207. Treatment-Resistant Depression: TMS, Ketamine, Spravato, and What Comes Next | Rocky Sullivan, DO

EPISODE DESCRIPTION If antidepressants haven't worked, is that the end of the road? Dr. Patrick "Rocky" Sullivan returns to break down transcranial magnetic stimulation — what it actually does to the brain, how it differs from ECT, and where it fits alongside ketamine and Spravato. He covers accelerated theta burst protocols, why insurance decides your session count, the gap between response and remission, and what clinics are overselling. Treatment-resistant, he argues, doesn't mean untreatable. TOPICS COVERED What TMS is doing at the level of the brain, and how it differs from ECT Why depression is likely several conditions sharing one label Standard vs. accelerated protocols — theta burst, SAINT, and the 36-session insurance ceiling Choosing between TMS, ketamine, Spravato, and ECT for a specific patient Neuromodulation for chronic pain — CRPS, fibromyalgia, and the pain-mood overlap Field critique: what clinics oversell, and what patients should ask before starting RESOURCES & LINKS MENTIONED Studies & protocols STAR*D trial — diminishing returns with each successive antidepressant (https://www.nimh.nih.gov/funding/clinical-research/practical/stard) SAINT / Stanford accelerated protocol — Dr. Nolan Williams (https://med.stanford.edu/nolanwilliams.html) Clinical TMS Society — annual meeting, TMS-for-pain training (https://www.clinicaltmssociety.org/) Concepts & tools Transcranial magnetic stimulation (https://en.wikipedia.org/wiki/Transcranial_magnetic_stimulation) · Theta burst stimulation (https://en.wikipedia.org/wiki/Theta_burst_stimulation) Electroconvulsive therapy (https://en.wikipedia.org/wiki/Electroconvulsive_therapy) · Esketamine / Spravato (https://en.wikipedia.org/wiki/Esketamine) Dorsolateral prefrontal cortex (https://en.wikipedia.org/wiki/Dorsolateral_prefrontal_cortex) · Primary motor cortex (https://en.wikipedia.org/wiki/Primary_motor_cortex) Treatment-resistant depression (https://en.wikipedia.org/wiki/Treatment-resistant_depression) · D-cycloserine (https://en.wikipedia.org/wiki/Cycloserine) Complex regional pain syndrome (https://en.wikipedia.org/wiki/Complex_regional_pain_syndrome) · Fibromyalgia (https://en.wikipedia.org/wiki/Fibromyalgia) · Central sensitization (https://en.wikipedia.org/wiki/Central_sensitization) Deep TMS / Brainsway (https://www.brainsway.com/) · IntellxxDNA genomic testing (https://intellxxdna.com/) Related episodes Ep. 177: Rocky Sullivan on ketamine (round one) Ep. 191 & 192: Metabolic psychiatry two-parter with Dr. Matt Bernstein FOLLOW US Dr. Patrick "Rocky" Sullivan Initia Nova — Cherry Hill, NJ & Wilmington, DE (https://myinitianova.com/) The Show Website: medicineredefined.com (https://medicineredefined.com) Instagram / X: @medredefined (https://instagram.com/medredefined) Dr. Altamash Raja Instagram: @draltraja (https://instagram.com/draltraja) LinkedIn: Altamash Raja (https://www.linkedin.com/in/altamash-raja-do-rmsk-cscs) Refining Health & Performance (https://refininghealthrx.com) Dr. Darsh Shah Instagram: @doctor.darsh (https://www.instagram.com/doctor.darsh/) LinkedIn: doctordarsh (https://www.linkedin.com/in/doctordarsh/) Ready to stop guessing and start performing? Dr. Raja is now seeing patients through his telemedicine practice — limited founding member spots available at refininghealthrx.com (https://refininghealthrx.com).