Ketamine provides relatively rapid relief by creating psychological flexibility—patients can access and process emotions that were previously blocked. TMS works more gradually by stimulating the prefrontal cortex, and strengthening executive function, impulse control, and mood regulation through repeated daily sessions over 4-6 weeks. 

TMS is like physical therapy for your brain. An electromagnetic field stimulates specific brain regions—usually the left prefrontal cortex for depression. No surgery, no pain, just a tapping sensation on the scalp.

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This brain region controls executive function, mood regulation, and impulse control. Patients don't report sudden mood improvements day to day like they do with ketamine, but over 4 to 6 weeks of daily sessions while neural circuitry rewiring takes place, patients start feeling better.

For acute cases: start ketamine immediately for crisis stabilization, then initiate TMS while continuing ketamine maintenance. For non-acute treatment-resistant depression: start with either TMS or ketamine as the foundational treatment, adding the other one if you get only partial treatment response.

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The sequencing depends on four clinical factors:

1. What does this patient need right now? (Speed vs. durability)

2. What will they need in three months? (Crisis management vs. long-term stability)

3. What's the primary pathology? (Trauma processing vs. executive dysfunction)

4. What can they access? (Insurance coverage vs. out-of-pocket capacity)

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Not everyone needs both. But when both fit the clinical picture, combination therapy offers what neither provides alone.d re

Rapid improvement from ketamine does not appear to carry psychological risks in clinical practice. Some patients experience disorientation when symptoms improve quickly—they may interpret a single bad day as treatment failure rather than normal mood variation.

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Someone depressed for 20 years doesn't immediately understand that feeling down on Tuesday doesn't predict Wednesday. That reprogramming takes time. It's not a complication of the treatment—it's part of the recovery process.

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But rapid improvement offers something invaluable: proof the brain can still feel good. Many patients have wondered if they permanently lost that capacity. One ketamine session that produces even temporary relief shows them the switch still exists.

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That knowledge changes everything, even if the effect fades. It reframes the goal from "learn to live with this" to "figure out how to access that state consistently."e so

Although there are no known contraindications to receiving both treatments on the same day, many clinics schedule them separately (e.g., TMS on Monday and ketamine on Tuesday). In cases where both treatments are done on the same day, they would be separated by a rest period (e.g., TMS in morning, ketamine in afternoon) to allow monitoring between sessions and avoid patient fatigue.py.

Insurance typically covers TMS for treatment-resistant depression (after 2 failed antidepressant trials). IV/IM ketamine has some out-of-pocket cost though intranasal esketamine (Spravato) is FDA-approved and covered by many plans.  We recommend checking with your insurance carrier or our billing team to see if both treatments would be covered.

Both treatments have excellent safety profiles with few contraindications. TMS is contraindicated for patients with metallic implants in the head/neck. Ketamine requires careful monitoring for patients with aneurysms and uncontrolled hypertension.

What we're after is healing that sticks. Ketamine opens the door. TMS builds the foundation. Together, they offer immediate support while constructing lasting infrastructure.

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Anxiety and depression are complex conditions. Their treatments should match that complexity.