TMS therapy for West Palm Beach — outpatient TRD care, 28 minutes from home.

RECO Integrated Psychiatry runs the full FDA-cleared rTMS course — motor threshold mapping, 36 sessions at 120% MT over the left DLPFC, taper, and outcome tracking with the PHQ-9 and MADRS — from a Delray Beach office 28 minutes south of Downtown West Palm Beach on I-95. Both the standard 10 Hz protocol and the three-minute iTBS protocol are offered, and prior authorization with Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS is handled in-house. Clients drive themselves, stay at work, and do not have to enroll in a PHP or IOP to access specialist-level TMS.

West Palm Beach sits 18 miles north of RECO Integrated Psychiatry’s Delray Beach office — a 28-minute run down I-95 outside rush hour, or a slightly slower cruise on Federal Highway. For adults living between Downtown WPB, El Cid, Flamingo Park, Northwood Hills, and SoSo who have already failed multiple antidepressant trials, the outpatient TMS suite in Delray is the nearest specialist-level rTMS provider running the full FDA-cleared protocol without requiring PHP or IOP enrollment. Treatment happens in the psychiatry office; clients drive themselves, keep their jobs, and do not accrue a facility fee.

Insurance-covered TRD candidacy and how we document it

Commercial rTMS coverage in Florida — Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS — is not automatic. Payers require documented failure of at least two adequate antidepressant trials from separate mechanistic classes, each dosed at or above the minimum therapeutic range (for example, sertraline 150-200 mg, venlafaxine XR 225 mg, escitalopram 20 mg, or bupropion XL 450 mg) for a minimum of six weeks with confirmed adherence. Many plans further require a documented augmentation trial — aripiprazole 2-5 mg, lithium titrated to a serum level of 0.6-0.8, or quetiapine XR — or a completed course of evidence-based psychotherapy such as CBT before authorizing.

At the intake, RECO’s psychiatry team reviews the full pharmacotherapy history, reconstructs prescription records through Florida’s E-FORCSE PDMP and prior treaters where the record is scattered, and drafts the letter of medical necessity in the format the specific payer requires. Symptom severity is documented with the PHQ-9 and MADRS at baseline. When the trial history is thin — a common pattern for clients who have moved between prescribers — the intake produces a structured Antidepressant Treatment History Form (ATHF) reconstruction rather than treating the client as antidepressant-naive.

Prior authorization runs 5-15 business days depending on the payer. RECO tracks the authorization, appeals denials citing APA and Clinical TMS Society guidelines, and only schedules motor threshold mapping after coverage is confirmed in writing.

Motor threshold mapping and the first week

Session one is not a treatment session — it is motor threshold determination. The clinician positions the figure-of-eight coil over the left primary motor cortex and delivers single pulses at descending intensities until the minimum stimulator output that evokes a right-thumb (abductor pollicis brevis) twitch in five of ten pulses is identified. Treatment intensity is then set at 120% of that resting motor threshold. The coil is translated 5-6 cm anteriorly to the left dorsolateral prefrontal cortex — the F3 location under the Beam F3 method — where every subsequent session is delivered.

Sessions two through five are the acclimation window. The standard 10 Hz protocol delivers approximately 3,000 pulses per session across 75 four-second trains with 26-second inter-train intervals, for a total session length near 37 minutes. Scalp discomfort under the coil is most notable during the first week and typically fades as the trigeminal nerve accommodates; when discomfort limits tolerability, intensity is titrated up from 100% MT over the first week rather than starting flat at 120%. Post-session headache is common and responds to acetaminophen or ibuprofen.

Clients drive themselves to and from every session. No sedation is used, no monitoring is required afterward, and there is no cognitive fog — clients return directly to work or school. The main scheduling constraint is that the six-week active phase requires five consecutive weekday sessions, which is why West Palm Beach residents typically build the drive into a morning slot rather than mid-day.

