TMS vs Spravato: Comparing Two Options for Hard-to-Treat Depression

When pills have not worked, two supervised treatments come up again and again: TMS and Spravato. They are very different in how they feel, how often you go in, and what to expect. Here is an honest side-by-side to help you ask better questions.

If you have reached the point where standard antidepressants have not lifted your depression, you have probably run into two names that sound nothing alike: TMS and Spravato. Both are real, evidence-based options for depression that has resisted the usual medications, and both are done under medical supervision rather than at home. But they work through completely different mechanisms and fit different lives. Understanding the contrast makes the conversation with your clinician far easier.

First, the shared ground. Neither one is a first step. Doctors generally reach for them after someone has tried at least a couple of antidepressants without enough relief, the situation covered in our guide on when antidepressants are not working. Neither is a cure, neither works for everyone, and both are meant to be part of a broader plan that can still include therapy and medication.

How each one works

TMS (transcranial magnetic stimulation) is a device-based treatment. A padded coil rests against your scalp and sends focused magnetic pulses to mood-related areas of the brain that tend to be underactive in depression. No drug enters your body. You stay fully awake, and there is no sedation. Our full TMS explainer walks through a session in detail.

Spravato (esketamine) is a medication, a prescription nasal spray closely related to ketamine. It acts on the brain's glutamate system, a different chemical pathway than the serotonin most antidepressants target, which is part of why it can help people who never responded to standard pills. Our Spravato guide covers how a visit works.

TMS sends magnetic pulses and adds no drug. Spravato is a medication you take under supervision. Same goal, very different experience.

What the schedule looks like

This is where the two often diverge most for real life. A standard course of TMS runs five days a week for roughly six weeks, with sessions that can last from a few minutes to about 20 depending on the protocol. You drive yourself in and out and go on with your day. The daily rhythm is demanding, but each visit is short and you are clear-headed the whole time.

Spravato is less frequent but each visit takes longer. It usually starts at two visits a week for the first month or so, then tapers based on how you respond. Because it can cause drowsiness and a temporary floaty feeling, you are monitored in the clinic for about two hours after each dose and cannot drive for the rest of that day, so you arrange a ride.

Side effects and how they feel

TMS is generally well tolerated. The most common complaints are mild scalp discomfort or a headache during or right after a session, which usually eases within the first week. Because strong magnetic fields are involved, a clinic will screen for certain metal implants first.

Spravato commonly causes short-lived dizziness, a dissociated or floaty sensation, nausea, or a brief rise in blood pressure, which is exactly why the monitoring window exists. It is given through a federal safety program at certified clinics rather than picked up at a pharmacy.

Which tends to fit which person?

There is no universal winner. TMS often appeals to people who want a drug-free option and can commit to a daily stretch of short visits. Spravato can suit people who prefer fewer trips per week, do not mind the longer monitored appointment, and have a ride available. Coverage, your medical history, and other medications all factor in. This is a decision to make with a clinician who can weigh your specific situation, not one to settle from a web page.

Cost and coverage in Missouri

Both TMS and Spravato are covered by many insurance plans specifically for treatment-resistant depression, and coverage has broadened over the years. In Missouri, that can include MO HealthNet at clinics that accept it. Because approval usually depends on documenting that you tried and did not respond to earlier medications, the paperwork side matters, and a clinic that offers both treatments can often help you sort out which one your plan will cover. Our questions and answers page covers insurance basics.

The honest bottom line

TMS and Spravato are not rivals so much as two different doors into the same room: relief for depression that would not respond to the standard route. Some people try one, do not get enough benefit, and respond to the other. The most useful thing you can do is bring both names to a clinician who offers them, describe what you have already tried, and let the decision follow your history rather than a headline.