A patient tells you the third antidepressant has not helped either. You agree it is time to look further. Then comes the part nobody trained you for: where, specifically, do you send them, and will that place take their insurance?

This piece gives primary care physicians and fellow referrers a ready answer. It walks through building a one-page local referral map for treatment-resistant depression, one you can hand to staff and update a few times a year. Our figures come from 443 adults polled across ten Midwest states and are final, though the method works anywhere.

Why the map belongs in primary care

Asked how they would begin looking into ketamine or esketamine for depression, 56 percent of respondents said primary care, only 12 percent a search on their own, and 5 percent had no idea. And 74 percent said their own doctor's word would be what moves them.

Most patients, in other words, are not arriving with a destination in mind. They are arriving with a problem and waiting for you to point. A referral map turns that moment from a hunt into a handoff.

Layer one: psychiatry

List at least two psychiatry options, and note for each:

Name, phone, and fax or electronic referral route.
Typical wait for a new patient, as reported by the practice. Call and ask.
Insurance accepted, specifically Medicaid, Medicare, and major commercial plans.
Whether they evaluate for esketamine or TMS, and whether they offer either on site.

Add at least one telepsychiatry option covered by common local plans. In areas with long psychiatry waits, a video evaluation can shorten the path considerably. If your system offers collaborative care or an embedded behavioral health specialist, put that first; it is often the fastest route to psychiatric input.

Layer two: certified esketamine sites

Only settings certified under the esketamine REMS may administer it. Start with the drugmaker's public locator of treatment centers, then verify by phone. Brain Recovery Centers also keeps a patient-facing overview of what Spravato treatment involves that you can attach to referrals. For each nearby site, record:

Whether the site accepts direct referrals from primary care or requires a psychiatric evaluation first, and whether it has its own prescriber.
Payers accepted.
Whether the drug is handled under the medical or pharmacy benefit for common plans, which affects patient cost.
Session days and hours, since patients need a driver every time.
Distance and realistic travel time from your practice.

Distance is not a minor detail. Among our respondents, 43 percent counted nearness to home in their two main provider priorities, behind only coverage. Early treatment involves twice-weekly sessions, each requiring post-dose observation and a ride home, so a site an hour away may be impractical for a patient without dependable transportation.

Layer three: other evidence-based options

TMS providers. A drug-free, FDA-cleared option. Many respondents cared about avoiding more medication; 64 percent valued a drug-free choice, while roughly a quarter knew TMS by name.
Psychotherapy. Therapists offering evidence-based approaches such as CBT, with notes on who takes which plans and who has openings.
ECT. The nearest program, for severe cases.

Layer four: payer filters

Your map is only as good as its fit with your panel. Our respondents named commercial coverage at 39 percent, a hair above Medicaid at 37 percent; Medicare came in at 23 percent, TRICARE 5 percent, and no coverage 9 percent, multiple answers allowed. Your own panel will differ, but a list built for only one of the two big payers strands many patients.

For each layer, note which options accept Medicaid, Medicare, and TRICARE. For uninsured patients, add sliding-fee options such as federally qualified health centers and the county mental health center.

Layer five: transportation and support

Medicaid plans typically include non-emergency medical transportation. Note the number for your area's major plans, since this can make esketamine feasible for patients without a driver. Confirm whether a ride arranged this way satisfies the site's policy for post-dose discharge.
For military retirees and families on TRICARE, note which psychiatry practices and certified sites accept it and whether a referral or authorization is required.
Note local peer support and family support organizations.

Layer six: crisis

Put the 988 Suicide and Crisis Lifeline at the top of the page, along with any local mobile crisis team and the nearest emergency department with psychiatric services. Patients waiting on referrals are sometimes at their most vulnerable.

Keep it to one page

The map should fit on a single sheet or screen, with one line per destination. Have staff re-verify each listing every few months; a stale map sends patients to dead ends.

Pair the map with a documentation habit

The map tells patients where to go. The chart tells the destination and the payer why. For each patient being considered, document each antidepressant trial with drug, dose, duration, and response, along with serial symptom scores. Coverage weighed heavily for respondents, 65 percent of whom said insurance would carry big or deciding weight on trying esketamine or similar care. Clean documentation is how you help them clear that bar.

A note on what the map is not

A referral map is logistics, not a treatment recommendation. Esketamine's FDA indication centers on adults with treatment-resistant depression; consult the label for the full list. Infusion clinics use IV ketamine off-label for depression, and home-use ketamine prescribed by telehealth is a separate, less supervised arrangement. Which destination fits a given patient is a clinical judgment.

Make sure every patient leaving with a referral also leaves knowing that the Suicide and Crisis Lifeline sits at 988, answering texts and calls even at 3 a.m. The wait between referral and first appointment is a good time to say it out loud.

Methodology

The data behind this map: Pollfish's consumer panel answered survey 395586438 until its June 23, 2026 close, producing 443 completes; every panelist counted was 18 through 64 and lived in Oklahoma, Wisconsin, Indiana, Missouri, Iowa, Minnesota, Nebraska, Ohio, Kansas and Illinois. Payer answers are multi-select. Numbers are validated whole-sample shares. The publisher asked for the survey and underwrote it.

Building a local referral map for treatment-resistant depression