Standard 10 Hz versus intermittent theta burst (iTBS)

The standard 10 Hz DLPFC protocol runs 20-40 minutes of chair time depending on the platform. Intermittent theta burst stimulation — iTBS — is an FDA-cleared alternative that compresses the effective dose into a three-minute session using 50 Hz triplet bursts delivered at 5 Hz for two seconds on, eight seconds off, across 600 pulses total. The THREE-D trial (Blumberger et al., 2018) established non-inferiority of iTBS to 10 Hz for major depression.

For West Palm Beach clients balancing a 28-minute drive with work, iTBS often converts a logistically impossible six-week commitment into a feasible one — total appointment time including check-in is under 15 minutes. Reimbursement for iTBS varies: some commercial plans reimburse at the same CPT code as 10 Hz (90867/90868/90869), others carve it out or require a peer-to-peer. RECO confirms specific reimbursement before scheduling rather than after.

For treatment-resistant OCD, the protocol is different — deep TMS with the H7 coil over the medial prefrontal cortex and anterior cingulate cortex, 20 Hz, paired with a brief symptom-provocation exposure. YBOCS is the tracking scale. OCD coverage is less consistent than depression and typically requires documented failure of high-dose SSRI trials and a course of exposure-and-response-prevention therapy.

Response, taper, and the retreatment question

Published response rates for rTMS in treatment-resistant depression sit between 40% and 60%, with remission rates between 25% and 40%. Response is not immediate — most responders show meaningful PHQ-9 or MADRS reduction between sessions 15 and 25, meaning treatment weeks three through five. Clients showing no movement by session 20 are re-evaluated: options include switching from 10 Hz to iTBS, adjusting cortical target using neuronavigation, or adding an augmentation agent such as lithium, aripiprazole, or serial ketamine.

The final six sessions of the 36-session course are a taper — three sessions in one week, two the next, then one — designed to consolidate response rather than end abruptly. Antidepressants are continued during and after the TMS course; TMS does not replace pharmacotherapy in the maintenance phase for most patients.

Roughly a third of responders relapse within 12 months. A second full 36-session retreatment course is well-supported in the literature and typically covered by commercial insurance on documentation of prior response and current relapse (PHQ-9 return to baseline). Maintenance TMS — weekly or biweekly sessions after taper — reduces relapse rates and is considered case-by-case based on the initial response trajectory.

Getting to RECO from West Palm Beach

The Delray Beach office is 18 miles south of Downtown West Palm Beach — 28 minutes on I-95 outside rush hour, 35-45 minutes at rush. Federal Highway (US-1) is the surface alternative and is often faster than I-95 southbound between 4:30 and 6:00 PM. Clients from El Cid, Flamingo Park, SoSo, and Northwood Hills typically schedule morning appointments between 7:30 and 9:00 AM to avoid the southbound afternoon backup on the return.

Because TMS therapy runs five weekdays a week for six to nine weeks, RECO reserves a consistent daily time block for out-of-town clients so the drive becomes a fixed part of the routine rather than a new negotiation each week. For clients closer to the northern end of West Palm Beach, Tri-Rail from Mangonia Park to Delray Beach is a realistic backup on days when driving is impractical.

What the first visit looks like

The intake is a 60-90 minute psychiatric evaluation with a board-certified psychiatrist. It covers a DSM-5 diagnostic review with a careful bipolar rule-out (TMS is not appropriate for undiagnosed bipolar depression without mood stabilization), a complete medication trial history using the ATHF, TMS contraindication screening (ferromagnetic intracranial hardware, cochlear implants, seizure history, active substance use), and baseline scaling with the PHQ-9, GAD-7, and MADRS; YBOCS is added for OCD candidates and the ASRS when ADHD is a differential.

If TMS is the right fit, the prior authorization packet is drafted at the same visit. If a client is better served by esketamine (Spravato), IV ketamine, or an unfinished medication optimization sequence — for instance, when adequate augmentation trials have not been documented — that recommendation is made at intake rather than after a denied authorization.

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