St. Louis referral routes for stubborn depression, compared

For a St. Louis primary care physician, the question is rarely whether a patient with treatment-resistant depression needs something more. It is which door to send them through, given the patient's insurance, where they live, and how long they can realistically wait. The region offers several routes. They are not equivalent.

This comparison lays out the main referral routes available to referrers in the St. Louis area, framed by our ten-state poll of 443 Midwest adults, with both Missouri and Illinois in the sample. Its numbers are final now that Pollfish has validated them.

The context: patients are counting on you to choose

As a first stop for ketamine or esketamine, our respondents leaned hard toward primary care (56 percent), then psychiatry (23 percent), then a search of their own (12 percent). A doctor's recommendation was the most persuasive voice, cited by 74 percent.

That leaves the routing decision largely with you. Here are the options.

Route one: outpatient psychiatry

• What the patient gets: A full psychiatric evaluation, medication optimization, and assessment for esketamine, TMS, or other options.
• Speed: Often the slowest route. New patient waits in the region can be long, particularly for patients with Medicaid.
• Best for: Diagnostic uncertainty, complex comorbidity, or patients who need ongoing specialty management.
• Your documentation burden: Moderate. Send the medication history so the psychiatrist does not start from zero.

Route two: a certified esketamine treatment center directly

• What the patient gets: Evaluation specifically for esketamine, then treatment at the same site if appropriate.
• Speed: Sometimes faster than general psychiatry, because the center's prescriber evaluates candidacy directly. Prior authorization is usually the rate-limiting step.
• Best for: Patients with well-documented treatment-resistant depression, no obvious contraindications, and reliable transportation.
• Your documentation burden: High and decisive. Drug, dose, duration, and response for each trial, plus symptom scores, drive the prior authorization.
• Caveat: Not every site accepts direct primary care referrals, and payer acceptance varies. Call first.

Route three: integrated or collaborative care inside your system

• What the patient gets: Behavioral health support in the primary care setting, with psychiatric consultation to guide your prescribing.
• Speed: Often the fastest access to psychiatric input.
• Best for: Patients who have not yet had fully optimized trials, or who need support while waiting for specialty care.
• Limit: Does not itself provide esketamine or TMS, though the consulting psychiatrist can recommend and route.

Route four: telepsychiatry

• What the patient gets: Evaluation and medication management by video.
• Speed: Can be faster than in-person psychiatry.
• Best for: Patients in outlying areas such as Jefferson, Franklin, Lincoln, or western St. Charles County, or those with limited mobility.
• Limit: Esketamine requires in-person administration at a certified site, so a telepsychiatrist can recommend it but the patient will still need to travel for treatment. Be wary of conflating legitimate telepsychiatry with online services offering at-home ketamine, which is off-label and far less supervised.

Route five: a TMS provider

• What the patient gets: A drug-free, FDA-cleared treatment delivered in daily sessions over several weeks.
• Best for: Patients reluctant to add another medication. Our respondents valued a drug-free path at 64 percent, but roughly a quarter recognized TMS.
• Limit: A demanding schedule, and coverage criteria that also require documented medication trials.

Route six: evidence-based psychotherapy

• What the patient gets: A structured therapy such as cognitive behavioral therapy, alone or alongside medication and other treatments.
• Best for: Nearly every patient with persistent depression, including those waiting on psychiatry or prior authorization, and those who prefer a non-drug approach.
• Limit: Therapist availability and network participation vary widely across the region, especially for Medicaid. Keep a short list of therapists who have openings and accept MO HealthNet and Illinois Medicaid plans.

The St. Louis variables that change the answer

Insurance. Our respondents' coverage was nearly a tie, 39 percent commercial against 37 percent Medicaid, and 23 percent reported Medicare; more than one answer was allowed. Your panel will have its own mix, but a referral plan that only works for commercial plans leaves many patients stranded. Identify which routes accept MO HealthNet and Medicare.

The state line. Metro East patients on Illinois Medicaid may face network limits for Missouri providers, and vice versa. Medicaid managed care networks are state-specific, so check before routing across the river.

Distance. Early esketamine treatment means two visits a week, each with observation afterward and someone else driving home. For a patient in Festus or Wentzville, a central-corridor site may be impractical. Among respondents, 43 percent put proximity in their two main priorities, trailing only insurance.

Patient tolerance for process. Half of our respondents would rather clear insurance hurdles than pay out of pocket for a smoother path. Most patients will wait for coverage if they know what to expect.

A quick routing guide

• Unclear diagnosis or complex history: outpatient psychiatry, with collaborative care as a bridge.
• Clear treatment-resistant depression, good documentation, transportation available: a certified esketamine site, if it accepts direct referrals and the patient's plan.
• Strong preference to avoid medication: a TMS provider, alongside psychotherapy.
• Outlying county, long psychiatry wait: telepsychiatry plus a plan for the nearest certified site if esketamine is recommended.
• Waiting on any of the above: start psychotherapy now so the patient has support while the referral or authorization is pending.

Scope

This is a logistics comparison, not clinical guidance. Esketamine's FDA label covers adult treatment-resistant depression among its indications, with REMS rules confining it to certified sites. For patients, Brain Recovery Centers maintains a patient-level page on what Spravato treatment involves that you can share at referral. IV ketamine for depression is off-label. The right route for a given patient is a clinical judgment.

Whatever route you choose, make sure the patient leaves with 988 written down; that Suicide and Crisis Lifeline number works for calls or texts, day and night, while they wait. The gap between referral and first visit is when that reminder counts.

Methodology

Fieldwork for Pollfish survey 395586438 ended June 23, 2026, once 443 consumer-panel members had completed it, each aged 18 through 64, from Missouri, Illinois, Kansas, Iowa, Ohio, Indiana, Wisconsin, Minnesota, Nebraska or Oklahoma. Payer items were multi-select. Results are final. The publisher asked for this study and paid for it.