When a single-modality treatment repeatedly falls short for a patient with treatment-resistant depression, the logical clinical question becomes whether the brain’s pathways to recovery might be more successfully activated by addressing multiple neurobiological mechanisms at the same time. Research emerging over the past decade suggests that combining ketamine infusions with Deep TMS — Transcranial Magnetic Stimulation delivered through the H-coil — may produce synergistic benefits that neither treatment achieves alone. At our Bellaire practice, we are one of a small number of psychiatric providers in the Houston area offering this combination protocol, and we believe it represents a meaningful advance for the subset of patients who have not found sufficient relief from conventional or single-modality interventional treatments.
How IV Ketamine and Deep TMS Work Together
To understand why the combination works, it helps to understand what each treatment does at the neurological level. Ketamine, used here in its IV form as an off-label psychiatric treatment, acts primarily on NMDA glutamate receptors to produce a rapid but often transient antidepressant effect. One of ketamine’s most important mechanisms is its ability to promote neuroplasticity — the brain’s capacity to form new synaptic connections — particularly in regions like the prefrontal cortex and hippocampus that are structurally impaired in severe, chronic depression. This window of enhanced neuroplasticity is time-limited, typically spanning the 24 to 72 hours following an infusion. Deep TMS, which is FDA-cleared for major depressive disorder, delivers focused magnetic pulses to stimulate cortical neurons in the prefrontal regions implicated in mood regulation. When Deep TMS is timed to coincide with the neuroplastic window that ketamine opens, the theory — increasingly supported by preliminary clinical data — is that the TMS stimulation more effectively reinforces the newly formed neural pathways, extending and deepening the antidepressant response.
A Personalized Protocol at Our Bellaire, TX Practice
At Dr. Prashad’s practice, the combination protocol is designed individually for each patient. We do not apply a single template, because the relative timing of ketamine infusions and TMS sessions, the frequency of TMS, and the overall duration of the combined course all depend on a patient’s neurobiological profile, prior treatment history, and response patterns. Dr. Prashad’s experience administering over 9,000 treatments gives her unusual insight into how patients with varying patterns of treatment resistance respond to different protocols, and this informs how we structure the combination approach. The process begins with a thorough evaluation in which we map your history, understand the specific clinical features of your depression — including any seasonal component, anxiety comorbidity, or cognitive symptoms — and build a plan that reflects your individual situation rather than a generic protocol.
One of the most common questions we hear from patients considering the combination approach is whether it is safe. Deep TMS is FDA-cleared and has a well-established safety profile established through clinical trials and widespread clinical use. IV ketamine‘s side effect profile, including transient dissociation and blood pressure elevation during infusions, is well-documented and managed through clinical monitoring. When the two are used in combination, the safety profile of each modality remains essentially unchanged — they are administered in separate sessions, not simultaneously, and we monitor patients closely throughout both. We are careful to establish each patient’s tolerance for ketamine before introducing TMS and to assess TMS response before determining whether the combination protocol is the right direction.
Treatment Burden, Cost, and Candidacy for Houston Patients
A barrier that keeps some patients from pursuing the combination protocol is the perceived intensity of committing to two concurrent treatment modalities. Depression itself depletes energy, motivation, and executive function — and asking someone in the depths of a depressive episode to coordinate both ketamine infusion appointments and TMS sessions can feel overwhelming before it even begins. We address this directly by managing the scheduling on behalf of patients to the greatest extent possible, coordinating appointments close together when clinically appropriate, and maintaining flexible communication so that patients can flag when they need the pace adjusted. Our team understands that the patient experience of initiating this level of treatment is emotionally and logistically demanding, and we structure our support accordingly.
The question of cost is the second barrier we engage with honestly and early. A combination protocol involves more sessions than either treatment alone, and because IV ketamine for psychiatric indications is off-label, its cost is typically out-of-pocket. Deep TMS, which is FDA-cleared, has different insurance pathways that we help patients explore before assuming the entire protocol will be self-pay. We walk through the financial picture during the initial consultation so patients can make a fully informed decision about whether the combination protocol fits their circumstances, and so we can identify whether there are ways to sequence treatments that make sense both clinically and financially. Results vary by individual, and we never promise a specific level of response, but we can share what we have observed across the patients in our practice who have completed combined protocols.
For patients who are not yet at the point of considering combination therapy, we offer each modality independently. IV ketamine as a standalone approach and Deep TMS as a standalone approach each have meaningful evidence bases and clinical utility for treatment-resistant depression. The combination protocol is not necessarily a first step — it is often best suited for patients who have tried one modality and found partial but incomplete response, or for whom the severity and chronicity of their depression makes the most aggressive evidence-based approach the right clinical choice from the outset. Discuss with your provider where you sit on that spectrum and which starting point reflects your clinical picture, your goals, and your practical capacity.
Frequently Asked Questions
How is Deep TMS different from traditional TMS for depression?
