain antidepressants carry FDA approval specifically for PTSD.

"Have you served in the armed forces, or worked as a firefighter, police officer, or paramedic?"

Service history can change both the clinical picture and the coverage pathway, including TRICARE options.

"How has sleep been? How much are you drinking in a typical week?"

Sleep disorders and alcohol use are common contributors to apparent treatment resistance.

Asking about safety, every time

"When people feel stuck like this, sometimes they have thoughts of not wanting to be alive or of ending their life. Have you had thoughts like that?"

Ask directly. Asking does not plant the idea, and patients with stalled treatment deserve particular attention here.

Naming the situation

"We have now tried two medications at good doses for long enough, and you are still not where you should be. That has a name, treatment-resistant depression. Plenty of people have it, you did not cause it, and it tells us to look at other options."

Naming it reframes failure as information and sets up the next step.

Introducing options

Patients mostly have not heard of later-line treatments. To 73 percent of our respondents the name Spravato was unfamiliar, and just 6 percent could explain it. About a quarter knew what TMS was. Few will ask.

"Besides changing or adding medications, there are options such as TMS, or esketamine, a nasal spray taken under supervision. They are not right for everyone. Would you like me to walk you through them, or refer you to someone who specializes in this?"

Accuracy matters here. Esketamine's FDA approval is limited to adults with treatment-resistant depression, and it is given only in certified centers that monitor patients after each dose. It is not approved for PTSD, and patients should not be led to think it is. A patient-level Spravato summary can help them see what it is and is not. TMS is cleared for major depression. For a patient whose primary problem is PTSD, the conversation should start with trauma-focused therapy and evidence-based medication.

If the patient raises at-home ketamine:

"That is different from the supervised esketamine treatment. Ketamine is not FDA-approved for depression, and at-home use has much less monitoring. I want to make sure you have the full picture before you decide anything."

Addressing cost and access

"What insurance do you have now? Has cost kept you from treatment before?"

Coverage topped patient priorities: 85 percent ranked it among the top two things in choosing a provider. In the payer mix respondents reported, commercial coverage, at 39 percent, edged out Medicaid, at 37 percent. For Missouri patients on MO HealthNet, prior authorization criteria will shape which options are realistic.

"How far could you realistically travel for treatment, and do you have someone who could drive you?"

For 43 percent, distance ranked as a top-two concern. In rural Missouri it can be decisive.

Closing the loop

"Here is our plan, and here is when we will check whether it is working. If you feel worse before then, call us."

End with a safety net. Give every patient the Suicide and Crisis Lifeline, open at any hour, in the simplest words you have: 988, whether they call or text; veterans press 1 after dialing.

Methodology

Patient-perspective figures reflect our Pollfish survey, answered by 443 people aged 18 to 64 from Minnesota, Illinois, Nebraska, Wisconsin, Oklahoma, Missouri, Ohio, Iowa, Kansas, and Indiana before it closed June 23, 2026. We report top-line results only, without subgroup analysis. All numbers are final. Commissioning and paying for the survey fell to the publisher. These scripts are communication aids and do not replace clinical guidelines or judgment.