In this case report, we present a patient with treatment-resistant depression (TRD) and comorbid generalized anxiety disorder, eating disorder, post-traumatic stress disorder, and borderline personality disorder. Over a 10-year period, our case transitioned from adolescence to adulthood and received antidepressant monotherapy, adjunctive therapy with antipsychotics, lithium, or lamotrigine, several series of electroconvulsive therapy (ECT), ketamine infusion (KET-IFU), compounded ketamine intranasal spray (COM-KET), and intranasal esketamine (ESK). She had seventeen documented hospitalizations, five self-reported hospitalizations, three intensive outpatient program treatments, two partial hospitalization program treatments, and three residential treatments. She attempted suicide seven times. She received five acute ECT series, one series of KET-IFU, one series of acute ESK with weekly ECT, a series of COM-KET treatment for more than two years, and a series of ESK for more than two years. The patient had some short-term benefit from ECT and KET-IFU. However, she had two-years stability with COM-KET or ESK at two different times. She has been relatively stable without hospitalization or suicide attempt with ESK for more than two years, suggesting that patients with TRD with complex representations may benefit from ketamine treatment at different times of life development.