Comparing options

Esketamine (Spravato) vs TMS: how to think about the choice

By the editorial team - Reviewed for plain-language accuracy

Once your depression is recognized as treatment-resistant, two of the most talked-about next-line options are esketamine (Spravato) and transcranial magnetic stimulation (TMS). People often want to know which is better. The honest answer is that neither is universally better; they work differently, fit different lives, and are chosen with a clinician based on your history. What follows is a fair, plain-language comparison so you can walk into that conversation informed.

How each one works

Esketamine (Spravato) is a nasal spray derived from ketamine, FDA-approved for treatment-resistant depression and used alongside an oral antidepressant. It acts on glutamate signaling, a different brain system than standard antidepressants, which is part of why it can help people who did not respond to the usual medications.

TMS uses focused magnetic pulses delivered through the scalp to stimulate a region of the brain involved in mood regulation. It is FDA-cleared for depression that has not responded to medication. Nothing enters your body; the effect comes from the magnetic stimulation itself, which is why it is described as drug-free.

What a course actually looks like

This is where the two feel most different day to day.

• Esketamine is taken in a certified medical setting. You use the spray under supervision and stay for monitoring afterward, usually about two hours, because it can cause temporary dizziness, dissociation, or a rise in blood pressure. Visits follow a set schedule, more frequent at first and then spacing out.
• TMS is delivered while you sit awake in a chair, with no anesthesia. A typical course runs over several weeks with sessions on most weekdays, each lasting from a few minutes to around forty depending on the protocol. You can usually drive yourself home and return to your day.

Side effects, in plain terms

With esketamine, the common short-term effects are dissociation or a dreamlike feeling, dizziness, nausea, and a temporary rise in blood pressure, which is exactly why the supervised monitoring period exists. These effects typically ease within the monitoring window. With TMS, the most common side effect is scalp discomfort or a headache near the treatment site, which tends to lessen as the course goes on. Because it is drug-free, TMS avoids medication-style side effects, which is one reason people who cannot tolerate drugs consider it.

Who each tends to suit

These are tendencies, not rules, and your clinician weighs them against your specific history:

• Esketamine may appeal when a faster response is hoped for and when you can arrange transportation and time for supervised sessions. It is used together with an oral antidepressant.
• TMS may appeal when you want to avoid adding another drug and its side effects, and when a steady weekday schedule over several weeks is workable for you.

Cost, insurance, and availability

Both are FDA-approved or FDA-cleared for medication-resistant depression, and both are covered by many insurance plans when medical criteria are met. Coverage specifics vary by plan, and not every clinic offers both, so availability near you is a real part of the decision. It is worth confirming coverage and offerings with the provider and your insurer before you start.

You do not have to settle this on your own. Bring your history and your practical constraints to a clinician, and the choice becomes a shared, workable decision rather than a guess. And if one option does not help enough, the other remains available; not responding to one does not close the other.

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