Comparison table
| TMS | Ketamine | Spravato | |
|---|---|---|---|
| How it works | Magnetic pulses stimulate the area of the brain that regulates mood. Not a drug. | A medication that acts on the brain's glutamate system. | Esketamine nasal spray. Acts on the same glutamate system as ketamine. |
| FDA status | Cleared for depression that has not improved with medication. Certain systems are cleared for OCD. | Approved as an anesthetic. Use for depression is off-label. | Approved for treatment-resistant depression in adults. |
| Time per visit | A few minutes to about 40 minutes, depending on the protocol. | Treatment plus recovery time in the office. | At least two hours, because of the required monitoring. |
| Number of visits | Typically five a week for four to six weeks. | Usually a series over a few weeks, then reviewed. | Twice a week for four weeks, weekly for four weeks, then weekly or every other week. |
| Common side effects | Scalp discomfort, headache. Seizures are rare. | Dissociation, dizziness, nausea, raised blood pressure, for a short time after treatment. | Dissociation, dizziness, nausea, sleepiness, raised blood pressure, for a short time after the dose. |
| Driving afterwards | Yes. | No. You need a ride home. | No. Not until the next day. |
| Insurance | Covered by most major plans when you meet their criteria. | Usually not covered for depression. | Covered by many plans, usually with approval in advance. |
Who each suits
TMS may suit you if you want a treatment that is not a medication, if antidepressant side effects have been a problem, or if you need to drive and work straight after each session. It asks for a short visit most weekdays for several weeks.
Spravato may suit you if your depression has not improved after at least two antidepressants and you want an FDA-approved, insurance-covered treatment that can act quickly. It asks for two-hour visits and a ride home each time.
Ketamine may suit you if you are looking for fast relief and other options have not worked or are not available to you, and you are able to pay out of pocket.
None of these is a first treatment for depression, and none works for everyone. Your diagnosis, medical history, current medications and insurance all affect which is reasonable to try first.
Can they be combined?
Sometimes. Some people have one treatment after another, for example TMS after a course of Spravato or the other way round, and most stay on their usual medication and therapy throughout. Whether to combine or sequence treatments is a clinical decision made with you, based on how you respond.
Next step
You do not need to choose before you call. Book a free 20-minute call and tell us what you have tried. A clinician will recommend where to start, and we will check your insurance so you know what it would cost.