Deep TMS uses an H-coil design that stimulates neurons at greater depth and breadth within the prefrontal cortex compared to conventional figure-eight TMS coils. The H-coil has FDA clearance for major depressive disorder, and the technology used at our practice has been studied specifically for its ability to reach the subcortical circuits involved in mood regulation. The practical difference for patients is that the stimulation field is broader and penetrates more deeply into the relevant brain regions.
Does combining ketamine and TMS mean I do double the number of sessions?
Not exactly. The specific schedule is designed by Dr. Prashad based on your clinical profile. In most combination protocols, ketamine infusions are timed to precede TMS sessions during the window of enhanced neuroplasticity, which means the ketamine infusion schedule and TMS session schedule overlap rather than running fully in parallel as independent full-length courses. The total treatment burden is greater than either alone, but it is not simply additive.
Can I try the combination protocol if I’ve already done TMS without adequate response?
Yes — in fact, patients who have had a partial response to TMS alone are among the most promising candidates for a combination approach. The addition of ketamine may reopen neuroplastic pathways that have become less responsive to TMS stimulation alone. We review prior TMS response in detail during evaluation, including the coil used, protocol employed, and degree of response, to determine how to calibrate the combined approach.
Is the ketamine used in this combination the same as SPRAVATO®?
No. The ketamine component of this combination protocol refers to IV ketamine, used off-label as a psychiatric treatment. SPRAVATO® is a different FDA-approved drug — esketamine nasal spray — with its own distinct approval history and administration requirements. At our practice, we can discuss whether SPRAVATO® might be a component of a combination strategy for some patients, but the combination protocol we have developed uses IV ketamine alongside Deep TMS.
How do I know if the combination protocol is right for me?
The combination protocol is most appropriate for patients with documented treatment-resistant depression who have tried and had insufficient response to standard antidepressants and possibly to one or more single-modality interventional treatments. The evaluation process at our Bellaire practice is designed precisely to answer this question — we map your treatment history, your current symptom profile, and your neurobiological risk factors to determine which treatment path is most appropriate. Results vary by individual.
Key Takeaways
- Combining IV ketamine with Deep TMS is designed to leverage the neuroplastic window that ketamine opens, allowing TMS stimulation to more durably reinforce new neural pathways.
- Ketamine used in psychiatric practice is off-label; Deep TMS is FDA-cleared for major depressive disorder.
- The combination protocol is individualized — Dr. Prashad designs timing, frequency, and duration based on each patient’s clinical history.
- Cost and treatment burden are real considerations; our team addresses both transparently during the initial consultation.
- This multi-modal approach is not a first-line recommendation for everyone — it is most appropriate for patients with severe or long-standing treatment resistance.
If you have tried multiple antidepressants, and perhaps a single interventional treatment, without reaching the level of relief you need, the combination of IV ketamine and Deep TMS may be the most meaningful next step available to you. At our Bellaire office, Dr. Prashad has the clinical experience and the full range of tools to build a protocol specifically for where you are. We encourage you to schedule a consultation and bring your complete treatment history — let us help you determine whether this approach belongs in your path forward. Discuss with your provider all available options, and take that first step toward a consultation. It costs nothing to explore, and it could change everything.
References
FDA — TMS Device Clearances: https://www.fda.gov/medical-devices/neurological-devices/transcranial-magnetic-stimulation-tms-devices
Journal of Psychiatric Research — Ketamine + TMS Combination: https://www.journals.elsevier.com/journal-of-psychiatric-research
National Institute of Mental Health — Brain Stimulation Therapies: https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies
JAMA Psychiatry — Neuroplasticity and Ketamine: https://jamanetwork.com/journals/jamapsychiatry
American Psychiatric Association — Treatment-Resistant Depression: https://www.psychiatry.org/patients-families/depression
About Dr. Sandhya Prashad
Dr. Sandhya Prashad, MD, is a board-certified psychiatrist who has been treating patients in the Houston area since 2011, specializing in treatment-resistant depression and interventional psychiatric care. She has personally administered over 9,000 treatments for patients whose depression has not responded to traditional antidepressants, developing deep expertise in the neurobiological factors — including seasonal triggers, environmental stressors, and genetic predisposition — that shape treatment response. Dr. Prashad’s practice offers IV ketamine therapy, SPRAVATO® (esketamine), and comprehensive psychiatric evaluation, with a commitment to finding a path forward even for the most complex and long-standing cases.
Medical Disclaimer
The information provided in this article is intended for educational purposes only and does not constitute medical advice. It is not a substitute for professional psychiatric evaluation, diagnosis, or treatment. Results vary by individual, and not all patients will experience the same outcomes from ketamine therapy, Deep TMS, or a combination of both. Always discuss your treatment options with a qualified medical provider before making any changes to your care plan. If you are experiencing a psychiatric emergency or thoughts of self-harm, please call 988 (Suicide and Crisis Lifeline) or go to your nearest emergency room immediately.