Depression treatment for Palm Beach Gardens — the full escalation pathway, 35 minutes away.

RECO Integrated Psychiatry is a Delray Beach outpatient psychiatry practice — 35 minutes south of Palm Beach Gardens via I-95 — that treats major depressive disorder from first-episode SSRI response through treatment-resistant escalation to TMS, Spravato, and IV ketamine inside one office. Every plan is anchored to a documented DSM-5-TR diagnosis, a baseline PHQ-9, and adequate-trial documentation that keeps the interventional pathway open when medication alone falls short. First visits are structured for the round trip from PGA National, Mirasol, and BallenIsles; telepsychiatry follow-up is offered inside Florida after stabilization.

Palm Beach Gardens sits 25 miles north of Delray Beach — roughly 35 minutes down I-95 in ordinary daytime traffic. For residents of PGA National, Mirasol, BallenIsles, Frenchman’s Reserve, and Old Palm, that drive opens access to a level of outpatient psychiatric density — medication management, TMS, Spravato, and IV ketamine coordinated inside one practice — that the northern half of Palm Beach County is not structured to deliver. RECO Integrated Psychiatry treats major depressive disorder in the outpatient setting from first-episode presentations that respond to first-line SSRI treatment through treatment-resistant cases that require the full interventional escalation pathway, each plan built on a documented DSM-5-TR diagnosis, a baseline PHQ-9, and a written algorithm for medication trials, augmentation, and interventional escalation when pharmacology alone doesn’t produce remission.

The diagnostic questions primary care doesn’t ask

Before treating what a client calls “depression,” the psychiatrist has to rule out bipolar spectrum illness. Antidepressant monotherapy in unrecognized bipolar I or II induces mixed states, agitation, and rapid cycling — the outcome most family medicine visits are structured to miss, because the 15-minute visit does not include a manic history. RECO’s intake screens with the MDQ and HCL-32, walks the mood timeline in both directions, and asks about hypomanic episodes, family psychiatric history, and antidepressant-induced activation — questions clients often have not been asked before.

Untreated substance use, subclinical thyroid dysfunction, chronic sleep deprivation, obstructive sleep apnea, iron and B12 deficiency, and undertreated OCD, ADHD, or PTSD all present as “depression” in primary care and all require the underlying condition to be treated rather than layered antidepressants. The initial evaluation is structured to catch these misdiagnoses at intake — not on trial four, after eighteen months on a medication that was never going to remit the picture.

First-line pharmacotherapy done well

For a new diagnosis of major depressive disorder, first-line pharmacotherapy is an SSRI (sertraline, escitalopram, fluoxetine) or SNRI (venlafaxine XR, duloxetine), started at a starting dose, titrated to a therapeutic dose within two to four weeks, and given a full six-to-eight-week trial at target dose before response is judged. Bupropion is the first-line option when sexual side effects, weight gain, or sedation rule out SSRIs. Mirtazapine is the option for insomnia-predominant or appetite-suppressed presentations, and buspirone is available for the residual anxiety component when clinically indicated.

Response is measured — not asked about. PHQ-9 is repeated at every visit and the delta from baseline is what drives the next decision. “Adequate trial at adequate dose and duration” is the exact language commercial payers later require to authorize TMS or Spravato, and it is the documentation that scattered treatment histories almost never carry. Every trial run at RECO is documented to that standard from the first prescription, so the escalation pathway remains open later without a retrospective chart reconstruction.

Augmentation and switching after partial response

Partial responders — clients whose PHQ-9 drops meaningfully but not into remission — are augmented before they are switched. First-line augmentation options with the strongest randomized evidence: aripiprazole (2 to 15 mg), lithium (target 0.4 to 0.8 mEq/L for augmentation, monitored with trough level, TSH, and creatinine), and triiodothyronine (T3) at 25 to 50 mcg. Bupropion augmentation is the option for residual anergia and anhedonia. Quetiapine XR (150 to 300 mg) and olanzapine are used selectively when comorbid anxiety or sleep disturbance drives the residual picture.

For non-responders — no meaningful PHQ-9 movement after an adequate trial — a within-class switch (SSRI to SSRI) has limited evidence and is used sparingly. A cross-class switch (SSRI to SNRI, or SSRI to bupropion, or the addition of mirtazapine as combination therapy) has better evidence and is the default. Every augmentation and switch decision is logged with the specific PHQ-9 scores that triggered it, so the trial history stays legible to the next clinician and to the insurer reviewing an interventional authorization.

The interventional escalation pathway: TMS, Spravato, and IV ketamine

After two adequate antidepressant trials at adequate dose and duration have failed to produce remission, the client meets the standard definition of treatment-resistant depression — and meets medical-necessity criteria for TMS and for esketamine (Spravato). RECO names the interventional option out loud at trial two rather than at trial four or five, because clients left in unremitted depression across additional failed medication trials lose months of function that the escalation pathway could have returned. Escalation is planned, not accidental.

Repetitive TMS is delivered as a standard course of 36 sessions over six to nine weeks — high-frequency 10 Hz stimulation to the left dorsolateral prefrontal cortex at 120% of motor threshold, roughly 3,000 pulses per session, about 20 minutes in the chair with no anesthesia. Spravato (esketamine) is delivered inside the REMS program with the required two-hour post-dose monitoring, added on top of an oral antidepressant for clients whose situation calls for a rapid-response option. IV ketamine remains available as a cash-pay option for clients who need a compressed schedule or do not meet Spravato coverage criteria. The full protocol is documented on the depression treatment service page.

What to expect on your first visit

The initial psychiatric evaluation runs about 60 minutes. It covers the full mood history in both directions, a DSM-5-TR differential (MDD, persistent depressive disorder, bipolar I and II, cyclothymia, unspecified depressive disorder with mixed features), and structured screens for the conditions most often mistreated as unipolar depression: GAD-7 for anxiety, MDQ for bipolar spectrum, ASRS for ADHD, YBOCS when OCD features are present, and a substance use history. Prior labs are reviewed; TSH, CBC, CMP, B12, folate, vitamin D, and a urine toxicology screen are ordered when they are missing or stale.

Clients leave the first visit with a written plan: the working diagnosis, the medication decision (start, adjust, augment, taper, or hold), the target dose and titration schedule, the specific PHQ-9 delta that will define response, the follow-up interval, and — where relevant — the interventional escalation option that will be named next. Therapy referrals are made when psychotherapy is indicated: CBT and behavioral activation for MDD, CPT or EMDR for trauma-driven presentations, ACT for chronic residual symptoms, and MI-informed work when ambivalence about treatment adherence is part of the picture.

Insurance and admissions from Palm Beach Gardens

RECO Integrated Psychiatry is in-network with Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS. Standard psychiatric evaluations and medication management visits are covered under outpatient behavioral health benefits with a specialist copay. TMS and Spravato are covered under separate medical-necessity authorization once two adequate antidepressant trials are documented; the practice manages that authorization once the trial history supports it.

New client admissions from PGA National, Mirasol, BallenIsles, Frenchman’s Reserve, and Old Palm are scheduled with the 35-minute drive to Delray in mind — first visits are grouped so a single round trip is productive, and telepsychiatry follow-up is offered inside Florida for clients who need to reduce the drive burden after stabilization on a medication regimen. In-person days are reserved for TMS, Spravato, and the visits that clinically require the chair.

Serving residents of: BallenIsles, Frenchman's Reserve, Mirasol, Old Palm, PGA National.