Depression treatment for Hollywood — the full escalation pathway, 50 minutes away.

Hollywood is 50 minutes up I-95 from RECO Integrated Psychiatry's Delray Beach office — close enough to sustain weekly medication visits, a full 36-session TMS course, or a Spravato induction series without residential accommodation. Every treatment plan starts with a documented DSM-5-TR diagnosis, a baseline PHQ-9, and a defined algorithm for medication trials, augmentation, and interventional escalation. Escalation to TMS or Spravato is named at trial two, not trial five, so a treatable depression doesn't drift into chronicity.

Hollywood sits 35 miles south of RECO Integrated Psychiatry’s Delray Beach office — a straight run up I-95 that clears in roughly 50 minutes outside of rush hour. For Hollywood adults who need specialist-level psychiatric care for major depressive disorder but not the disruption of a residential program, the distance is short enough to sustain weekly medication visits, a full 36-session TMS course, or a Spravato induction series without relocating. The clinical work — depression treatment from first-line pharmacotherapy through interventional escalation — happens in an outpatient rhythm that fits around work and family.

The diagnostic questions primary care doesn’t ask

Before a patient is treated for “depression,” a psychiatrist rules out bipolar spectrum illness. The MDQ and HCL-32 are the standard screens, but the clinical history matters more: past episodes of decreased need for sleep with increased goal-directed activity, family history of bipolar disorder, prior antidepressant-induced hypomania, or a very early age of onset all push toward bipolar II or the soft bipolar spectrum. Antidepressant monotherapy in unrecognized bipolar disorder is not a benign misstep — it induces mixed states, rapid cycling, and a worse long-term course.

The differential extends beyond mood disorders. Untreated OCD presents with the anergia, guilt, and social withdrawal of MDD but requires SSRI dosing two to three times standard depression doses plus ERP-based CBT. PTSD masquerades as treatment-resistant depression when the nightmares and hyperarousal aren’t asked about. Subclinical hypothyroidism, obstructive sleep apnea, iron deficiency, and chronic alcohol use each drive depressive phenomenology and each require the underlying condition treated instead of a fourth antidepressant trial. RECO’s initial evaluation catches these misdiagnoses at intake — TSH, CBC, CMP, structured trauma screening, YBOCS if OCD is in question — not on trial four.

First-line pharmacotherapy done well

For a first depressive episode without bipolar features, first-line pharmacotherapy is an SSRI or SNRI at an adequate dose for an adequate duration. Sertraline started at 50 mg and titrated to 100-200 mg. Escitalopram at 10 mg, titrated to 20 mg. Venlafaxine XR pushed past 150 mg — below that dose it functions as an SSRI and the norepinephrine benefit is lost. Duloxetine at 60 mg when comorbid neuropathic pain or fibromyalgia is in the picture. A full 6-8 week trial at therapeutic dose is required before response is judged; PHQ-9 is remeasured at every visit.

Bupropion is first-line for patients where sexual dysfunction, sedation, or weight gain would end an SSRI trial in the first two weeks. Mirtazapine at 15-30 mg for insomnia-predominant depression, where the sedation and appetite stimulation are features rather than side effects. What separates a real first-line trial from what most patients arrive with: documented dose, documented duration, PHQ-9 tracked at each visit. Insurance requires those two data points to authorize any later interventional escalation, and scattered treatment histories almost never have them.

Augmentation and switching after partial response

Partial responders — patients with meaningful but incomplete PHQ-9 reduction after an adequate trial — are augmented before switching. The strongest evidence supports aripiprazole at 2-15 mg, lithium at levels of 0.4-0.8 mEq/L for augmentation (lower than mood-stabilization dosing), and T3 at 25-50 mcg, particularly for patients with low-normal thyroid function. Quetiapine XR at 150-300 mg is an FDA-approved augmentation for MDD but its weight and metabolic burden move it down the list.

Bupropion augmentation targets residual anergia, anhedonia, and cognitive slowing that SSRIs don’t reach. Buspirone augmentation has supporting evidence with a smaller effect size but a favorable side-effect profile. For genuine non-responders — patients who show no PHQ-9 movement at all — a within-class SSRI-to-SSRI switch has limited evidence. A cross-class switch to venlafaxine XR, duloxetine, or bupropion has a better track record. Every augmentation and switch decision is documented against the PHQ-9 trajectory so the next clinician doesn’t have to reconstruct the sequence from memory.

The interventional escalation pathway

After two adequate antidepressant trials at adequate dose and duration, the patient meets the FDA and payer definition of treatment-resistant depression — and qualifies for interventional options. RECO’s protocol names the escalation option at trial two rather than at trial four or five, because delayed escalation is one of the most common reasons a treatable depression becomes chronic.

Repetitive transcranial magnetic stimulation (rTMS) delivers 3000 pulses per session at 120% of motor threshold to the left dorsolateral prefrontal cortex, over a 36-session course — five sessions per week for six to nine weeks. No sedation, no systemic medication burden, and patients drive themselves to and from appointments. Spravato (esketamine) is the REMS-monitored intranasal option for patients where a rapid-response mechanism is clinically indicated; induction is twice weekly for four weeks, then tapered to weekly and biweekly maintenance. IV racemic ketamine is available as a cash-pay option for compressed schedules or for patients who don’t tolerate esketamine. Escalation is planned against the PHQ-9 and the treatment history — not improvised at the appointment.

What to expect at the initial evaluation

The initial psychiatric evaluation runs 60-75 minutes. The psychiatrist reviews the full mood history, prior medication trials with doses and durations, family psychiatric history, medical comorbidities, substance use, sleep, and trauma history. Structured instruments — PHQ-9, GAD-7, MDQ, and ASRS if attention is in question — are administered and scored at intake to establish a baseline. Labs are ordered if not recent: TSH, CBC, CMP, B12, vitamin D, and hemoglobin A1c for patients starting or on a second-generation antipsychotic.

The output of the first visit is a written treatment plan: DSM-5-TR diagnosis, target symptoms, medication selection with dose and titration schedule, safety plan, and a defined interval for the next PHQ-9. If interventional options are on the horizon based on prior trial history, that pathway is named at visit one. Follow-up visits are typically every two to four weeks during titration and every one to three months once stable. Adjunctive therapy — CBT, ACT, or referral for EMDR when trauma is comorbid — is coordinated with community therapists.

Insurance and admissions from Hollywood

RECO Integrated Psychiatry is in-network with Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS plans for outpatient psychiatric evaluation and medication management. TMS and Spravato require prior authorization and documented failed trials of at least two antidepressants at adequate dose and duration — which is why the medication history is documented in detail at intake. Verification of benefits and out-of-pocket estimates are provided before the first visit; the admissions team handles the prior auth submission and appeal process when initial denials come back.

Hollywood Beach, Emerald Hills, Hollywood Lakes, Hollywood Hills, and Oakwood are all a 50-minute drive from the office outside of peak traffic. Weekly medication visits and biweekly maintenance are sustainable from Hollywood without accommodation; TMS courses and Spravato induction phases sometimes benefit from a short-term stay closer to Delray during the most intensive weeks. Telepsychiatry follow-up is available once a treatment plan is established and the patient is stable on their regimen.

Serving residents of: Hollywood Beach, Emerald Hills, Hollywood Lakes, Hollywood Hills, Oakwood.