Yes, you need a psychiatric evaluation before TMS or Spravato. It confirms that you have major depressive disorder, documents the antidepressants you have tried, and screens for safety issues such as metal implants, seizures, blood pressure or aneurysms. The same visit gives your insurance plan the information it usually needs for prior authorization.
If you have been living with depression that medication has not fixed, you may have read about Deep TMS or Spravato and wondered how to get started. The first step is almost always the same: a full psychiatric evaluation. It is not a formality. It is how we work out whether either treatment is likely to help you, whether it is safe for you, and what your insurance plan will want to see.
This article walks through what the evaluation before TMS or Spravato covers, why each part matters, and how to prepare so the visit moves your care forward instead of adding another delay.
Why the evaluation comes first
TMS and Spravato are not first-line treatments. Both are meant for people whose depression has not responded well enough to standard care. Deep TMS uses an FDA-cleared magnetic coil to stimulate areas of the brain involved in mood. Spravato is an FDA-approved nasal spray form of esketamine that you take in a certified office while a clinician watches over you.
Because these are next-step treatments, they come with specific requirements. A psychiatric clinician needs to confirm that you have major depressive disorder rather than a condition that resembles it, that earlier treatments had a fair trial, and that nothing in your medical history makes the treatment risky. Insurers ask the same questions before they approve coverage, so one careful evaluation answers both.
It also helps to know you are not unusual. In the STAR*D study, about one third of participants reached remission on their first antidepressant, according to the National Institute of Mental Health's summary of the trial. Many people need more than one approach, and a thorough evaluation is how you find the right next one.
What the evaluation covers
An evaluation before TMS or Spravato looks a lot like any thorough first psychiatric visit, with extra attention in a few areas. You can read about the general structure on our psychiatric evaluation page. Here is what we focus on when an interventional treatment is on the table.
Confirming the diagnosis
We start by making sure we understand what is going on. That means a structured interview about your current symptoms, how long they have lasted, how they affect your work, sleep and relationships, and whether you have had similar episodes before. We use standard rating scales such as the PHQ-9 to measure severity. If you would like a head start, our depression self-check uses the same PHQ-9 questions.
We also look for conditions that change the plan. Bipolar disorder is the most important. Bipolar depression can look exactly like unipolar depression, but it is treated differently, and both TMS and Spravato call for extra caution when there is a history of mania or hypomania. We also ask about anxiety, obsessive-compulsive symptoms, trauma, attention problems, psychotic symptoms, sleep and substance use.
Your treatment history
This is the part that matters most, both clinically and for insurance. We build a timeline of every antidepressant you have tried: the name, the dose, roughly how long you took it, and what happened. Did it help partly, not at all, or cause side effects you could not live with? We also ask about add-on medications and about any psychotherapy you have done.
The details count because a medication only qualifies as a real trial if you took it at an adequate dose for long enough. A few weeks at a starting dose usually does not count. The FDA prescribing information for Spravato, for example, describes the treatment-resistant patients in its clinical studies as people whose current episode had not responded adequately to at least two different antidepressants of adequate dose and duration.
Medical and safety screening
The two treatments carry different safety concerns, so the screening covers both.
- For TMS: metal in or near the head, implanted devices such as cochlear implants or brain stimulators, a history of seizures or serious head injury, and medications that can lower the seizure threshold.
- For Spravato: blood pressure and heart history, any history of aneurysm or bleeding in the brain, pregnancy or plans to become pregnant, past or current substance use, and medications that might interact, such as sedatives or stimulants.
- For both: your other medical conditions, current medications and supplements, and any recent lab work.
We will also ask about thoughts of death or suicide. Every patient is asked, and an honest answer helps us choose the safest and quickest path. Spravato has an FDA-approved use for adults with major depression and acute suicidal thoughts or behavior, given along with an oral antidepressant, but the FDA label is clear that it does not replace hospital care when that is needed.
If you are thinking about suicide or hurting yourself, call or text 988, the Suicide and Crisis Lifeline, any time. If you are in immediate danger, call 911.
How the evaluation differs for TMS and Spravato
Much of the visit is the same either way. The differences show up in safety screening and in what treatment days look like.
| Deep TMS | Spravato | |
|---|---|---|
| What it is | FDA-cleared magnetic stimulation with a BrainsWay H-coil; no medication or anesthesia | FDA-approved esketamine nasal spray taken under supervision |
| Where we offer it | Palm Beach Gardens | Boynton Beach, Palm Beach Gardens and Royal Palm Beach |
| Key safety questions | Metal, implants, seizure risk | Blood pressure, vascular history, substance use, pregnancy |
| On treatment days | You can usually drive yourself and return to your day | The FDA label requires monitoring for at least two hours after each dose, and you need a ride home |
| Program rules | Prior authorization is common | Given only in offices certified under the FDA's Spravato REMS program |
If you want to check the criteria before you book, our pages on whether you are a candidate for TMS and whether you are a candidate for Spravato go through them in detail.
