TMS and Ketamine Together: What Clinicians Need to Know

We recently received a question from a psychotherapist in our KAP network that we think many clinicians are asking:

"I have a client whose depression has returned after a course of TMS. They're weighing whether to try ketamine, repeat TMS, or do both at the same time. Is there any reason they can't do TMS and ketamine concurrently?"

This is an increasingly common clinical scenario. Here's what the current evidence says.

Are TMS and Ketamine Contraindicated Together?

No. There is no known contraindication to concurrent TMS and ketamine therapy. In fact, a growing body of research suggests the combination may be synergistic.

A 2024 systematic review in Cureus analyzed six studies on combined TMS-ketamine treatment and found:

• Substantial and sustained improvement in depressive symptoms across all studies
• Adverse effects were generally mild and transient — nausea, vertigo, local discomfort
• Zero patient dropouts during combined therapy across all reviewed studies
• One retrospective study showed Clinical Global Impression scores dropping from 6.1 to 1.7, with improvements sustained at two-year follow-up

A case report published in the American Journal of Psychiatry Residents' Journal (2025) documented concurrent TMS and IV ketamine leading to full symptom remission in a patient with treatment-resistant depression.

Why the Combination May Work

TMS and ketamine target different but complementary mechanisms:

• TMS uses magnetic pulses to stimulate specific brain regions (typically the left dorsolateral prefrontal cortex), modulating neural circuits involved in mood regulation
• Ketamine works through NMDA receptor antagonism, triggering a rapid cascade of glutamate release, BDNF production, and synaptogenesis

The theory is that ketamine's rapid neuroplasticity "primes" the brain, making it more responsive to TMS's targeted neuromodulation. A 2024 pilot study of 235 participants with treatment-resistant MDD found that both Deep TMS alone and Deep TMS + IV ketamine showed significant symptom reduction.

When a Patient Has Tried TMS Before and Depression Recurs

Depression recurrence after TMS is common — it doesn't mean TMS "failed." It means the effects weren't permanent, which is true of most depression treatments.

For a patient in this situation, the clinical decision involves several factors:

Consider ketamine if:

• The patient wants faster relief (ketamine can work within days; TMS typically takes 4-6 weeks)
• Previous TMS produced only partial response
• The patient prefers at-home treatment over daily clinic visits
• Comorbid anxiety is prominent (ketamine shows strong anxiolytic effects — 92.6% of Isha Health patients with elevated anxiety reach minimal levels)
• Cost is a factor (Isha Health: $350 per appointment covering approximately one month of treatment, plus $50-150/month for medication vs TMS: $300-400 per session, typically 36 sessions over 6-9 weeks)

Consider repeating TMS if:

• TMS produced strong response previously and recurrence is recent
• The patient prefers a non-pharmacological approach
• There are contraindications to ketamine (uncontrolled hypertension, active psychosis, pregnancy)

Consider both if:

• The depression is severe or treatment-resistant to multiple approaches
• The patient is open to a multimodal strategy
• You want to leverage ketamine's rapid neuroplasticity alongside TMS's targeted stimulation

What the Guidelines Say

The CANMAT 2023 clinical guidelines position both rTMS and ketamine/esketamine as valid options after pharmacological failures. They recommend a personalized approach considering speed of onset, comorbidities, patient preferences, and treatment accessibility.

Notably, the guidelines do not list concurrent use as contraindicated. The field is moving toward multimodal treatment rather than sequential monotherapy.

How Isha Health Can Help

If your client decides to explore ketamine, here's how the collaboration works:

1. You refer the patient to Isha Health for a medical evaluation
2. Our physician evaluates candidacy, prescribes ketamine, and monitors medical safety
3. You continue providing therapy — ideally timed within the neuroplasticity window after each ketamine session
4. We coordinate with you on dosage, frequency, and response tracking

The patient can continue TMS with their TMS provider concurrently. We recommend scheduling ketamine sessions on different days than TMS sessions for patient comfort, though there's no medical requirement to separate them.

Our clinical outcomes across 500+ patients show an 88.8% improvement rate for moderate-to-severe depression using this collaborative model.

The Bottom Line

TMS and ketamine are not contraindicated together. The emerging evidence suggests they may be complementary. For a patient with depression recurrence after TMS, adding ketamine — especially oral ketamine that can be done at home — is a reasonable and increasingly evidence-supported option.

The most important thing is that the patient has a coordinated care team: a prescribing physician managing the ketamine, a TMS provider if they continue that treatment, and a therapist like you providing the integration work that makes both treatments more effective.

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References:

• Arubuolawe OO et al. Combination of Transcranial Magnetic Stimulation and Ketamine in Treatment-Resistant Depression: A Systematic Review. Cureus. 2024.
• Concurrent TMS and Ketamine Therapy: Case Report. American Journal of Psychiatry Residents' Journal. 2025.
• Synergistic use of deep TMS therapy with IV ketamine infusions for MDD: a pilot study. Psychopharmacology. 2024.
• CANMAT Clinical Guidelines for Treatment-Resistant Depression. 2023.

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