Chronic Pain · Pain and Mood Overlap · Reviewed by Samuel Caruthers, MD
You did the hard thing. You went through an assessment for treatment-resistant depression, you were approved, and you committed to a schedule that asked a great deal of you: repeated visits, two hours of monitoring each time, someone to drive you home, weeks of rearranging your life around appointments. And at the end of it you are not where you hoped to be.
That is a demoralizing place to be, and it often comes with a quiet conclusion that is worth challenging: that if the strongest available option did not work, nothing will.
This article raises one specific possibility that frequently goes unexamined in that situation. If you also live with chronic pain, the pain may be a substantial part of why the depression treatment underperformed.
If you are in crisis right now
If you are having thoughts of harming yourself, please reach out immediately. In the United States you can call or text 988 to reach the Suicide and Crisis Lifeline, available 24 hours a day. If you are in immediate danger, call 911 or go to your nearest emergency department. Please tell someone rather than waiting.
First, what we are not saying
We want to be clear about this before going further, because this is a subject where a great deal of marketing is not.
Esketamine is FDA approved for treatment-resistant depression, delivered under a restricted safety programme in certified settings, and it is covered by most insurance. Those are real advantages and it helps a great many people. If it has helped you even partially, staying with it while working on something else may well be the right plan.
We are a pain management practice. We do not offer infusion therapy as a treatment for depression, we are not suggesting you leave the care you are receiving, and we are not telling you that something we do works better than something an approved treatment does. Those comparisons are not ours to make and the evidence would not support them.
What we can speak to is pain. And in a person who has both, untreated pain is one of the most common reasons depression treatment does not deliver.
Why the pain matters to the depression
Chronic pain and depression are not neighbouring conditions that happen to co-occur. They share neurotransmitter systems, overlapping brain regions, and stress and inflammatory pathways. We covered that overlap in more detail here.
The practical consequence is that treating one while the other runs unchecked tends to produce a ceiling. Pain fragments sleep, and poor sleep worsens mood and lowers pain thresholds at the same time. Pain limits activity, and reduced activity removes the exercise, social contact, and sense of role that support recovery from depression. Pain is itself a continuous stressor that keeps pulling in the opposite direction to whatever the treatment is doing.
So a partial response to a depression treatment in someone with significant untreated pain is not necessarily evidence that the treatment failed. It may be evidence that the treatment was working against a headwind nobody addressed.
The question worth asking
During your assessment for depression treatment, how much time was spent on your pain? For most patients the honest answer is very little, because that assessment is designed to evaluate depression. It is not a criticism of anyone. It is a gap that exists because of how care is organised, and it can be closed.
The visit burden, and why it is a clinical issue rather than an inconvenience
There is a second reason courses of treatment do not go as planned, and it has nothing to do with whether the medication works.
Esketamine requires administration in a certified setting with a monitoring period after each dose, and the schedule is frequent in the early phase. For someone managing a job, caring responsibilities, transport limitations, or a chronic pain condition that makes sitting for long periods difficult, that is a demanding commitment.
Patients who cannot attend consistently do not get a fair trial of the treatment, and the outcome then gets recorded as non-response when the more accurate description is incomplete treatment. If that describes what happened to you, it is worth saying out loud to your prescriber, because the conclusion drawn from it may have been wrong.
What we would actually look at
If you come to us, the subject is your pain. A consultation would cover what the pain is, whether it has been properly diagnosed, whether it has features suggesting nerve involvement or central amplification, and what has been tried.
Depending on what that finds, options might include interventional procedures aimed at a specific pain source, neuropathic pain medications, or, in selected cases with a centralized pain picture, ketamine infusion therapy directed at the pain. Some patients receiving infusions for pain report that their mood improves as well, which is unsurprising given the shared biology, and we would describe that as an observation rather than a promise.
Throughout, we would expect your psychiatric care to continue. With your permission we would rather communicate with whoever manages it than work in parallel without contact.
Please do not stop anything
Nothing here is a reason to discontinue esketamine, an antidepressant, or therapy. Stopping psychiatric treatment without supervision can be harmful, and a partial response is not the same as no response. Any change belongs in a conversation with the clinician managing it.
Why the pain often goes unassessed
It is worth understanding how this gap opens, because it is nobody’s error and it is very common.
A patient presents to a psychiatric clinician with depression. Pain comes up, and it is recorded as a contributing stressor, which is accurate. But assessing and treating chronic pain is not within that clinician’s scope, so it stays in the notes as context rather than becoming something anyone acts on.
