For many people, depression doesn’t respond the way it’s supposed to. Medications may help a little, then stop working. Therapy may provide insight, but symptoms linger. When this happens after multiple well-planned treatments, psychiatrists often describe the condition as treatment-resistant depression (TRD).
TRD can be frustrating and discouraging, but it also opens the door to treatment approaches that go beyond standard antidepressants. At the Sterling Institute, psychiatrists work with patients to evaluate next-step options based on clinical history, daily life demands, and realistic expectations. The lake view location is conveniently situated near major highways, making it accessible for patients traveling from surrounding communities, including Fairfield County and nearby areas of New York. This accessibility is especially helpful for patients attending frequent appointments, such as daily TMS sessions.
This overview explains two advanced treatments offered at Sterling—Transcranial Magnetic Stimulation (TMS) and Spravato® (esketamine)—and how decisions between them are typically made. More information is available at https://sterlingsinstitute.org.
When Depression Becomes Treatment-Resistant
Treatment-resistant depression usually means that a person has tried at least two antidepressant medications—at adequate doses and for an appropriate length of time—without meaningful improvement. For some, symptoms never fully lift. For others, relief fades quickly.
People with TRD may continue to struggle with low mood, limited motivation, disrupted sleep, slowed thinking, or difficulty functioning day to day. At this stage, a psychiatric reassessment is often helpful to determine whether advanced interventions are appropriate.
Transcranial Magnetic Stimulation (TMS)
TMS is a non-invasive brain stimulation treatment that targets areas involved in mood regulation. Magnetic pulses are delivered through a coil resting on the patient’s head. No anesthesia or sedation is used, and patients remain fully awake during treatment.
At the Sterling Institute, a typical TMS course involves:
- 36 sessions, scheduled consecutively
- Three to five days per week
- Each session lasting 20 to 45 minutes
- The ability for patients to drive themselves to and from appointments
Because TMS does not involve systemic medication, many patients are able to continue work, school, and daily responsibilities without interruption.
Spravato® (Esketamine) Ketamine Therapy
Spravato® is an FDA-approved intranasal medication used alongside an oral antidepressant for adults with treatment-resistant depression. Unlike traditional antidepressants, it acts on glutamate pathways and is administered under direct medical supervision.
Important practical considerations include:
- An induction phase of twice-weekly treatments
- Each visit lasting at least two hours for observation
- Appointments that typically begin at 8:00 AM
- A requirement that patients do not drive afterward
- A designated adult who can provide transportation and sign the patient out
For some patients, Spravato is considered when symptom severity is high or when faster relief is clinically appropriate.
How Psychiatrists Help Patients Choose
TMS and Spravato are both well-established options for treatment-resistant depression. Rather than promoting one approach over the other, psychiatrists focus on fit.
Recommendations are shaped by factors such as:
- Prior treatment response
- Medical and psychiatric history
- Lifestyle demands and scheduling flexibility
- Transportation availability
- Insurance coverage and authorization
The goal is not simply symptom reduction, but choosing a treatment a patient can realistically complete.
Combining TMS and Ketamine: An Emerging Area of Care
Some patients and clinicians ask about combining TMS and ketamine for difficult-to-treat depression. The published literature on this approach—often called combined TMS–ketamine (CTK)—is still limited, but growing.
What the literature shows so far
- Retrospective clinical series report meaningful symptom improvement in TRD patients treated with coordinated TMS and ketamine
- Individual case reports, including bipolar depression, describe substantial clinical improvement
- A 2024 systematic review notes promising outcomes while emphasizing the need for larger, standardized trials
- Ongoing clinical trials are evaluating intranasal ketamine used alongside rTMS
How combination treatment is typically approached
- Sequential: Completing a ketamine course before or after a full TMS series
- Concurrent: Scheduling ketamine sessions during an active TMS treatment course
Safety considerations
Across published reports, combined treatment has generally been described as feasible and tolerated. However, the evidence base remains heterogeneous, and decisions about combination therapy are made conservatively and individually.
A Practical, Individualized Approach
There is no single pathway that works for everyone with treatment-resistant depression. At the Sterling Institute, treatment recommendations are grounded in psychiatric judgment, current evidence, and the realities of each patient’s life.
Patients considering TMS, Spravato, or combination approaches are encouraged to discuss goals, concerns, and logistics openly with their care team.
To learn more or request an evaluation at our Danbury lake view office, visit https://sterlingsinstitute.org.
