A plateau can feel like the moment everything stalls. You show up, you do the work, you notice real improvement, and then things stop moving. That frustration makes sense, especially during ketamine therapy for depression. But a plateau shows up often enough that most clinicians do not read it as failure.
Here is the more useful frame: A plateau acts like a clinical signal, not a stop sign. It tells the care team to slow down, look at the data, and adjust the plan in a deliberate way.
This article walks through how clinicians spot a plateau, why it can happen, and what thoughtful modifications can look like when progress needs a restart.
AI Overview Summary
Ketamine treatment for depression often produces strong early improvement, followed by a period where progress slows or stabilizes. Clinicians call this a plateau, and it is not considered treatment failure. Instead, it signals the need for structured reassessment using symptom scales like PHQ-9 or MADRS and a review of dosing, frequency, and functional outcomes. Evidence from FDA esketamine prescribing guidance and large clinical outcome studies shows that response patterns commonly flatten after early gains. Care teams typically respond with measured adjustments — including schedule changes, integration-focused therapy, and whole-health review — to safely restore forward movement.
How Clinicians Define and Identify a Plateau
Clinicians usually start with one simple move: They track progress the same way, every time, over time. They also compare scores to real-life function, because numbers can miss what daily living reveals.
Standardized scales help the team avoid guesswork. Many clinics use PHQ-9 trends because a change of about 5 points often signals a meaningful clinical shift, and a PHQ-9 score under 5 often functions as a remission marker in U.S. measurement frameworks. Others use MADRS, which shows up throughout esketamine trials and gives clearer trial-based definitions for response patterns.
A response plateau looks like this: After initial improvement, symptoms and functional gains stabilize for a short stretch, such as two or three sessions, without continued upward movement. The key detail is consistency. Clinicians want the same scale, the same timing, and the same context before they call it a plateau.
They also separate plateau from fluctuation or regression. The 2025 U.S. FDA SPRAVATO prescribing information defines “stable remission” as MADRS ≤12 for at least 3 of the last 4 weeks, and “stable response” as a 50% or greater MADRS reduction over the last 2 weeks without meeting remission criteria. The same label defines relapse as MADRS ≥22 for 2 consecutive weeks or a serious clinical deterioration.
Those cutoffs give teams a structure for deciding whether someone sits in a stable flat phase or whether symptoms have started to slide.
Common Reasons for a Ketamine Treatment Plateau
A plateau rarely has one cause. Clinicians usually treat it like a puzzle with several pieces, because that mindset keeps the plan flexible instead of fatalistic.
Neurobiological Adaptation
Sometimes the brain responds fast early, then levels out. The 2025 U.S. FDA SPRAVATO prescribing information describes a pattern that fits this idea: The largest difference between groups appeared at about 24 hours, and that difference did not increase through Day 28, even while both groups kept improving. That does not mean progress stops. It just means the curve can flatten after the first wave.
This pattern matters because patients often expect steady week-to-week gains. Clinicians expect a steeper early slope and a slower middle phase, so they plan for adjustments when the early jump stops doing the heavy lifting.
Psychosocial Factors
A plateau can also show up when symptoms improve faster than life conditions. Stress at home, pressure at work, or resurfacing trauma can quietly cap further gains. When a patient says, “I feel lighter, but I still cannot get through the day,” clinicians treat that as a functional clue, not a contradiction.
In practice, the team asks targeted questions:
- Did sleep collapse again?
- Did conflict spike?
- Did avoidance return?
Treatment Parameters
Sometimes the plan simply stops matching the phase of recovery. Frequency plays a big role here, especially in maintenance decisions.
In the FDA SPRAVATO label’s maintenance-phase description, 69% of stable remitters received every-other-week dosing most of the time, while 23% stayed on weekly dosing. Among stable responders, 55% received weekly dosing most of the time, and 34% received every-other-week dosing.
That split suggests a practical point: People who improve but do not reach remission often need a tighter schedule for longer. A plateau might signal that the plan stepped down too early, or that the current cadence no longer fits.
