Content note: This article contains discussion of suicide and depression.
Edgardo Rosa, a veteran in Central Florida, first enlisted in the U.S Army at 25 years-old. Originally from Puerto Rico, the retired Army Sergeant Major served for 20 years before retiring in Florida with his family.While on active duty, Rosa was deployed on three combat tours to Iraq and two to Afghanistan, leaving him with lasting memories of things he’d seen, things he’d done. The anniversaries of these dates stick with him.
For years, he dismissed signs of depression and post-traumatic stress disorder — common conditions in the veteran and military populations — even as his symptoms grew worse. “You kind of ignore it, and push it aside, and get ready for the next deployment,” Rosa tells Orlando Weekly.
It wasn’t until a close friend of Rosa’s, an active duty soldier he looked up to, died by suicide in 2016 that he began to reevaluate the distress he was experiencing himself. According to the U.S. Department of Veterans Affairs (VA), suicide is the second-leading cause of death among veterans under 45 years old.
Rosa, then in his early 40s, had no idea his friend was in that kind of pain, or that he was having thoughts of ending his life. His friend's death was a wake-up call. In a way, it saved his own life.
“It kind of woke me up to the fact that, you know, I was on that road if I didn't do something about it,” says Rosa, recounting the story in a way that lets you know he’s told it before, but that it took some time for him to finally tell it. “That’s when I really got serious about therapy and finding help.”
So began Rosa’s journey in seeking help for his mental health. But, as he describes it, that journey has been a “long, tedious” process. He sought out therapy, tried various prescription medications, and got a service dog who helped him get out of the house. Temporarily, with these treatments, he would feel better.
Then things would get bad again. He’d have flashbacks, become jumpy, grow anxious in large crowds. His depressive symptoms made it difficult for him to do anything about it. He’d distance himself from family, make up excuses for why he hid himself away indoors. He felt little motivation to do much of anything that wasn’t absolutely necessary to get by.
Rosa isn't alone. According to Johns Hopkins Medicine, up to 33 percent of people with depression don't respond to conventional antidepressants, which generally target brain chemicals such as serotonin, dopamine and norepinephrine. Research is mixed on how much of a role these chemicals, particularly serotonin, actually play in depression, which can be influenced by a number of socioeconomic, genetic and environmental factors.
In 2019, Rosa retired from the Army and moved to DeLand, Florida — about 40 miles north of Orlando — with his family. Both he and his wife are from Puerto Rico, and it’s an easier trip back there from Florida to visit their families, compared to their other option of San Antonio, Texas.
But the transition to civilian life for Rosa — as it is for many veterans — was difficult. “I retired and everything kind of got worse,” he shares. He found himself with too much time on his hands. Got too much in his own head.
His depression grew worse. His PTSD — a condition that affects roughly 29% of veterans from his service era — got worse. And, for the first time, he began having thoughts of suicide.
During this particularly dark time in his life, his family became his North Star. Rosa didn’t talk to them about what he was struggling with. He was worried he would become a burden to them.
But he also knew he had to stay alive for them. If not for himself, then for his wife and kids. “The pain will end for me, but only start for them,” he thought. The cycle of therapy, medication and relapse continued.
Making a difference
Last year, things changed. In March 2023, the Orlando VA — serving over 100,000 veterans in Central and East Florida — launched one of the state's first and only esketamine treatment programs for treatment-resistant depression through the VA healthcare system.
Treatment-resistant depression is essentially a form of depression that hasn’t been helped by other conventional, evidence-based treatments, such as behavioral therapy or other antidepressants.
Esketamine is a derivative of ketamine, an anesthetic and dissociative hallucinogenic drug that is safely administered in clinical settings to relieve pain or cause sedation. Esketamine is a more potent version of ketamine, and earned approval from the U.S. Food and Drug Administration (FDA) in 2019 as a treatment for people with treatment-resistant depression.
The U.S. Department of Veterans Affairs approved Spravato, a nasal spray form of esketamine, for veterans’ use almost right away. Although this treatment can cost thousands of dollars for the general public, for veterans enrolled in the VA healthcare system, it’s completely cost-free.
Even so, the rollout of this treatment across the VA has been slow. Initially, some expressed concern that the U.S. Food and Drug Administration had hastened its approval process of the drug in a politically calculated move for former President Donald Trump. The number of veteran suicides had reached a devastating record high of 6,796 in 2018.
But Dr. Roopa Chavda, a clinical psychiatrist at the Orlando VA Medical Center in Lake Nona, tells Orlando Weekly she’s been encouraged so far by the results they’ve seen here with veterans through the local program. The only other VA health system in Florida so far that offers the treatment is located in Gainesville.
When Dr. Chavda's patients first walk in, she says, you can see they’re carrying a weight on their shoulders. But with the initiation of treatment, spread out in two-hour sessions under clinical supervision, some veterans see results within just a few weeks.
“You'll see them actually smile and hear them laugh for the first time,” Dr. Chavda tells Orlando Weekly, herself unable to hold back a smile.
Rosa swears he felt a difference within himself in just the first week. He felt lighter. And it wasn’t just himself who noticed. His family did, too. “My wife mentioned it. … She was like, ‘You look better. I think this is working.’”
According to Chavda, that isn’t just a placebo effect. Not everyone feels a difference that quickly, but some do. On the flip side, the treatment itself isn’t guaranteed to be effective for everyone. The Orlando VA’s esketamine treatment team — made up of two psychiatrists and two nurses — generally recommends patients give it a go for at least eight sessions.
The difference in those whom the treatment does help can be immensely gratifying. One veteran in the program, says Chavda, recently announced he’d started taking singing lessons. “This is, again, another person who would not step out of the house, is [now] going to church, is taking singing lessons.”
