Depression treatment for West Palm Beach — the full escalation pathway, 28 minutes away.

RECO Integrated Psychiatry's Delray Beach office is 28 minutes south of downtown West Palm Beach and El Cid — the nearest outpatient practice offering the full major depressive disorder escalation pathway under one roof. First-line SSRI and SNRI trials, evidence-based augmentation with aripiprazole, lithium, or T3, and on-site TMS and Spravato are delivered inside a single medical record, so no step is lost between providers. Every treatment plan names the next two escalation steps in writing at the first visit rather than at trial four.

West Palm Beach sits 18 miles north of RECO Integrated Psychiatry’s Delray Beach office — a 28-minute drive south on I-95 or Federal Highway outside of rush hour. For adults living in El Cid, Flamingo Park, Northwood Hills, SoSo, or downtown West Palm Beach, the Delray campus is the nearest outpatient practice delivering the full major depressive disorder escalation pathway — structured diagnostic evaluation, evidence-based medication trials, TMS, Spravato, and IV ketamine — inside a single medical record. What follows outlines what specialist-level outpatient care for depression looks like when it is done systematically rather than reactively.

The diagnostic questions primary care doesn’t ask

Roughly 60–70% of antidepressant prescriptions in the United States are written in primary care, where a 15-minute visit rarely permits the differential workup that “depression” actually requires. Before RECO’s psychiatrists initiate or continue treatment, the intake screens for bipolar spectrum illness using the MDQ, HCL-32, and a structured mood and family history — because antidepressant monotherapy in unrecognized bipolar II or cyclothymia induces mixed states, rapid cycling, and iatrogenic worsening that later gets misread as “treatment resistance.”

The differential extends past mood polarity. Untreated obstructive sleep apnea, subclinical hypothyroidism, alcohol use disorder, cannabis use disorder, undertreated OCD (verified with the YBOCS), and PTSD each present with anhedonia, low energy, and cognitive slowing that meet PHQ-9 criteria for moderate-to-severe depression. Layering a fourth antidepressant on any of these produces disappointment; treating the underlying disorder resolves the depressive presentation as a byproduct.

Adult ADHD is screened with the ASRS and generalized anxiety with the GAD-7, because demoralization secondary to unmanaged executive dysfunction or chronic worry is a common driver of persistent low-magnitude PHQ-9 responders. RECO’s initial evaluation is structured to surface these misdiagnoses at intake, not at trial four.

First-line pharmacotherapy done well

An SSRI — sertraline, escitalopram, or fluoxetine — or an SNRI — venlafaxine XR or duloxetine — is started at a starting dose, titrated to a therapeutic dose within two-to-four weeks, and given a full six-to-eight-week trial before response is judged. That is what a “trial” means. Most scattered treatment histories that arrive at RECO document neither the therapeutic dose reached nor the duration held; without those two data points, commercial payers will not authorize interventional escalation later.

Bupropion is first-line for patients where sexual dysfunction, sedation, or SSRI-associated weight gain are non-negotiable, assuming no seizure history and no active eating disorder. Mirtazapine at 7.5–15 mg is selected for insomnia-predominant or appetite-suppressed presentations, taking advantage of the H1 antagonism at low doses. Vortioxetine is reserved for patients with prominent cognitive complaints where the pro-cognitive signal justifies the cost.

Every prescription is recorded with target dose, target date, and a predefined response criterion — a 50% PHQ-9 reduction — so the next decision is not made from impressions. Adjunctive CBT for depression, behavioral activation, ACT, or motivational interviewing is coordinated concurrently rather than delayed until the medication “settles in.”

Augmentation and switching after partial response

Partial responders — meaningful but incomplete PHQ-9 reduction at eight weeks — are augmented before they are switched. First-line augmentation options, ranked by evidence: aripiprazole 2–15 mg with metabolic monitoring; lithium titrated to a serum trough of 0.4–0.8 mEq/L (lower than the mood-stabilization target); and T3 at 25–50 mcg. Quetiapine XR at 150–300 mg and olanzapine are reserved for patients where an atypical is already indicated for another reason, given the metabolic burden.