Clinical Strategies to Overcome a Plateau
Clinicians usually start with the least disruptive change that still makes biological and practical sense. They also keep safety in view, because intensifying care can increase side effects or monitoring needs.
Optimizing Ketamine Parameters
When a plateau appears, clinicians may adjust dose or frequency, especially if the patient improved early and then leveled off. The goal is to find the smallest parameter change that restores momentum.
The SPRAVATO label includes a clear step back concept, too. If someone misses doses and symptoms worsen, the clinician can return to the prior schedule. That approach translates well to real-world planning because it gives a reversible option instead of a permanent escalation.
This is often where a ketamine treatment plan feels most “medical.” The team tries something measurable, watches the next few data points, then decides whether the adjustment helped.
Enhancing Integration
Medication effects do not automatically turn into new habits or new coping skills. A plateau can signal that the person needs stronger integration work between sessions, even if the dosing strategy remains steady.
Clinicians may increase psychotherapy touchpoints, tighten post-session reflection, or focus therapy on what newly surfaced as mood lifted. If the patient says, “I feel less depressed but more aware of old patterns,” that awareness can become the next treatment target.
Holistic Reevaluation
A plateau also triggers a wider review. Clinicians look at sleep quality, nutrition, co-existing medical issues, and the broader psychiatric medication plan. They also check whether side effects have crept in and started limiting the overall benefit.
Wilde et al. reported outcomes across 14,222 patients and about 1.4 million sessions, with dissociation reported in 0.7% of sessions and increased blood pressure in 0.9% of sessions. That kind of data reminds the team to adjust thoughtfully, not aggressively.
Patient and Clinician as a Decision-Making Team
A plateau works best when both sides treat it as shared information. The clinician brings training, protocols, and safety monitoring. The patient brings the lived detail that scales cannot fully capture.
Clinicians often schedule a dedicated review visit. They pull the symptom scores, revisit functional goals, and ask what changed quietly in the background. They also ask about side effects in plain language, because tolerability can shape which adjustments are realistic.
This is where the follow-up at a ketamine clinic matters. In the check-in, patients can describe subtle shifts, like motivation returning but sleep worsening, or mood stabilizing but anxiety spiking. Those details often guide the next move more than a single number does.
The Plateau Is a Pivot Point, Not an Endpoint
A plateau usually reflects the complexity of depression and the brain’s pace of change. When clinicians track response consistently, use clear definitions for response and relapse, and make careful adjustments, the plateau becomes a pivot point into more tailored care.
If your progress with ketamine therapy for depression has stabilized, we can help you sort out what that signal means. At Zeam, we review your progress carefully, look at your symptom trends and daily functioning, and adjust your plan with you. If ketamine progress has stalled, reach out to schedule a full plan check and map your next steps today.
Key Takeaways
- A ketamine treatment plateau is defined by stable symptom scores and functional gains across multiple sessions rather than continued upward improvement. Clinicians confirm this using consistent PHQ-9 or MADRS tracking.¹
- FDA esketamine prescribing guidance defines stable response, stable remission, and relapse using MADRS cutoffs, helping clinicians distinguish plateaus from regression.¹
- Esketamine trial data shows the largest treatment effect differences often appear early, with later improvement curves flattening — a pattern consistent with plateau phases.¹
- Maintenance dosing patterns differ between remitters and responders, with responders more often requiring continued weekly treatment frequency.¹
- Large real-world ketamine outcome datasets covering over one million supervised sessions show low rates of serious adverse events, supporting careful parameter adjustment when needed.²
- Plateaus are commonly addressed through dosing or frequency optimization, psychotherapy integration, and broader lifestyle and medication review rather than abrupt treatment discontinuation.
Citations
- FDA Prescribing Information — SPRAVATO (esketamine), 2025 label update.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/211243s016lbl.pdf - Wilde et al. Large-Scale Safety and Utilization Outcomes in Ketamine Treatment Sessions. American Journal of Psychiatry, 2024.
https://psychiatryonline.org/doi/10.1176/appi.ajp.20240655
