IV Ketamine, TMS and ECT for Depression and Whole-Person Wellness
A Plano physician compares IV ketamine, TMS and ECT for treatment-resistant depression and explains why whole-person care matters after treatment.
A HILLMED perspective on treatment-resistant depression, what comparative studies show, and why an individualized wellness plan matters beyond the initial treatment series.
By Jerron C. Hill, M.D., Anesthesiologist and Founder of HILLMED
When depression has not improved after at least two adequate antidepressant trials, it is often described as treatment-resistant. IV ketamine, transcranial magnetic stimulation (TMS), and electroconvulsive therapy (ECT) are options with research supporting their use. Choosing among them requires a careful review of symptoms, prior treatment, medical history, and patient preferences.
At HILLMED, we provide IV ketamine and focus on whole-person wellness. In my clinical experience, I see more sustainable improvement in some patients when treatment is paired with an individualized, multimodal approach to mental health. That means addressing daily stress, sleep, movement, nutrition, and ongoing psychological and psychiatric care. This is a clinical observation, not a guarantee of lasting benefit or proof that our approach is superior to TMS or ECT.
The three treatments at a glance
IV ketamine | TMS | ECT | |
|---|---|---|---|
How it works | A low-dose IV medication that acts on the brain's glutamate system | Magnetic pulses stimulate a mood-related area of the brain | A brief, controlled seizure induced under general anesthesia |
Typical schedule | A series of infusions, often twice a week at first | Sessions on most weekdays, typically over about six weeks | Sessions several times a week over a few weeks |
Anesthesia | No general anesthesia; sedation and monitoring required | No | Yes, general anesthesia each session |
How quickly it can work | Often within hours to days | Usually over several weeks | Over one to several weeks |
Main side effects | Dissociation during the infusion, temporary rise in blood pressure, nausea | Usually mild, such as headache or scalp discomfort | Memory problems, muscle aches, and the risks of anesthesia |
Can you drive home? | No, you need a driver | Yes, usually | No |
[1, 2, 3]
What the research shows
Evidence supports all three options. A 2025 network meta-analysis of 69 randomized trials involving 10,285 participants found benefits for ECT, TMS, theta-burst stimulation, and ketamine. ECT had the largest estimated response effect versus placebo or sham. These comparisons draw on different studies and patient populations; they do not establish which option is best for an individual. [1]
Ketamine and ECT head to head. The 2023 ELEKT-D trial randomized 403 patients with nonpsychotic treatment-resistant depression to three weeks of IV ketamine or ECT. Response rates were 55.4% and 41.2%, respectively. Ketamine met the trial's criterion for noninferiority. ECT was associated with greater short-term memory-recall decline, which gradually improved during follow-up; ketamine was associated with dissociation. These findings do not establish superiority across all forms of depression or long-term outcomes. [2]
Faster TMS. Standard TMS usually takes about six weeks. A newer accelerated protocol from Stanford gives many sessions a day over five days. In a small 2022 trial of 29 people, depression scores fell by 52.5% with active treatment and 11.1% with sham treatment four weeks later. It's promising, but the trial was small and longer-term results are still being studied. [3]
How I think about choosing
There's no single best treatment for everyone. In my experience, these questions matter most:
How quickly do you need relief? Ketamine can work within hours to days, which matters when depression is severe. If you're having thoughts of suicide, call or text 988 or go to an emergency room first.
How much time can you commit? TMS means frequent visits over several weeks, ECT means several sessions a week under anesthesia, and ketamine usually means a series of infusions followed by a maintenance plan.
What about memory and anesthesia? TMS does not require anesthesia. IV ketamine for depression uses subanesthetic doses but can cause sedation and altered perception and requires monitoring. ECT requires general anesthesia and may cause memory difficulties, including persistent gaps in some patients. Each option needs an individualized risk discussion.
What's your medical history? Uncontrolled high blood pressure or a history of substance misuse needs careful evaluation before ketamine. ECT remains an important option for severe depression, including depression with psychotic features, which the ELEKT-D trial didn't include.
What have you already tried, and what will support recovery afterward? Review prior medications, psychotherapy, TMS, ECT, and ketamine, including how long any benefit lasted. Ongoing treatment and daily wellness practices belong in the discussion from the beginning.
If you're already considering esketamine (Spravato), our guide to IV ketamine and Spravato explains how those two compare. People with bipolar disorder should read about ketamine for bipolar depression.
The HILLMED approach to whole-person wellness
At HILLMED, we provide physician-supervised IV ketamine therapy at our Plano clinic. Every patient starts with a medical and psychiatric evaluation, and we coordinate with your psychiatrist or other physicians. If TMS or ECT would serve you better, we'll tell you. To learn more about ketamine itself, read about ketamine for treatment-resistant depression and what to expect at your first infusion.
