Everything you need to know about TMS and Ketamine Together: The Combination Therapy Patients Are Asking About — how it works, what it costs, and how to find a provider who actually knows what they're doing.
TMS vs. Medication: A Side-by-Side Guide
Free PDF — compare effectiveness, side effects, cost, and timelines so you can choose with confidence.
TMS and ketamine are different kinds of treatment. TMS uses magnetic pulses to stimulate specific brain regions, usually over weeks. Ketamine acts on the glutamate system and can produce rapid effects that tend to fade without repeat dosing. Its nasal-spray form, esketamine (Spravato), is FDA-approved for treatment-resistant depression. Some clinics offer both, and patients increasingly ask whether combining them makes sense.
What You’ll Learn
- Why people are interested in combining TMS and ketamine
- What the evidence does and does not show
- How the two treatments differ in regulatory status and coverage
- Who should be cautious
- Questions to ask a clinic that offers both
Why the combination is of interest
Because the two treatments act through different mechanisms and on different timelines, some clinicians and researchers have wondered whether a fast-acting drug could help bridge the weeks it can take for TMS to work, or whether the two might complement each other. This is a hypothesis rather than an established benefit.
What the evidence shows
Published reports on combining TMS with ketamine or esketamine are, as far as we could find, mostly case reports, small observational studies, and naturalistic comparisons. For example, recent literature includes case reports of esketamine combined with accelerated theta burst stimulation and of ketamine infusions combined with accelerated theta burst stimulation in treatment-resistant bipolar depression (Front Psychiatry, 2026; Asian J Psychiatr, 2026). We did not find large randomized trials showing that the combination outperforms either treatment alone, so any claims of specific remission rates for the combination should be treated skeptically.
Spravato vs. IV ketamine
- Spravato (esketamine nasal spray) is FDA-approved for treatment-resistant depression and must be administered in a certified healthcare setting with monitoring after dosing. Insurance coverage varies by plan.
- IV ketamine is used off-label for depression. It is generally not covered by insurance, and protocols vary by clinic.
The two are different drugs with different regulatory status, and whether one is better than the other when combined with TMS has not been established.
Cost
Costs vary widely by clinic, insurance plan, and treatment schedule. TMS is commonly covered for treatment-resistant depression when criteria are met, Spravato is covered by many plans with prior authorization, and IV ketamine is usually self-pay. Ask each clinic for an itemized written quote and check coverage with your insurer before starting either treatment.
Who should be cautious
Ketamine and esketamine are not appropriate for everyone. Conditions that generally call for caution or exclusion include active substance use disorders (ketamine has misuse potential), uncontrolled hypertension (ketamine can raise blood pressure), a history of psychosis, and certain cardiovascular conditions. TMS also has its own screening requirements, such as seizure risk and metal implants near the head. A psychiatrist should screen you for both.
Questions to ask a clinic offering both
- What evidence supports combining the two for my situation?
- Who supervises the ketamine or esketamine sessions, and what monitoring is used?
- How do you sequence the treatments?
- Do you coordinate with my prescribing psychiatrist?
- What will each part cost, in writing?
Use our provider directory to find TMS clinics and ask about additional treatments they offer.
Key takeaways
- TMS and ketamine/esketamine work differently, and some clinics offer both.
- Evidence for combining them is limited to case reports and small studies; it is not an established protocol.
- Spravato is FDA-approved for treatment-resistant depression; IV ketamine is off-label.
- Discuss risks, costs, and alternatives with a psychiatrist before combining treatments.
