TMS therapy for Palm Beach Gardens — outpatient TRD care, 35 minutes from home.

RECO Integrated Psychiatry runs the full FDA-cleared TMS course — consult, motor threshold mapping, 36 sessions, and protocol taper — from the Delray Beach office 35 minutes south of Palm Beach Gardens. Clients from PGA National, BallenIsles, and Mirasol drive themselves in, return to work the same day, and stay under the same psychiatry team managing augmentation (aripiprazole, lithium, quetiapine) or concurrent Spravato. Prior authorization with Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS is handled by the clinical team, not the client.

Palm Beach Gardens sits 25 miles north of RECO Integrated Psychiatry’s Delray Beach office — a 35-minute run down I-95 that puts residents of PGA National, BallenIsles, Mirasol, Frenchman’s Reserve, and Old Palm inside the catchment of a full outpatient TMS therapy program without the scheduling weight of a residential or PHP setting. For treatment-resistant depression that has not moved on two or more adequate antidepressant trials, RECO delivers the FDA-cleared repetitive TMS course — consult through motor threshold mapping through 36 sessions through taper — as a drive-yourself outpatient service. Deep TMS for OCD runs on the same platform when clinically indicated, with YBOCS-scaled treatment planning.

Insurance-covered TRD candidacy and how we document it

Commercial coverage for repetitive TMS in treatment-resistant major depressive disorder is never automatic. Every major payer — Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS — requires documentation of at least two failed adequate antidepressant trials before authorization. “Adequate” is a defined term: therapeutic dose (for example, sertraline titrated to 100-200 mg, or venlafaxine XR to 225 mg or above), duration of six weeks or more at target dose, and adherence confirmed through pharmacy fill history. A documented course of psychotherapy — CBT, ACT, or IPT — is generally required in the same window.

The intake at RECO is built around this documentation. The consulting psychiatrist reconstructs the antidepressant history in the format the payer requires: agent, dose, duration, PHQ-9 change scores where available, and reason for discontinuation. For clients whose care has been fragmented across multiple prescribers — a primary care physician, a former psychiatrist, a telehealth prescriber during the pandemic — pulling that record together is part of the visit, not a separate homework assignment.

Prior authorization submission, peer-to-peer review if the initial request is denied, and re-authorization at mid-course are handled by RECO’s psychiatry team. Clients do not negotiate with the insurer directly, and treatment does not begin until the authorization letter is in file.

Motor threshold mapping and the first treatment week

Session one is not a treatment session — it is motor threshold determination. The psychiatrist positions the figure-eight coil over the left primary motor cortex and delivers single pulses at incrementally rising intensities until the minimum output that reliably evokes a visible right-thumb twitch is identified. That value — the resting motor threshold, or MT — sets the treatment intensity for the entire course at 120% of MT, per the FDA-cleared protocol. The coil is then repositioned to the treatment target, the left dorsolateral prefrontal cortex, using the Beam F3 method or neuronavigation.

Sessions two through five are the acclimation window. Standard 10 Hz stimulation delivers approximately 3,000 pulses per session over 20-40 minutes at 120% MT. Scalp discomfort under the coil and mild frontal or temporal headache are most notable during this first week and typically diminish by session ten. Ibuprofen or acetaminophen taken 30-45 minutes before the session addresses most of it; MT is periodically re-checked and intensity adjusted as tolerance builds.

Clients drive themselves to and from treatment. There is no sedation, no anesthesia, and no post-session monitoring beyond a brief check-in. Work, driving, and childcare resume immediately after the appointment — a distinction that matters for adults in PGA National or Old Palm who cannot absorb the productivity cost of a residential program.

Standard 10 Hz versus intermittent theta burst (iTBS)

The original FDA-cleared protocol for rTMS in major depression is 10 Hz stimulation over the left DLPFC, 20-40 minutes per session, 36 sessions across six to nine weeks. Intermittent theta burst stimulation is an FDA-cleared alternative that compresses the same clinical dose into a three-minute session. Head-to-head trials — most notably the THREE-D non-inferiority study — show equivalent response and remission rates between the two protocols in treatment-resistant depression.

For clients commuting from Palm Beach Gardens, the difference is logistical. A three-minute iTBS session plus room turnover is a 15-minute appointment; a 10 Hz session is 45 minutes on the treatment chair. Over 36 sessions, that is roughly 18 hours of time returned to the client — the difference between iTBS being feasible alongside a full work schedule and not being feasible at all.

Not every commercial plan reimburses iTBS at parity with standard 10 Hz — some cover only the traditional protocol, others cover both equivalently. RECO’s psychiatry team confirms coverage of the specific CPT code before the prior authorization is submitted. If the plan does not cover iTBS, the standard 10 Hz protocol is scheduled instead — the clinical outcome is the same.

Response, taper, and the retreatment question

Published response rates for rTMS in treatment-resistant depression sit between 40 and 60 percent; remission rates between 25 and 40 percent. Response — defined as a 50% or greater reduction in PHQ-9 or HAM-D — typically emerges between sessions 15 and 25, though a subset of clients respond earlier and a subset only in the final two weeks of the acute phase. PHQ-9 and GAD-7 are administered weekly during treatment and become the clinical record of trajectory.

The final six sessions of the 36-session course are a protocol taper: three sessions the first taper week, two the second, one the third. The taper is not optional — abrupt discontinuation at the end of the acute course is associated with earlier symptomatic relapse.

Responders who later relapse — most commonly six to twelve months after the taper ends — are candidates for a second full course. Commercial insurers typically cover retreatment on documentation of a prior response and a current relapse meeting TRD criteria. For clients who respond but plateau below full remission, augmentation with aripiprazole, lithium, or quetiapine — or a switch to esketamine (Spravato) — is discussed as concurrent care rather than an alternative.

What to expect on your first visit

The initial consult runs 60 to 90 minutes with an attending psychiatrist. It covers current symptoms scaled with the PHQ-9, GAD-7, and — where OCD is on the differential — the YBOCS; the full antidepressant history in payer-ready format; concurrent medical conditions and medications; and a targeted neurological screen. Seizure history, active substance use, and ferromagnetic implants near the coil are the primary contraindications reviewed.

If TMS is indicated, the psychiatrist frames it against alternatives — esketamine, oral augmentation with aripiprazole, lithium, or olanzapine, or a referral to ECT for the most severe or catatonic presentations. Clients working with an outside therapist in CBT, DBT, ACT, or EMDR keep that relationship; RECO coordinates the psychiatric care around it rather than duplicating it in-house.

Insurance and logistics from Palm Beach Gardens

RECO is in-network with Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS for both psychiatric consultation and TMS treatment. Clients from BallenIsles, Mirasol, and PGA National generally schedule early-morning or mid-afternoon blocks to sit outside I-95 peak windows; the 25-mile southbound run is 35 minutes off-peak and 50-55 minutes during rush hour.

The full course — 36 sessions over six to nine weeks — is delivered from the same Delray Beach office by the same psychiatry team that manages the medication regimen and any Spravato induction that runs in parallel. Nothing is subcontracted, and the treating psychiatrist is the same clinician who signed the prior authorization.

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