“It’s very, very satisfying,” she says. As a provider, “I think, OK, we really made a difference.”
Rosa, for his part, wasn’t terribly hesitant when his physician first presented the treatment opportunity to him nearly a year ago. He was willing to try anything to get more lasting relief. He was scared of what might happen if he didn’t.
Plus, he’d already received infusions of ketamine for back pain years before while he was still on active duty. So he had some familiarity with the drug and its common side effects: a temporary sense of spaciness, losing track of time, some heightened sensitivity to noise.
Esketamine can cause some other temporary side effects, such as nausea and dizziness, which generally peak 40 minutes after use. The drug has a low potential for misuse, but this is not unlike most other prescription medication (e.g. benzodiazepines) if that medication is taken in ways other than as prescribed. The drug ketamine, from which it's derived, has a history of being misused recreationally as a "party drug," but it's primarily used as an anesthetic in clinical settings, like hospitals. Unlike the nasal spray form of esketamine, ketamine is not FDA-approved for any psychiatric condition.
The esketamine treatment program through the VA is carefully dosed and structured in a way to prevent misuse and to prevent side effects from lingering for too long, according to Dr. Chavda.
The treatment is provided entirely onsite at the VA facility — it’s not available for take-home use — under the close supervision of a physician and nurse, who can oversee patients’ vitals signs and ensure there are no complications that arise.
Patients begin with treatment sessions twice per week to start, with each session lasting about two hours. This allows time for the drug’s effects, usually including some drowsiness, to wear off. Most patients sleep or doze off during this time, says Chavda.
This was true for Rosa, too. “Once I woke up, I was fine,” he says.
Chavda says esketamine is only FDA-approved for the treatment of major depressive disorder and suicidal ideation — not for post-traumatic stress disorder. Additionally, there are some eligibility requirements that a healthcare provider will consider before referring patients for this treatment.
Ideal candidates, according to the VA, are veterans 65 years old and younger who have tried at least four antidepressant medications without seeing lasting relief, and who have taken at least two supplemental medications — such as a second antidepressant or antipsychotic medication — on top of the first to boost its effects, with no luck.
Essentially: You’ve reached the point where you’ve exhausted your options. Medication isn’t the only treatment for depression (a living wage can help, too, actually), but it’s one of the most widely used.
There are some other characteristics that could make patients ineligible: a history of severe heart problems, a history of seizures, other unstable medical conditions or an active substance use disorder.
Substance use disorder, also known as substance abuse or addiction, is more prevalent in veterans, who may begin to misuse drugs or alcohol as a means to cope with mental health or trauma.
Chavda says they won’t turn away veterans with a history of substance use disorder (or someone who’s taking medication like Suboxone or methadone for opioid addiction). “We don’t want to exclude them,” she emphasizes. But patients interested in the esketamine program do need to be medically stable, generally substance-free, and able to engage in their treatment in order to participate.
Stay in the fight
After beginning his treatment last year, Rosa is currently considered in remission. He attended 12 treatment sessions all in all: two doses per week for four weeks, one dose a week for four more weeks, and then a few more after that, spread out.
It’s not a cure, he stresses, and Chavda seconds this. Continuing to see a therapist, psychiatrist, whatever is recommended by the treatment team based on the patient's needs, is an important part of recovery. Rosa himself still attends therapy and takes medication for his depression.
The VA also offers a Veterans Crisis Line for veterans experiencing significant stress, depression or thoughts of suicide. It’s a free service, confidential, and you don’t need to be enrolled in the VA system or healthcare to call and get help.
There are still days when Rosa wakes up and feels sad. But it’s not as overwhelming, as overpowering as before. “I’m not in my room stuck for, you know, two, three weeks at a time with no contact,” he explains.
Life is more manageable. He can attend his trade school program. Go out with his family. Those are things he couldn’t always do before, he says, when the depression was really bad.
As someone who has struggled with major depression and PTSD for over 12 years, Rosa describes the esketamine treatment as “life-altering.” But he’s also mindful of how the logistical barriers of treatment could hinder access.
Rosa lives an hour away from the Lake Nona VA facility, and initially had to be at the VA twice a week, to start. Then he’d stay two hours each time for monitoring. He usually asked someone else to drive him, too, just in case some of the effects of the medication lingered.
But for him, “it was worth it.” Today, he volunteers with veteran-focused nonprofits and is four months into a technical college program studying auto mechanics.
Before he received the esketamine, his depression made it difficult for him to even conceive of long-term goals. That’s how it works, he says. “Your goal is to make it that day.”
That’s not the case anymore. The current plan is to complete his trade education. Eventually, he wants to open a nonprofit where he can provide cost-free auto services to underprivileged families. He’s looking into his options for setting that up.
Rosa understands that some other vets may have reservations about the esketamine treatment, and he didn’t originally plan on becoming any sort of spokesperson for it either. But he knows how important it can be to hear the benefits from someone who has lived through it.
“If you hear a doctor saying it, it’s one thing,” he says. “But to hear a fellow veteran that's going through the same thing you're going through, that understands what you're going through, saying, ‘I know what you're going through. I've been there. I'm there right now, and this works.’ It's different. It has a little bit more value to it.”
To other veterans out there, Rosa offers this message: “Don’t give up.”
“That's something that, in the military, it’s ingrained in us, you know? Stay in the fight,” he says. “I think we’ve got to take that mentality and bring it into, you know, the fight against depression and PTSD.”
Central Florida veterans who are interested in the esketamine treatment program through the Orlando VA can ask for a referral from their mental health provider. For additional information, call 407-631-4762.
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