Clinical experience and lasting improvement
Over nine years of providing IV ketamine, I have cared for patients who previously received ECT or TMS. Some described relief lasting approximately six months before symptoms returned. These individual experiences do not define the typical duration of benefit for either treatment. They reinforce why I discuss a continuing care plan rather than focusing only on the initial response.
In my practice, I see sustainable results in some patients when IV ketamine is part of a multimodal approach. Our goal is to help people function better in everyday life while building habits that support their physical and emotional health. The comparative trials above did not test the HILLMED wellness approach, so they cannot tell us how much it adds to treatment or whether it prevents relapse.
What a whole-person plan includes
Stress management and mindfulness. We educate patients about recognizing stress patterns and practicing realistic coping skills, such as paced breathing, mindfulness, and planned time for rest.
Sleep. We discuss consistent sleep and wake times and encourage evaluation of persistent insomnia, sleep apnea symptoms, or other barriers to restorative sleep.
Movement and nutrition. We encourage physical activity suited to each patient's health and abilities, along with balanced meals and practical eating habits. Depression can make these steps difficult; goals should be manageable and adjusted as recovery progresses.
Psychotherapy and psychiatric care. We encourage appropriate therapy and coordination with prescribing clinicians. Wellness practices complement medical treatment, and medications should not be changed without the prescriber's guidance.
Follow-up and maintenance. We review mood, daily functioning, tolerability, and the duration of benefit. Additional infusions or other treatments are considered individually. Relapse can occur after ketamine, TMS, or ECT; no fixed six-month outcome or permanent response should be promised.
Safety
Common effects of IV ketamine include dissociation, temporary increases in blood pressure and heart rate, nausea, dizziness, and sedation. Repeated exposure also warrants attention to misuse, urinary symptoms, and liver problems. [4] Ketamine is not FDA-approved for depression; its use is off-label. A physician monitors every infusion at HILLMED, and you'll need someone to drive you home.
If you are having thoughts of suicide, call or text 988 for the Suicide & Crisis Lifeline, or call 911.
Frequently asked questions
Is ketamine better than TMS?
Neither is better for everyone. Both have strong evidence for treatment-resistant depression. Ketamine often works faster, while TMS doesn't involve medication and lets most people drive themselves home. The right choice depends on your symptoms, schedule and medical history. [1]
Is ketamine as effective as ECT?
In ELEKT-D, IV ketamine met the noninferiority criterion versus ECT for short-term response in nonpsychotic treatment-resistant depression. Response is improvement, not necessarily remission or lasting recovery. These findings do not apply to every form of depression. ECT remains an important option for severe and psychotic depression. [2]
Can I have ketamine if TMS didn't work for me?
IV ketamine may be considered after an inadequate response to TMS or ECT, but benefit is not assured. Bring your prior treatment records so we can assess whether it is appropriate for you.
Can ketamine and TMS be used together?
Combining ketamine and TMS remains an area of investigation. Evidence is more limited than for either treatment alone, and the studies cited here do not establish that combining them improves long-term outcomes. Any combination should be coordinated by the treating clinicians.
Do I need to stop my antidepressants?
Usually not. Ketamine and TMS are often added to an existing treatment plan. Don't change any medication without talking to the physician who prescribes it.
Does insurance cover ketamine, TMS or ECT?
Coverage varies. Insurance plans often cover TMS and ECT when certain criteria are met, while IV ketamine is often not covered. Contact HILLMED for current pricing and payment information, and check coverage directly with your insurer.
Learning more about treatment
Choosing IV ketamine, TMS, or ECT is one part of a broader recovery plan. At HILLMED, we emphasize individualized care and whole-person wellness, with attention to stress management, mindfulness, sleep, exercise, nutrition, and coordination with your mental health clinicians.
To learn more, book a complimentary teleconference consultation online or call HILLMED at 972.212.4341. We serve patients in Plano and throughout Dallas–Fort Worth, including Dallas, Frisco, Richardson, and McKinney.
About the author
Jerron C. Hill, M.D., is an anesthesiologist and the founder of HILLMED in Plano, Texas, and Dr. CBD & Nutrition Centers in University Park. He brings decades of anesthesia experience and nine years of clinical experience treating patients with IV ketamine to individualized, physician-supervised care, and personally formulates the Dr. CBD line of third-party-tested CBD products and supplements.
Selected references
Saelens J, et al. Relative effectiveness of antidepressant treatments in treatment-resistant depression: a systematic review and network meta-analysis of randomized controlled trials. Neuropsychopharmacology. 2025;50(6):913–919.
Anand A, et al. Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression. N Engl J Med. 2023;388(25):2315–2325.
Cole EJ, et al. Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial. Am J Psychiatry. 2022;179(2):132–141.
Pfizer. Ketamine Hydrochloride Injection prescribing information.
This article is for education only and is not medical advice. Talk with your physician before starting or changing any treatment.
