For most of the past two decades, community practice has managed treatment-resistant depression (TRD) the way STAR*D described: one medication after another, with remission rates falling below 15 percent by the third trial. Repetitive and deep transcranial magnetic stimulation (TMS), FDA-cleared since 2008, and intranasal esketamine (Spravato), approved in 2019, have changed what a community psychiatrist can offer. In pooled trial data and in real-world cohorts, the two now work about as well as each other.
Running a community interventional practice has taught me that delivering these treatments outside an academic center is less about buying equipment than about redesigning how a practice runs. When esketamine was approved, the authors of a 2019 JAMA analysis warned that its requirements for space, staff, controlled-substance handling, and Risk Evaluation and Mitigation Strategy (REMS) reporting might confine it to the largest clinics. They noted that about one-third of psychiatrists practiced alone. Community programs that succeed treat those requirements as design problems to solve.
Patient education starts before the referral is accepted
What patients understand at the outset shapes the course of treatment more than any device setting. For TMS, patients need to understand the daily commitment: roughly 4 to 6 weeks of weekday sessions. Treatment is done awake, without anesthesia, and patients drive home afterward. Headache and scalp discomfort are common early and usually fade. Patients should also know that response may be slower when anxiety is prominent or benzodiazepines are in use. In one real-world cohort, both predicted a slower time to response with TMS. For esketamine, the key points are:
- Each dose is taken in the clinic under supervision.
- Blood pressure is checked before and after dosing, and the patient is observed for at least two hours.
- Dissociation and transient hypertension are expected and generally manageable.
- Patients cannot drive until after a night of sleep, so transportation must be arranged for every visit.
Many early dropouts in community programs trace back to unplanned logistics, not to side effects or lack of response.
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Insurance navigation needs dedicated staff
Insurance is the main operational burden, and it deserves dedicated staff, not leftover clinician time. Across 18 large U.S. commercial plans, esketamine coverage varied widely in step-therapy requirements (one to five prior steps for TRD), required severity scales, and prescriber criteria. Claims data show the cost of getting this wrong:
- Only 34.6 percent of first esketamine pharmacy claims were approved, and coding errors and missing prior authorizations accounted for much of the rejection rate.
- Approval rose to 85.2 percent by the second session.
- Only 17.6 percent of patients completed induction on the labeled schedule.
TMS coverage for depression is broad but tied to strict prior authorization criteria, and coverage for obsessive-compulsive disorder (OCD) remains inconsistent. Three practical steps help:
- Use templates that document each failed medication trial with dose, duration, and reason for stopping.
- Build baseline and serial rating scales into intake.
- Decide early between buy-and-bill and specialty pharmacy purchasing for esketamine, given its drug cost and cash-flow implications.
Staffing can scale to a community clinic
Staffing and training follow published standards, and both can be scaled down to a small practice. For TMS, consensus recommendations call for a credentialed prescriber who supervises a trained device operator. The operator may be a medical assistant, technician, nurse, or physician assistant. They must be able to determine motor threshold, keep the coil in position, and recognize cortical excitation. They must also be able to respond to a seizure as a first responder with basic life support training. Each practice should have a written credentialing policy. Medications should be reconciled before each session, because changes that affect seizure threshold may call for rechecking motor threshold. Esketamine requires:
- REMS certification of the site and its pharmacy
- Schedule III storage and logs
- A monitored recovery area with blood pressure equipment
- Staff who can recognize and manage dissociation, nausea, and blood pressure spikes
Many community clinics run both services from a shared space with cross-trained staff. This keeps costs down and lets a nurse or technician who knows the patient monitor either treatment.
Procedures inside continuing care, not instead of it
The most important lesson is that these treatments work best as part of ongoing psychiatric care, not as standalone procedures. Current TMS practice does not require stopping medications, so pharmacotherapy, psychotherapy, and management of comorbid conditions continue alongside the course. Insomnia, sleep apnea, and substance use in particular should be addressed, since each can slow or blunt response.
Measurement-based care means standardized scales at intake, at set intervals, and at the end of treatment. It supports insurance reauthorization, and it gives the practice its own outcome data. This is the same learning health system approach that has improved community mental health care more broadly.
Plan for durability from the start. Esketamine maintenance continues in clinic weekly or every other week. TMS responders may need tapering, continuation, or a repeat course. Some patients will move between the two treatments, or combine them, based on early experience and case reports. Programs that handle referrals well do three things:
- Send treatment summaries back to the referring clinician.
- Set clear criteria for re-treatment.
- Keep the patient’s primary psychiatrist responsible for overall care.
Built this way, a community interventional service becomes a dependable next step for patients whose depression has not responded to medication, wherever they live relative to an academic center.
Ravi Singareddy is the founder and medical director of Empower Psychiatry & Sleep in north metro Atlanta, where he leads an interventional psychiatry practice offering transcranial magnetic stimulation (TMS) and Spravato (esketamine) for treatment-resistant depression. Double board-certified in psychiatry and sleep medicine, he brings more than two decades of clinical and academic experience to patients who haven’t found relief with medications alone. He is affiliated with Emory Healthcare.
His interest in neuromodulation dates back to his years as associate professor of psychiatry at Penn State College of Medicine. There, he taught annually on vagus nerve stimulation and novel depression therapies, and he published on long-term combined electroconvulsive therapy and vagus nerve stimulation in the American Journal of Psychiatry. He has authored numerous peer-reviewed papers on sleep disorders, insomnia, anxiety, and depression, with work appearing in Sleep, the Journal of Clinical Sleep Medicine, and Psychiatry Research.
Singareddy is a Fellow of the American Psychiatric Association and the American Academy of Sleep Medicine and practices measurement-based care, tracking outcomes to guide every treatment decision. He shares updates on Instagram.
