TMS and ketamine can be used together for treatment-resistant depression, and emerging research suggests the combination may be more effective than either treatment alone. The challenge is logistical: most NYC clinics specialize in one modality, which means patients often end up coordinating care across two separate providers. Integrated treatment, where one psychiatric team manages both under a single plan, simplifies this process.
When you need both TMS and ketamine therapy for treatment-resistant depression, you usually end up at two different clinics. One handles TMS sessions. The other provides ketamine infusions. Each has its own intake process, its own psychiatrist, and its own insurance authorization. The two teams rarely talk to each other.
This fragmented setup creates real problems: delays in starting treatment, conflicting medication decisions, and weeks spent managing paperwork instead of focusing on recovery. Integrated care, where one psychiatric team manages both TMS and ketamine under a single treatment plan, solves most of these issues.
Here’s how the coordination gap affects people seeking treatment in New York City, what the evidence says about combining these two modalities, and why a unified approach can make the process faster, simpler, and more effective.
The multi-clinic coordination problem
Most mental health clinics in NYC specialize in one treatment modality. A clinic offering transcranial magnetic stimulation (TMS) may not offer ketamine infusion therapy. A clinic providing IV ketamine may refer you elsewhere for TMS. TMS is a non-invasive treatment that uses magnetic pulses to stimulate underactive brain regions. IV ketamine is a rapid-acting treatment that works through the brain’s glutamate system to support new neural connections.
This creates a chain of handoffs. Your TMS provider doesn’t know your ketamine dosing schedule. Your ketamine provider doesn’t see how you responded to last week’s TMS session. Neither coordinates with the other on timing, medication interactions, or treatment adjustments.
The practical consequences add up:
- Two separate intake evaluations, each requiring its own medical history, psychiatric assessment, and treatment plan
- Two insurance pre-authorization requests, which can each take one to three weeks to process
- No shared outcome tracking, so neither provider sees the full picture of your progress
- Conflicting scheduling that may leave gaps in treatment during the most acute phase of depression
For someone already dealing with severe depression, managing two sets of appointments, two billing departments, and two care teams adds a logistical burden at the worst possible time.
Why it matters to have one psychiatrist managing both
When the same psychiatrist oversees both TMS and ketamine, treatment decisions can happen in real time. If a ketamine session produces a strong initial response, the psychiatrist can adjust TMS timing to reinforce that response during the window of heightened neuroplasticity (the brain’s ability to form and reorganize neural connections). While no studies have directly compared outcomes between integrated and multi-clinic models, the clinical logic for real-time coordination is supported by what we know about how these treatments interact with brain plasticity. If TMS sessions reveal a pattern of improvement in certain symptom clusters, the ketamine protocol can be modified accordingly.
This kind of cross-modality decision-making is difficult when two separate providers are involved. Information gets relayed through patient self-reports or faxed notes, and decisions that could happen in hours take days or weeks.
An integrated model also simplifies medication management. Many people undergoing TMS or ketamine treatment are also taking antidepressants or other psychiatric medications. One psychiatrist can manage all of these together, adjusting doses based on how you respond to each modality rather than making changes in isolation.
At Nushama, the same care team manages TMS scheduling, ketamine infusions, medication adjustments, and preparation and integration support. There’s no referral to a second clinic, no duplicated paperwork, and no gap between modalities. Your psychiatrist sees every data point, from your PHQ-9 scores (a standard questionnaire that measures depression severity on a 0–27 scale) to your session-by-session responses, in one chart.
TMS and ketamine: when to sequence, when to combine
The question isn’t whether TMS or ketamine is better. It’s how they work together, and when each one is most useful.
IV ketamine can produce meaningful mood improvement within hours to days. A 2025 network meta-analysis in Psychiatry and Clinical Neurosciences Reports found no significant differences in response rate, remission rate, or tolerability between IV ketamine, rTMS, and ECT for treatment-resistant depression, though the authors cautioned that confidence in the evidence remains low due to limited study sizes. Ketamine’s speed advantage is supported by a separate body of research showing meaningful mood improvement within hours and reduction of suicidal thoughts within 24 to 72 hours of administration.
TMS works on a different timeline. It typically requires daily sessions over several weeks before full effects emerge. But the improvements it produces tend to build progressively. A 2024 study in the American Journal of Psychiatry found TMS produced a 37.5% response rate versus 14.6% for switching antidepressants in people with moderate treatment-resistant depression.
The combination approach uses each treatment’s strength to cover the other’s gap:
| Phase | Timeline | Approach |
|---|---|---|
| Acute stabilization | Weeks 1-2 | Ketamine may provide rapid stabilization for people in crisis, especially those experiencing suicidal ideation or severe functional impairment. This creates a window where the person can engage more fully in their TMS protocol and other therapeutic work. |
| Building | Weeks 2-6 | TMS sessions build on the initial ketamine response, reinforcing neural pathway changes over time. The same psychiatrist can observe how these two modalities interact in real time and adjust both protocols as needed. |
| Maintenance | Week 6 onward | Based on response patterns, the care team determines the right maintenance schedule, which might include periodic ketamine sessions, continued TMS, medication adjustments, or a combination. |
A 2023 review in Frontiers in Neuroscience noted the potential synergy of rTMS and ketamine, recommending “full protocols of both methods in a parallel, yet non-simultaneous, manner.” A retrospective study by Best et al. (2019) found a statistically significant reduction in symptom severity among 28 patients receiving combined TMS and ketamine, with improvements sustained over a two-year follow-up period.
