Depression Treatment: When to Consider TMS or Ketamine for Partial Response

"There's evidence that even with significant improvement, any residual symptoms of depression can make it more likely that you'll experience a relapse at some point," says Nissa Keyashian, MD, a psychiatrist in private practice in San Jose, California. That’s why it’s important to find a strategy that gives you better symptom control, whether that's switching your current medication or adding another treatment to boost its effectiveness.

Less-common options worth discussing with your doctor are transcranial magnetic stimulation (TMS), ketamine, and esketamine. Here's a look at what's involved with each and who might benefit.

It targets the dorsolateral prefrontal cortex, a region of your brain that's associated with dwelling on negative feelings and thoughts. Each treatment can last between 3 and 30 minutes, and it's delivered through a special cap fitted with a magnetic coil. TMS usually requires a patient to go into a clinic five days a week for at least a month, so it can be a time intensive.

"In terms of who is a good candidate, TMS is typically used after one or two different antidepressants have failed," says Dr. Keyashian. "Some patients who have tried antidepressants with only partial response, or who struggle with the side effects of those medications, may decide to try TMS."

"Unlike antidepressants that target serotonin and dopamine, ketamine increases synaptic plasticity, essentially helping the brain rewire and form new connections quickly," says Alex Dimitriu, MD, a psychiatrist and founder of Menlo Park Psychiatry and Sleep Medicine in California, and a medical reviewer for Everyday Health. "When someone feels horrible or is not responding to antidepressants, this type of rewiring can be helpful."

Typically used twice weekly for the first month, esketamine may be switched to weekly or biweekly after that point. You need to be monitored for at least two hours after each treatment for potential side effects. Esketamine can raise your blood pressure and can cause extreme sleepiness, fainting, trouble breathing, and a kind of mental disconnect called dissociation.

A major consideration when looking at TMS and ketamine is cost, particularly because some health insurers don't cover either option.

"While TMS and esketamine are increasingly covered, they often require extensive documentation of prior failed treatments," Dr. Dimitriu says. "Generic ketamine is frequently easier to administer and costs less, but it is still an out-of-pocket expense when it is used off-label for depression."

If you’re interested in these treatments, check with your insurance provider to see if they’re covered under your plan and what steps you need to take to get approval.

Although TMS and ketamine may be options to consider, they're not for everyone. Other strategies can boost the effectiveness of your current depression treatment, including adjusting your dosage, adding other medications, taking part in psychotherapy, and implementing lifestyle changes, says Naomi Torres-Mackie, PhD, a clinical psychologist at Northwell Lenox Hill Hospital in New York City.

"The first step here is to get clear on your own understanding of how well you think treatment is working, and then talk to your provider," she says. "If you and your provider agree that your treatment is not working, ask what your options are — emphasis on plural, so that you can have more than one option to weigh. You might also ask your provider why they think treatment stopped working so that you can prevent it from happening again."

Bridging the gap between treatment response and remission — between feeling better and feeling well — can take time and effort, Dr. Torres-Mackie says. Making sure that you know all your options, and having an in-depth conversation with your healthcare provider about the pros and cons of each, can help you feel more in control of your condition.

• If you’re taking an antidepressant for major depressive disorder, you might need additional treatment to bridge the gap between treatment response and remission.
• Two options for greater depression symptom relief are transcranial magnetic stimulation and ketamine or esketamine, which work differently than traditional antidepressants.
• You may need to show that at least two other types of depression treatment haven’t worked before your health insurance will cover either of these treatments.