When a patient asks if there is anything else: a clinician script

"Is there anything else?" It usually comes near the end of a visit, sometimes with the patient already standing. It rarely names a drug. But when depression has shrugged off the usual medications, it may be the most important question a patient asks all year.

Here is a script to help primary care clinicians answer it well in a few minutes, grounded in the ten-state Midwest poll we ran with 443 adults. Pollfish has finished validating its figures.

Why the question sounds like this

Patients bring this to primary care first. In our poll, 56 percent would raise something like ketamine or esketamine with a primary doctor first, and 23 percent with a psychiatrist. They also defer to you: a doctor's recommendation would move 74 percent.

And they do not have the vocabulary. Our respondents mostly drew a blank on Spravato (73 percent), and 6 percent could describe it. Their would-be searches read like "depressed" or "therapist near me." So the question arrives as "anything else," and the naming falls to you.

Step one: slow it down

If the question comes at the door, acknowledge it rather than rushing it.

"That's an important question, and I want to give it a real answer. Can you sit back down for a couple of minutes? If we need more time, we'll book it."

Step two: confirm what they mean

"Anything else" can mean a different pill, therapy, a non-drug option, or something they read about.

"When you say anything else, do you mean a different medication, or something other than medication altogether? Have you read or heard about anything in particular?"

This is where a patient might mention ketamine, often without distinguishing between approved esketamine, IV infusions, and at-home products. You will want to know which one they have in mind.

Step three: name the category

If the history supports it:

"You've tried several antidepressants at decent doses for long enough, and none has worked well. We call that treatment-resistant depression. It doesn't mean you're out of options. It means we should look at a different set of them."

Naming it tends to relieve patients. It reframes repeated failure as a recognized clinical situation rather than a personal one.

Step four: lay out the options briefly

Keep it short and honest.

"Here's the landscape. We can adjust or add to your medication. We can add a specific kind of therapy. There's TMS, which uses magnetic pulses and involves no medication. And there's esketamine, a nasal spray approved for exactly this situation, which is given at a certified clinic where you're monitored after each dose. Some of these I can start; others need a psychiatrist."

If avoiding more medication matters to them, flag TMS specifically. That concern is common. Among our respondents, 64 percent cared about avoiding drugs, yet only 25 percent knew the term TMS.

Step five: address ketamine directly if it came up

Patients may have mixed impressions. About a third of our respondents (34 percent) approached ketamine therapy warily but with an open mind; 21 percent doubted it and 9 percent opposed it. A clear distinction helps all three groups.

"There's a lot of different stuff called ketamine out there. The approved version, esketamine, is given in a clinic under supervision, and insurance often covers it after some paperwork. IV ketamine clinics use the drug off-label. And the at-home products from online companies have much less oversight. I'd only point you toward the options I'd be comfortable with."

Regulatory status matters to people: 59 percent of respondents rated FDA approval a deciding or big factor.

Step six: be honest about fit

"Whether esketamine makes sense for you depends on things like your blood pressure and other health history, and a psychiatrist would make that call. I don't want to promise it's right for you. I do think it's worth being evaluated."

Or, if it clearly does not fit:

"Given your blood pressure history, I don't think esketamine is the right next step. Let's talk about the other options."

Step seven: set the next step and the paperwork

"I'm going to refer you to psychiatry today. I'll also make sure your chart clearly shows each medication you've tried, the dose, and how long, because insurance will want that. Please call us if you haven't heard about an appointment within a couple of weeks."

That last sentence matters. Coverage looms large for patients; 65 percent of respondents gave insurance big or deciding weight, and half would tolerate extra steps to use it. Documentation you complete now shortens those hoops later.

Step eight: close with safety

"While you're waiting, if things get worse, or you have thoughts of hurting yourself, call or text 988 any time, or call us. Don't wait for the appointment."

If you only have ninety seconds

• Name it: "This sounds like treatment-resistant depression."
• Reassure: "There are real options beyond another pill."
• Act: "I'm referring you to psychiatry today and documenting your history for insurance."
• Protect: "Call or text 988 if things get worse."

Scope

This script supports communication; it is not prescribing guidance. Esketamine's label covers adults with treatment-resistant depression, among its indications, and certified sites dispense it under a REMS. Brain Recovery Centers offers a patient-friendly explainer on how Spravato treatment works that can accompany the referral. Suitability for any patient is a clinical decision.

A patient in crisis has 988 for a call or a text; the Suicide and Crisis Lifeline staffs every hour. Printing the number on the after-visit summary puts it where they will find it.

Methodology

Pollfish fielded survey 395586438 on its consumer panel and closed it June 23, 2026. There were 443 completes, every respondent 18 to 64, across Illinois, Kansas, Minnesota, Nebraska, Oklahoma, Wisconsin, Missouri, Indiana, Iowa and Ohio. We report final whole-sample totals. The publisher commissioned and underwrote the study.