The evidence base is still early. A 2024 systematic review in Cureus examined six studies, including case reports and one retrospective analysis, and concluded that “the combination of TMS and ketamine presents a promising treatment modality for patients with TRD.” However, the review noted that no randomized controlled trials have been completed for this combination and called for larger, controlled studies to confirm these preliminary findings.
No one should combine these treatments without close medical supervision. The sequencing, dosing, and timing should always be individualized by a psychiatrist who understands both modalities.
One authorization instead of two: the insurance reality
Insurance navigation is one of the most stressful parts of starting TMS therapy in NYC. TMS requires prior authorization from most insurance companies, a process that involves documenting your diagnosis, medication history, and clinical necessity. This can take one to three weeks depending on the insurer.
Now add ketamine to the picture. If you’re getting ketamine at a separate clinic, that’s a second pre-authorization process, often with different documentation requirements. Some insurers require evidence that you’ve failed multiple medication trials before approving either treatment. When two different clinics submit these requests independently, there’s no coordination on how your treatment history is presented.
With an integrated approach, one care team handles the entire authorization process:
- A single clinical file documents your full treatment history, making the case for medical necessity more complete and consistent
- Pre-authorization for both modalities can be submitted as part of one coordinated treatment plan
- When TMS is the insurance-covered anchor, ketamine sessions can sometimes be documented as augmentation within that treatment framework, potentially improving coverage
- If a prior authorization is denied, the same psychiatrist who knows your full history handles the appeal
Most major insurers in New York, including Aetna, UnitedHealthcare, Cigna, and Medicare, cover TMS for treatment-resistant depression when prior authorization criteria are met. Coverage for ketamine varies more widely, but having one team manage the documentation for both treatments removes about half the administrative burden.
At Nushama, the care team manages insurance paperwork so you can focus on getting better. If you have questions about what your plan covers, the team can walk you through your options before you commit to anything.
What to consider before starting integrated treatment
Combined TMS and ketamine treatment is not right for everyone. Both modalities have their own eligibility criteria and contraindications. TMS may not be appropriate for people with certain implanted devices, and ketamine infusion therapy requires medical screening for cardiovascular conditions and certain psychiatric conditions.
A thorough psychiatric evaluation is the first step. This assessment looks at your treatment history, current symptoms, medical conditions, and goals to determine which combination of treatments, if any, makes sense for your situation.
Some things to keep in mind:
- A standard TMS course typically costs between $6,000 and $10,000, though extended or specialized protocols can run higher. Ketamine infusion sessions add to that total. Insurance coverage, when available, can substantially reduce out-of-pocket costs.
- Treatment timelines differ. Some people notice improvement within days (especially with ketamine); for others, it takes several weeks of consistent TMS sessions. An integrated care team can set realistic expectations based on your specific presentation.
- Integration support matters. Both TMS and ketamine can bring up difficult emotions or shift how you experience daily life. Having preparation and integration sessions built into the treatment plan helps you process these changes in a supported environment.
If you’re exploring options for treatment-resistant depression and want to understand whether integrated TMS and ketamine care could be a good fit, book a consultation with Nushama’s care team. The conversation covers your history, your goals, and what a personalized treatment plan might look like. There’s no obligation to commit before you’re ready.
FAQs
Can TMS and ketamine be used at the same time?
Yes, emerging research supports using TMS and ketamine together for treatment-resistant depression. A 2023 review in Frontiers in Neuroscience recommended parallel protocols administered non-simultaneously, meaning both treatments within the same treatment period but not during the same session. The combination should always be managed by a qualified psychiatrist who can monitor for interactions and adjust protocols based on your response.
Does insurance cover both TMS and ketamine in NYC?
TMS is covered by most major insurance plans in New York when prior authorization criteria are met, typically after two or more antidepressant trials have not provided adequate relief. Ketamine coverage varies more widely. The FDA-approved nasal spray form (esketamine, marketed as Spravato) has broader insurance coverage than off-label IV ketamine. An integrated clinic can help coordinate authorization for both treatments under one treatment plan.
How long does a combined TMS and ketamine treatment plan take?
A typical course of TMS requires daily sessions over four to six weeks. Ketamine infusions are usually scheduled two to three times per week during the initial phase, often starting in the first one to two weeks. The total treatment timeline depends on your response, but many people complete the acute phase within six to eight weeks before transitioning to a maintenance schedule.
What’s the difference between getting treatment at one clinic versus two?
At a single integrated clinic, one psychiatrist oversees both TMS and ketamine, adjusting each protocol based on your full treatment picture. With separate clinics, your providers typically don’t share records or coordinate decisions, which can lead to delays, conflicting recommendations, and duplicate insurance paperwork. Integrated care also means one set of intake documents, one billing relationship, and one team tracking your outcomes.
Ready to stop juggling two clinics? Book a consultation with Nushama’s care team to find out whether integrated TMS and ketamine treatment is the right fit for you.
