Depression treatment for Miami — the full escalation pathway, 65 minutes away.

RECO Integrated Psychiatry sits about 65 minutes north of Miami on I-95, in Delray Beach, and is built for adults whose depression has already survived one or two uncoordinated medication trials. One prescriber owns the full pathway — first-line SSRI and SNRI trials, augmentation with aripiprazole, lithium, or thyroid, and interventional escalation to TMS or Spravato — so the escalation option is planned at trial two rather than trial five. Telepsychiatry follow-ups after the initial in-person visit keep the drive from Brickell or Coral Gables limited to the appointments that clinically require the client to be in-office.

For clients in Brickell, Coral Gables, or Coconut Grove, the trip up I-95 to RECO Integrated Psychiatry’s Delray Beach office runs about 65 minutes on a normal afternoon and longer through the morning and evening peaks. Miami has psychiatrists — what it often lacks, for treatment-resistant depression, is a single outpatient practice that owns the full escalation pathway from SSRI trial through TMS and Spravato under one prescriber. That continuity is what makes the drive worth it for adults whose depression has already survived two or three uncoordinated medication trials.

The diagnostic questions primary care doesn’t ask

Before a client is treated for “depression,” a psychiatric evaluation has to rule out the illnesses that mimic it and the illnesses that co-occur with it. Bipolar spectrum disorder is the most consequential miss: antidepressant monotherapy in unrecognized bipolar II or bipolar NOS destabilizes mood, induces mixed states, and accelerates cycling. The intake includes the MDQ, the HCL-32, and a structured mood history looking for hypomanic episodes, family history of bipolar illness, and prior antidepressant-induced activation.

The differential doesn’t stop at bipolar. Untreated OCD often presents as depression secondary to the exhaustion of managing intrusive thoughts — YBOCS scoring at intake catches it. PTSD in adults from Miami’s public safety, healthcare, and veteran populations frequently shows up as anhedonia and sleep disturbance long before the trauma history surfaces. Thyroid dysfunction, obstructive sleep apnea, chronic alcohol use, stimulant misuse, and untreated ADHD (screened with the ASRS) all present as “depression” and require the underlying diagnosis to be treated rather than layered antidepressants. The initial evaluation at RECO is structured to catch these misdiagnoses at intake, not on trial four.

First-line pharmacotherapy done well

A first-line antidepressant trial is straightforward on paper and frequently botched in practice. An SSRI — sertraline, escitalopram, or fluoxetine — or an SNRI such as venlafaxine XR or duloxetine is started at a conservative dose, titrated to a therapeutic dose within two to four weeks, and given a full six to eight weeks at that dose before response is judged against a repeat PHQ-9. Bupropion is preferred where sexual side effects, sedation, weight gain, or emotional blunting on an SSRI are non-starters. Mirtazapine is a reasonable first agent for insomnia-predominant depression with weight loss.

The two failure modes the protocol is designed to prevent are the two most common. First, dose insufficiency — clients kept on 25 mg of sertraline or 5 mg of escitalopram for months because a primary care visit didn’t include a follow-up to titrate. Second, premature abandonment — a medication called ineffective at week three, before it had a chance to work. Adequate dose and adequate duration, documented, are also what commercial insurance requires to later authorize TMS or Spravato, and are the two things scattered treatment histories usually don’t have.

Augmentation and switching after partial response

A partial responder — a client whose PHQ-9 has come down meaningfully but who still meets criteria for a major depressive episode — is augmented before being switched. First-line augmentation options with the strongest evidence base are aripiprazole at 2 to 15 mg, lithium titrated to a serum level of 0.4 to 0.8 mEq/L for augmentation (lower than the mood-stabilizer target), and triiodothyronine at 25 to 50 mcg. Quetiapine XR and olanzapine are options where sedation and anxiolysis are also clinically wanted. Bupropion added to an SSRI is a reasonable augmentation for residual anergia and cognitive slowing; buspirone is a lower-tier option.

For true non-responders — clients whose PHQ-9 has not moved — the evidence for a within-class SSRI-to-SSRI switch is weak. A cross-class switch, most commonly SSRI to SNRI or to bupropion, has better outcome data. Every augmentation and switch decision is timestamped in the chart with dose, duration, PHQ-9 delta, and side-effect profile. That documentation is what makes trial three coherent instead of a repeat of trial one.

The interventional escalation pathway

After two adequate antidepressant trials at adequate dose and duration, a client meets DSM-5-TR-consistent criteria for treatment-resistant depression — and, importantly, meets the coverage criteria that Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS require to authorize TMS and Spravato. The protocol for depression treatment at RECO names the escalation option at trial two rather than trial four or five, so the client is not stuck in an indefinite loop of medication changes without a pre-defined exit.

Transcranial magnetic stimulation — typically a course of thirty-six daily sessions at 120% of motor threshold, roughly 3,000 pulses per session over the left dorsolateral prefrontal cortex — is the fit for clients who prefer a non-medication interventional option and can commit to the daily schedule. Spravato (esketamine) under REMS in-office monitoring is the fit where a rapid-response agent is clinically indicated, particularly in depression with active suicidal ideation and intact outpatient safety. IV ketamine remains available as a cash-pay option for clients with compressed timelines. Referral to ECT is made when ECT is the correct treatment, not withheld out of institutional preference.

What to expect on your first visit

The initial appointment is a ninety-minute psychiatric evaluation with a prescriber. It covers presenting symptoms, prior medication trials with documented dose and duration, family psychiatric history, medical comorbidities, and a substance-use history structured by ASAM Criteria dimensions when relevant. Standardized scales — PHQ-9, GAD-7, MDQ, ASRS, and YBOCS when indicated — are administered and scored at the visit rather than deferred to a later appointment.

Clients leave the first visit with a written treatment plan: the working DSM-5-TR diagnosis, the first-line medication with starting dose and titration schedule, the target therapeutic dose, the timeline at which response will be reassessed, and the pre-defined escalation option if the trial fails. Adjunctive psychotherapy — CBT, ACT, or trauma-focused work with EMDR where PTSD is contributing — is coordinated with outside therapists in Miami or delivered by telehealth. Follow-up cadence for the first eight weeks is typically every two weeks, moving to monthly once a therapeutic dose is stable.

Insurance and admissions from Miami

RECO Integrated Psychiatry is in-network with Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and Blue Cross Blue Shield. Benefits are verified before the first visit, and expected out-of-pocket costs — deductible, co-insurance, and TMS or Spravato prior-authorization requirements — are quoted in writing before the client commits to a course of treatment.

• Miami-Dade neighborhoods regularly seen: Brickell, Coral Gables, Coconut Grove, Aventura, Pinecrest.
• Drive: roughly 50 miles, 65 minutes on I-95 outside of peak traffic.
• Follow-up: telepsychiatry after the initial in-person evaluation, with in-office visits reserved for TMS days, Spravato dosing days, and interval reassessments.

Serving residents of: Brickell, Coral Gables, Coconut Grove, Aventura, Pinecrest.