The insurance side of the evaluation
Many plans require prior authorization for both treatments, and the note from your evaluation becomes the core of that request. Plans differ, but many want to see a confirmed diagnosis, a severity score, a list of failed medication trials with doses and dates, and a history of psychotherapy or a reason it was not possible. Some plans have additional rules of their own.
Our staff compare your history against your plan's published policy before submitting, which helps avoid denials caused by missing details. Our article on how prior authorization works for TMS and Spravato explains the process step by step.
How to prepare for the visit
You do not need to arrive with everything figured out. These steps make the evaluation more productive, though, and often shorten the wait for insurance.
- List your past medications. Include antidepressants, add-on medications and anything for sleep or anxiety, with doses and rough dates if you know them.
- Ask your pharmacy for a printout. Pharmacy records fill in the gaps when memory is fuzzy.
- Gather prior records. If you saw another psychiatric clinician, request their notes or plan to sign a release so we can.
- Note your therapy history. The type of therapy, roughly when, and for how long.
- Bring medical details. Implants, surgeries, seizure history, heart conditions, recent blood pressure readings and current prescriptions.
- Write down your questions. Schedules, side effects, costs and anything else on your mind.
The evaluation can often be done by telehealth if you live in Florida or South Carolina. Your first TMS treatment or first Spravato dose takes place in person at the office that offers it.
What happens after the evaluation
By the end of the visit you should have a clear sense of where you stand. There are a few common outcomes.
- TMS looks like a good fit. We confirm your coverage, then schedule mapping and treatment at Palm Beach Gardens.
- Spravato looks like a good fit. We submit authorization, enroll you in the REMS program and schedule your first sessions at one of our three Spravato offices.
- Either could work. We talk through the tradeoffs together. Our page comparing TMS and Spravato covers the main differences.
- Neither is the right step yet. That might mean a different medication strategy, therapy, more workup, or prior records before deciding. We will tell you why and what we recommend instead.
No treatment can promise a specific result, and the evaluation does not commit you to anything. Its purpose is to give you accurate information so you can make the decision that fits your life.
Taking the next step
If depression has outlasted the treatments you have tried, an evaluation is a reasonable place to start. You can request an appointment online or call us, and we will help you figure out whether TMS, Spravato or another approach makes sense for you. There is no pressure to decide anything before you are ready.
Frequently asked questions
Can my regular doctor refer me straight to TMS or Spravato without an evaluation?
A referral from your primary care doctor or therapist is helpful, but it does not replace a psychiatric evaluation. Before starting either treatment, a psychiatric clinician needs to confirm the diagnosis, review your medication history, and complete safety screening. Insurers also generally expect this documentation from the treating practice. If your doctor sends records with the referral, including medication lists and notes, it can make the evaluation faster and more complete.
Can the evaluation be done by telehealth?
Often, yes. If you live in Florida or South Carolina, the evaluation can usually be done by secure video, which saves you a trip. Some parts of screening, such as blood pressure checks for Spravato, happen in person before or at your first treatment. Your first TMS session takes place at our Palm Beach Gardens office, and your first Spravato dose takes place at one of our three Spravato offices: Boynton Beach, Palm Beach Gardens or Royal Palm Beach.
What if I do not remember all the medications I have tried?
That is very common, and it is not a reason to delay booking. Bring what you remember, and ask your pharmacy for a printout of past prescriptions. With your permission, we can also request records from prior prescribers. Accurate details about each medication, including the dose and roughly how long you took it, matter because insurance plans usually want to see them before approving TMS or Spravato.
Does the evaluation commit me to treatment?
No. The evaluation gives you information, not an obligation. At the end, we explain whether TMS, Spravato, both or neither look like a good fit, and why. You can take time to think it over, ask questions, or talk with family before deciding. If neither treatment fits right now, we will recommend other options, such as a different medication approach or therapy, so you leave with a plan either way.
Related reading
- Treatment-Resistant Depression: What to Try Next
- How Prior Authorization Works for TMS and Spravato
- What Happens at Your First Psychiatrist Appointment
- Bipolar Depression vs Unipolar Depression: Why the Difference Changes Treatment
This article is educational and does not replace evaluation by a licensed clinician. If you are in crisis, call or text 988.