From our survey
Six layers for Missouri clinicians: psychiatry, interventional options, coverage fit, distance, what the patient carries out, and the packet.
A referral is only as good as the place it lands. For a Missouri clinician managing a patient whose depression has not responded to two antidepressant trials, the question is rarely "is there anything else?" It is "where, exactly, do I send this person, and will they get there?"
This guide is meant to help a primary care practice or other referrer build that map for their own corner of the state. Along the way, our commissioned survey of 443 Midwest adults shows why each piece of the map matters from the patient's side.
The need is not occasional. Seventy-two percent of our respondents reported depression, anxiety, or PTSD that outlasted standard medication, personally or in someone close. The split: 37 percent personally, 22 percent through someone close, 13 percent both ways. These are final, self-reported, top-line figures, and they are not a clinical prevalence estimate. They do indicate that stalled treatment is part of a large share of ordinary households, which means your panel likely includes more of these patients than your problem list shows.
Patients also expect you to steer. Primary care was where 56 percent of respondents would start; three in four also said that doctor's recommendation would weigh most in whether they tried something new. Only 5 percent lacked any idea where to start, which suggests most people have a plan, and the plan is you.
Every map needs a psychiatric consult route, even if wait times are long. Options in Missouri generally include:
Record for each: payers accepted, typical wait, whether they accept e-consults, and whether they offer interventional treatments on site.
TMS providers. TMS requires frequent sessions over several weeks, so distance matters more than for a one-time consult. Note which providers are within a realistic daily drive of your patients.
Certified esketamine treatment centers. Spravato, esketamine delivered as a nasal spray and approved for adults with hard-to-treat depression, may only be given in healthcare settings certified under its REMS program, with post-dose monitoring on site. The manufacturer maintains a public locator of certified centers. Confirm directly with each center which payers they bill and how they handle prior authorization. For patient education, a plain Spravato explainer can go in the handout.
ECT and other specialty services. Typically hospital-based and accessed through psychiatry.
Keep off-label ketamine providers in a separate column, if you list them at all. IV ketamine clinics and at-home telehealth programs operate outside the FDA-approved framework for depression, are often cash-pay, and involve different levels of oversight. Patients will ask about them. Having a clear, calm explanation of the difference is more useful than a referral.
Coverage decides whether a referral turns into treatment. Insurance was a top-two factor for 85 percent of respondents picking a provider, and for 65 percent, coverage would be either the decider or a major factor in trying the treatment.
Build the map around the payers your patients actually carry. Respondents reported:
Those are multi-select answers from a regional sample, not your panel, but the lesson holds: commercial plans and Medicaid are nearly tied, so a map built on one misses a large share of patients. A referral list that works only for commercial plans leaves out a large share of Missourians. For each destination, note whether it accepts MO HealthNet managed care plans, traditional Medicare, Medicare Advantage, and TRICARE.
After coverage, proximity was the most commonly chosen priority, at 43 percent. Delivery preference leaned toward in-person settings: 44 percent preferred a clinic, and 23 percent liked a clinic start with care later shifting home, a combined two-thirds wanting a physical site involved.
For Missouri, geography is the stubborn variable. A patient in the Bootheel or north of the Missouri River may be hours from the nearest certified esketamine center. Esketamine sessions require a ride home, and the early phase involves frequent visits. When you refer, ask the patient about transportation at the same time. Note any Medicaid non-emergency transportation benefit that may apply.
Awareness is low, so the handoff has to do some teaching. Most respondents, 73 percent, drew a blank on Spravato. About a quarter knew what TMS was. A patient told "I am referring you for esketamine" without context may not follow through.
A one-page handout helps. Include:
Send the receiving clinician, and by extension the payer, what they will need:
Referral maps go stale quickly. Assign someone in the practice to recheck each destination every few months: still accepting new patients, still in network, still offering the service. A map with two reliable destinations beats a list of ten that no one has called.
Make crisis information part of every depression handoff. Patients in any Missouri county can call or text 988, day or night, for the Suicide and Crisis Lifeline, with a press-1 line for veterans, and they should hear that from you before they leave the room.
Pollfish fielded the survey to its consumer panel, gathering 443 completed questionnaires from adults 18 to 64 in Kansas, Missouri, Wisconsin, Iowa, Indiana, Minnesota, Illinois, Nebraska, Ohio, and Oklahoma before a June 23, 2026 close. We cite top-line percentages, and multi-select totals exceed the sample. Every figure is from the final, validated Pollfish export. Our publisher commissioned and funded the study. This guide supports clinical judgment and does not replace it.