Meanwhile, if the patient has seen anyone about the pain, that clinician has been focused on the pain and has noted the depression as a complicating factor, similarly without acting on it. Both have done their job correctly. Neither is treating the interaction, and the patient is the only person with the full picture, usually without the clinical vocabulary to press the point.
Being the only person who sees the whole problem is an exhausting position, and it is where a lot of patients with both conditions end up.
Two paths that are both reasonable
| If your situation is | A sensible next step |
|---|---|
| Partial response, significant untreated pain | Have the pain properly assessed while continuing your current depression care |
| Could not attend consistently | Raise this with your prescriber, since the trial may not have been complete |
| Good response to esketamine, pain still limiting | Stay with what is working and address the pain separately |
| No chronic pain involved | This is a psychiatric question, and your mental health clinician is the right person for it |
That last row matters. If pain is not part of your picture, we are not the right practice, and we would rather say so plainly than take a consultation fee to reach the same conclusion in person.
What to raise with the clinician managing your depression
If this article has struck a chord, the most useful next step may be a conversation with the prescriber you already have, rather than with us.
Worth putting on the table: how much your pain interferes with sleep and activity, whether the pain has ever been formally diagnosed and treated in its own right, whether you were able to attend appointments as scheduled, and whether a partial response might reflect something else pulling in the opposite direction rather than a failed treatment.
Those questions tend to open up a plan rather than close one down. And a psychiatric clinician who knows the pain is being addressed elsewhere can make better decisions about what to do next on their side.
What partial response actually means
Patients often describe a treatment as not having worked when what they mean is that it helped somewhat and not enough. Those are meaningfully different, and conflating them can lead to abandoning something that was contributing.
In depression that is entangled with chronic pain, a partial response is close to what you would predict if only one of two linked conditions is being treated. Each condition sustains the other, so treating one produces improvement up to a ceiling set by the other.
The practical implication is that the sequence matters less than the coverage. Treating both, in whatever order is feasible, tends to outperform treating either one harder.
On going back
Some patients who pause a treatment return to it later with a different schedule or in different circumstances and do considerably better. That is a good outcome, not a failure, and nothing about seeking help for your pain closes that door.
Our Parsippany office serves Morris County, and our Clifton office serves patients from Passaic County and the surrounding area. No referral is required.
A note on how this tends to feel
Patients who reach this point often describe a particular kind of exhaustion. Not just low mood, but fatigue with the process itself: the assessments, the waiting, the hope invested in each new thing, the explaining. By the time a treatment as demanding as this one has underdelivered, many people are reluctant to start another process with anyone.
That is understandable, and it is worth naming rather than pretending otherwise. What we would say is that a consultation about your pain is a smaller commitment than what you have already done, and that its purpose is to answer one question: is there something here that has not been properly treated. A clear no to that is still worth having.
Frequently asked questions
Do you offer ketamine infusions for depression?
No. We are a pain management practice. Infusions here are directed at chronic pain. If you are looking for depression treatment specifically, a psychiatric provider is the right place.
Is IV ketamine better than esketamine?
That is not a claim we make. They are different medications, given differently, with different regulatory status and different evidence bases. Esketamine is FDA approved for treatment-resistant depression and infusion therapy for depression is not.
Should I stop my current treatment before seeing you?
No. Continue your psychiatric care. We would want to coordinate with it rather than replace it, and stopping without supervision can be harmful.
My pain has never been formally diagnosed. Is that a problem?
It is a reason to come in rather than a reason not to. A clear diagnosis is the starting point for any sensible treatment plan, and the absence of one is often the first thing worth fixing.
Can I be treated here while continuing esketamine?
Potentially, and it would need careful review of both treatments together. That review is part of the evaluation and it is a conversation we would want to have with your other clinician.
What does this cost?
This is an out-of-network practice that does not participate with Medicare or Medicaid. You will receive specific costs at your consultation before committing to anything.
If you have pain and nobody has looked at it properly, that is worth fixing.
A consultation about your pain, alongside the care you already have. We will tell you honestly if we do not think we can help.
Medical disclaimer. This article is for general educational purposes and is not medical advice, nor does it create a physician-patient relationship. North Jersey Interventional Pain Center is a pain management practice and does not provide psychiatric treatment or offer ketamine infusion therapy for depression. Nothing here is a comparison of the effectiveness of any depression treatment, nor a recommendation to discontinue any treatment. Ketamine infusion therapy for chronic pain is an off-label use and is not FDA approved for that indication. Individual results vary and no outcome is guaranteed. Do not start, stop, or change any medication, including psychiatric medication, based on this article. If you are having thoughts of harming yourself, call or text 988 to reach the Suicide and Crisis Lifeline, or call 911 if you are in immediate danger.