Depression treatment for Wellington — the full escalation pathway, 38 minutes away.

For Wellington adults 38 minutes east on the Turnpike, RECO Integrated Psychiatry runs the full depression pathway under one roof — DSM-5-TR-anchored diagnosis, adequate SSRI and SNRI trials, aripiprazole and lithium augmentation, and interventional escalation to TMS or Spravato once treatment-resistant criteria are met. Every visit is charted with PHQ-9 score, dose, and duration, so clients from Aero Club, Palm Beach Polo, and Versailles arrive with the documentation carriers require and leave with an algorithm rather than a refill. Board-certified psychiatrists coordinate CBT, behavioral activation, and ACT with in-network therapists in parallel with medication management.

Wellington sits about 28 miles inland from RECO Integrated Psychiatry’s Delray Beach office — a 38-minute drive east on the Turnpike from Aero Club, Palm Beach Polo, or Versailles. For adults who have already cycled through two antidepressants without reaching full remission, the clinical value of that drive is direct access to a psychiatrist who names the interventional escalation pathway at trial two rather than at trial five, and who documents each trial by dose and duration so that insurance authorization for TMS or Spravato is not the obstacle.

The diagnostic questions primary care doesn’t ask

Before depression gets treated, the differential has to be closed. That means screening every new adult for bipolar spectrum illness with the MDQ and, when the history is suggestive, the HCL-32 — because antidepressant monotherapy in unrecognized bipolar II induces mixed states, rapid cycling, and destabilization that later gets misread as treatment failure. Family history of mania or postpartum psychosis, prior antidepressant-induced hypomania, early age of onset, and an episodic rather than chronic course are questions the fifteen-minute primary care visit rarely reaches.

The same evaluation rules out the medical and psychiatric conditions that mimic MDD. Undertreated PTSD produces anhedonia and negative cognition that read as depression on a PHQ-9. OCD in the ego-dystonic rumination pattern presents as intrusive thought content the client labels depressive. Adult ADHD with executive dysfunction looks like psychomotor slowing. Hypothyroidism, obstructive sleep apnea, alcohol use above two drinks per night, and stimulant misuse all elevate PHQ-9 scores without a primary depressive process. RECO’s intake pulls a TSH, runs the AUDIT-C, screens with the ASRS and YBOCS where indicated, and documents the substance history — because layering a fourth SSRI on an untreated primary diagnosis is how clients end up on five medications and no better.

First-line pharmacotherapy done well

A first-line antidepressant trial only counts when the dose reaches the therapeutic range and the trial lasts long enough to judge response. For SSRIs, that means sertraline titrated to 100–200 mg, escitalopram to 20 mg, or fluoxetine to 40–60 mg over two to four weeks, then held at target for a full six to eight weeks before response is called. SNRIs — venlafaxine XR to 150–225 mg, duloxetine to 60–90 mg — are equivalent first-line options and are often preferred when comorbid pain or fatigue is prominent.

Agent selection is driven by side-effect profile and comorbidity, not by brand. Bupropion XL 300–450 mg is the first-line pick when SSRI-associated sexual dysfunction, weight gain, or sedation would compromise adherence, and it pairs well with clients who also carry ADHD features. Mirtazapine 15–45 mg at bedtime is the choice when insomnia and appetite loss dominate the presentation. What matters — and what scattered treatment histories almost always lack — is a documented dose, a documented duration, and a PHQ-9 trend that shows whether the trial was truly adequate. Insurance carriers require that documentation before authorizing TMS or Spravato, and RECO builds it into the chart from the first visit.

Augmentation and switching after partial response

Partial responders — clients whose PHQ-9 has dropped meaningfully but has not reached remission (under 5) — are augmented before they are switched. Augmentation strategies with the strongest evidence base include:

• Aripiprazole 2–15 mg added to the existing antidepressant — first-line based on STAR*D and multiple augmentation RCTs.
• Lithium titrated to a serum level of 0.4–0.8 mEq/L (below the mood-stabilizer range) — strong evidence, requires baseline TSH and BMP with periodic level monitoring.
• Liothyronine (T3) 25–50 mcg — particularly useful in female clients with borderline TSH.
• Bupropion 150–300 mg — added when residual symptoms are anergia, hypersomnia, and cognitive slowing.
• Quetiapine XR 150–300 mg or low-dose olanzapine — considered when prominent anxiety and insomnia coexist; buspirone is a lower-side-effect adjunct in anxious depression.

For true non-responders — clients who never crossed the response threshold — the evidence favors a cross-class switch (SSRI to SNRI, SSRI to bupropion, or SNRI to mirtazapine) over a within-class SSRI-to-SSRI change. Two adequate antidepressant trials at adequate dose and duration meets DSM-5-TR-consistent criteria for treatment-resistant depression, and RECO’s protocol is to name the interventional options at trial two rather than at trial four.

The interventional escalation pathway

Once TRD is established, RECO’s depression treatment program moves to interventional care with the same rigor applied to pharmacology. Repetitive transcranial magnetic stimulation delivers 3,000 pulses per session at 120% of motor threshold to the left dorsolateral prefrontal cortex, five days a week for six weeks, followed by a taper. It is FDA-cleared for TRD, requires no anesthesia or sedation, and preserves the client’s ability to drive to and from the office — which for a Wellington client on a 38-minute commute is often the deciding factor.

Spravato (esketamine nasal spray) is the alternative when a REMS-monitored, rapid-response option is the clinical fit — twice-weekly induction for four weeks, then weekly, then every-other-week maintenance, each session followed by a two-hour post-dose observation on site. IV racemic ketamine is available as a cash-pay pathway for clients who need a compressed six-infusion series. Whichever escalation is chosen, PHQ-9 is tracked visit to visit and remission — not partial response — is the stated endpoint.

What to expect at the first visit

The initial evaluation runs sixty to ninety minutes and produces a written formulation, not a script. The psychiatrist walks the mood history back to the first episode, screens with the PHQ-9, GAD-7, MDQ, and where indicated the PCL-5, ASRS, or YBOCS, and reviews every prior medication trial by dose, duration, and reason for discontinuation. Baseline labs — TSH, CBC, CMP, vitamin D, B12 — are ordered when they have not been drawn recently. If lithium augmentation is on the table, a BMP and TSH are drawn before the prescription is written.

Clients leave with a diagnosis stated in DSM-5-TR terms, an algorithm that names the next two decision points, and a follow-up interval — usually two to four weeks — matched to the pharmacology being initiated. Evidence-based psychotherapy (CBT for depression, behavioral activation, ACT, or MI when ambivalence is a factor) is coordinated in parallel with an in-network therapist, because medication-only treatment of moderate-to-severe MDD underperforms combined care.

Insurance and admissions from Wellington

RECO Integrated Psychiatry is in-network with Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and Blue Cross Blue Shield plans, and the front desk verifies benefits, prior-authorization requirements, and out-of-pocket cost before the first appointment. Wellington clients reach the Delray office via the Turnpike to exit 81 in roughly 38 minutes off-peak; those in Aero Club, Palm Beach Polo, or Wellington View often adopt a hybrid schedule — in-person for TMS or Spravato sessions, telepsychiatry for medication follow-ups — to keep the driving load manageable while remission is consolidated.

Telepsychiatry is offered to Florida residents for follow-up medication management, which is often the difference between staying in treatment and lapsing when work, weather, or an equestrian schedule interferes with the drive. Clients establishing care from Olympia, Versailles, or Wellington View typically start with an in-person initial evaluation and move to a mixed schedule once the treatment plan is stable.

Serving residents of: Olympia, Versailles, Aero Club, Palm Beach Polo, Wellington View.