Depression treatment for Jupiter — the full escalation pathway, 45 minutes away.

For adults in Jupiter, Abacoa, or Tequesta whose depression has already outlasted a primary-care SSRI trial, RECO Integrated Psychiatry offers the full escalation pathway — bipolar-spectrum rule-out at intake, adequate first-line trials documented for later prior authorization, evidence-based augmentation with aripiprazole, lithium, or T3, and interventional TMS or Spravato — 45 minutes south on I-95. Telepsychiatry follow-ups keep the Delray drive rare after the initial in-person evaluation, and interventional care is planned at trial two rather than trial five.

From Jupiter to Delray Beach is 32 miles south on I-95 — 45 minutes outside of rush hour and close enough to reach for a TMS course or a Spravato dose without moving anyone’s life around. For adults in Abacoa, Tequesta, Admirals Cove, or Jonathan’s Landing whose depression has already outlasted a primary-care SSRI trial, RECO Integrated Psychiatry is an outpatient specialist practice built for the next step: medication escalation, augmentation, and interventional treatment, without a residential program. What follows is how depression treatment is actually worked up and delivered when the first two antidepressants did not remit the illness.

The diagnostic questions primary care doesn’t ask

Before treating “depression,” the psychiatrist rules out bipolar spectrum illness. That means a Mood Disorder Questionnaire (MDQ), an HCL-32, and a longitudinal mood history taken from the client and, with consent, from a family member — because antidepressant monotherapy in unrecognized bipolar disorder can induce mixed states, rapid cycling, and, in a subset of patients, a first manic episode. A meaningful minority of clients labeled “treatment-resistant depression” turn out on careful re-evaluation to have bipolar II or a bipolar-spectrum illness that was never surfaced during ten-minute primary-care visits.

The intake also screens for depressive mimics. Untreated OCD measured on the Y-BOCS, unaddressed PTSD, adult ADHD screened with the ASRS, thyroid dysfunction, obstructive sleep apnea, low B12 or vitamin D, chronic alcohol use masking a mood disorder, and undertreated pain syndromes all present as “depression” in primary care. Layering a second antidepressant on top of any of these prolongs the illness rather than resolves it. The initial evaluation at RECO is structured to catch these misdiagnoses at intake — not on trial four.

First-line pharmacotherapy done well

For a client with a documented major depressive episode and no bipolar features, an SSRI — typically sertraline, escitalopram, or fluoxetine — or an SNRI — venlafaxine XR or duloxetine — is started at a conventional starting dose (sertraline 25-50 mg, escitalopram 5-10 mg, venlafaxine XR 37.5-75 mg) and titrated to a therapeutic dose within two to four weeks. Bupropion is chosen when sexual side effects, weight gain, or sedation would derail adherence. Mirtazapine is chosen when insomnia and appetite loss dominate the presentation. The PHQ-9 is re-scored at every visit so response is tracked as a number, not an impression.

The two things insurance later requires to approve TMS or Spravato are the two things scattered treatment histories rarely document: adequate dose and adequate duration. Six to eight weeks at a therapeutic dose is a trial. Two weeks at 25 mg of sertraline is not. Medication management notes are written so that if escalation becomes necessary, the trial history is already prior-authorization-ready and the client is not asked to repeat trials they have already failed.

Augmentation and switching after partial response

When the PHQ-9 drops but does not remit — a partial response — the evidence favors augmentation over switching. First-line augmentation options with the strongest data are aripiprazole (2-15 mg), lithium dosed to a trough of 0.4-0.8 mEq/L for augmentation, and liothyronine (T3) at 25-50 mcg. Quetiapine XR and olanzapine are effective augmentation agents where metabolic risk is acceptable and monitored. Bupropion augmentation is used for residual anergia, hypersomnia, and cognitive slowing. Buspirone augmentation is a reasonable option for clients with prominent residual anxiety.

For clients with no response — as opposed to a partial response — a switch is more defensible than augmentation. Within-class switches (SSRI to SSRI) have limited evidence; cross-class switches (SSRI to SNRI, SSRI to bupropion, or SNRI to mirtazapine) have better data. Every switch is planned with a taper schedule, a washout where required (fluoxetine’s long half-life, an MAOI transition), and a documented clinical rationale, so nothing about the sequence is accidental.

The interventional escalation pathway

After two adequate antidepressant trials at adequate dose and duration, the client meets standard criteria for treatment-resistant depression — and, importantly, meets coverage criteria for TMS or Spravato under most commercial plans. RECO’s protocol names the escalation option at trial two rather than at trial four or five, which is where scattered treatment histories often stall out for years.

Repetitive transcranial magnetic stimulation (rTMS) — a standard course is 36 sessions over about six weeks, delivering roughly 3000 pulses per session at 120% of motor threshold to the left dorsolateral prefrontal cortex — is offered for clients who prefer a non-medication interventional option. Spravato (intranasal esketamine) is offered for clients who need a rapid-response, REMS-monitored option and can build twice-weekly, then weekly, in-clinic dosing into their schedule. IV racemic ketamine is available as a cash-pay alternative for compressed timelines. The choice among the three is driven by cardiovascular history, seizure risk, work schedule, and insurance — not by which room happens to be open.

What the first visit from Jupiter actually looks like

The initial psychiatric evaluation runs 60 to 90 minutes. It covers the full mood history, prior medication trials with exact dose and duration, family psychiatric history, a substance use inventory, and a medical review — TSH, CBC, metabolic panel, B12, vitamin D, and an ECG before certain agents. Structured scales are administered rather than estimated: PHQ-9, GAD-7, MDQ, and where indicated ASRS or Y-BOCS.

By the end of the first visit, the client leaves with a working DSM-5-TR diagnosis, a specific medication at a specific starting dose, a titration schedule, and the exact date response will be re-assessed. Where CBT, ACT, or DBT skills work would clearly augment pharmacology, a referral to a therapist is made at the same visit. Telepsychiatry follow-ups are available so the Delray drive is required only when clinical need — a first visit, an ECG-monitored medication start, a TMS course, or a Spravato dose — actually requires an in-clinic visit.

Insurance and admissions from Jupiter

RECO Integrated Psychiatry accepts Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS for outpatient psychiatric evaluation and medication management. Coverage for TMS and Spravato is plan-specific and requires documented failure of two adequate antidepressant trials; benefits are verified and prior authorization is initiated before the client commits to an interventional course.

For families in Abacoa, Jupiter Inlet Colony, Tequesta, Admirals Cove, or Jonathan’s Landing, the practical model is straightforward: in-person for the initial evaluation and for any interventional treatment, telepsychiatry for the routine medication follow-ups. That reduces the 45-minute drive to a handful of clinical touchpoints and preserves specialist care without asking anyone in Jupiter to disrupt work, school, or family for every appointment.

Serving residents of: Abacoa, Jupiter Inlet Colony, Tequesta, Admirals Cove, Jonathan's Landing.