Bupropion augmentation is used for residual anergia and hypersomnia; buspirone is added when residual anxiety is the primary drag on function. For prominent sleep-onset insomnia, low-dose trazodone or a targeted CBT-I course is preferred to layering another sedating antidepressant on top of an already-loaded regimen.

For non-responders — no meaningful PHQ-9 movement at adequate dose and duration — a within-class switch (SSRI to SSRI) has weak evidence and is generally skipped in favor of a cross-class switch: SSRI to SNRI, SSRI to bupropion, or to an atypical antidepressant with a different mechanism. Every change is bounded by a defined re-evaluation window with a written next step; treatment does not drift, and refills do not accumulate past the point where they should have been reconsidered.

The interventional escalation pathway

After two adequate antidepressant trials at adequate dose and duration, the patient meets criteria for treatment-resistant depression — and, importantly, meets the coverage criteria most commercial carriers use to authorize TMS and esketamine. RECO’s protocol names the interventional option at trial two rather than at trial four or five, because the six-to-nine months typically lost to slow escalation is six-to-nine months of unremitted depression, elevated suicide risk, and eroded work and family function.

On-site depression treatment at RECO includes repetitive TMS delivered to the left dorsolateral prefrontal cortex at 120% of resting motor threshold, 3,000 pulses per session, 36 sessions across approximately six weeks — the FDA-cleared protocol with the strongest response and remission data in treatment-resistant depression. Patients who prefer a REMS-monitored rapid-response option receive esketamine (Spravato) in the certified in-office setting, twice weekly during induction and tapering to maintenance.

IV ketamine is available as a cash-pay option for patients whose schedules require a compressed series. ECT referrals are coordinated when the severity band — psychotic features, catatonia, or acute suicidality — places ECT above interventional outpatient options. Escalation is planned in writing at the first visit, not reached accidentally after years of scattered trials.

What the first visit looks like

The initial psychiatric evaluation is scheduled for 60–75 minutes. It includes a structured DSM-5-TR diagnostic interview; validated screens (PHQ-9, GAD-7, MDQ, ASRS, PC-PTSD-5, and a substance use screen); a review of every prior medication with dose, duration, response, and side effect documented; a family psychiatric history; and baseline labs (TSH, CBC, CMP, B12, folate, vitamin D, HbA1c). Pharmacogenomic testing is ordered when the medication history warrants it, not reflexively.

Patients leave the first appointment with a documented DSM-5-TR diagnosis, a written treatment plan naming the next two escalation steps, and a follow-up scheduled within two-to-four weeks — not eight-to-twelve. Adjunctive psychotherapy is either delivered in-network or coordinated with a matched community clinician: EMDR for trauma-driven presentations, DBT skills for affective instability, and CBT or behavioral activation for classic MDD.

Insurance and logistics from West Palm Beach

RECO Integrated Psychiatry is in-network with Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS. Prior authorizations for TMS, esketamine, and pharmacogenomic testing are prepared and submitted by the practice, including the medical-necessity documentation of prior adequate antidepressant trials that carriers require and that referring notes usually lack.

The Delray Beach office is 18 miles south of downtown West Palm Beach — approximately 28 minutes on I-95 outside rush hour, or a slightly longer trip on Federal Highway. Patients coming from El Cid, Flamingo Park, Northwood Hills, SoSo, and downtown West Palm Beach commonly use the Atlantic Avenue and Linton Boulevard exits. Once the initial in-person evaluation and any interventional protocol (TMS or Spravato) are complete, follow-up medication management transitions to telepsychiatry so ongoing care does not require the weekly drive north-and-south on I-95.

Serving residents of: El Cid, Flamingo Park, Northwood Hills, SoSo, Downtown WPB.