Treatment Options
Spravato vs TMS: comparing the two main options for stubborn depression
Once someone has tried a couple of antidepressants without enough relief, the same two names tend to come up: Spravato and TMS. They are the two best-known options for depression that has not responded to standard medication, and people naturally want to know which one is better. The honest answer is that neither is better in the abstract. They work in completely different ways, they ask different things of your schedule, and they fit different people. Here is a plain-English comparison to help you walk into a doctor's office already knowing the right questions to ask.
The one-sentence version of each
Spravato (esketamine) is a prescription nasal spray, closely related to ketamine, that you take under supervision in a certified clinic. It is FDA-approved for adults with treatment-resistant depression and for adults with major depression who are having suicidal thoughts. TMS (transcranial magnetic stimulation) is a drug-free treatment that uses gentle magnetic pulses, the same kind of energy used in an MRI, to stimulate mood-related areas of the brain. It is FDA-approved for depression that has not improved with medication. We cover each in depth on our Spravato explainer and our TMS guide.
| At a glance | MedicationSpravato (esketamine) | DeviceTMS therapy |
|---|---|---|
| What it is | A prescription nasal spray related to ketamine, taken under supervision in a certified clinic. | A drug-free treatment that uses gentle magnetic pulses, the same kind of energy used in an MRI. |
| FDA-approved for | Adults with treatment-resistant depression, and adults with major depression who are having suicidal thoughts. | Depression that has not improved with medication. |
| A typical visit | You self-administer the spray, then rest while staff monitor you for about two hours. | You sit awake in a chair and feel a light tapping on your scalp. No sedation. |
| Driving after | Not the same day. You need a ride home. | Yes. You can drive yourself and go back to work. |
| Schedule | Often twice a week to start, then spaced out over time. | A short sprint: often five days a week for about four to six weeks, twenty to forty minutes each. |
| Common side effects | Temporary dizziness, nausea, or a dreamy, disconnected feeling that usually fades before you leave. | Mild scalp discomfort or a light headache that usually eases after the first few sessions. |
| Usually not used when | Certain blood pressure or medical conditions are present. | Metal implants are in or near the head. |
| Cost and insurance | FDA-approved and covered by many plans, including MO HealthNet at some local clinics, when criteria are met. | Also FDA-approved and covered by many plans. Verify your benefits first. |
Neither treatment is guaranteed, and many people are candidates for either. A qualified provider confirms which one fits your history before anything begins.
How they actually differ
- Medication vs no medication. Spravato is a medicine that acts on a brain chemical called glutamate. TMS puts nothing into your body at all, which is a big part of its appeal for people tired of pill side effects like weight gain or feeling numb.
- How a visit feels. With Spravato you self-administer the spray, then rest while staff monitor you for about two hours, because it can raise blood pressure and cause a temporary floaty, disconnected feeling. With TMS you sit awake in a chair feeling a light tapping on your scalp, and there are no lingering effects afterward.
- Driving. After a Spravato session you cannot drive for the rest of the day and need a ride home. After a TMS session you can drive yourself and go straight back to work.
- The schedule. Spravato usually starts at twice a week, then spaces out over time. TMS is more of a short sprint: often five days a week for around four to six weeks, with each session running roughly twenty to forty minutes.
Side effects, in plain terms
Spravato's temporary effects, mild dizziness, nausea, or that dreamy disconnected feeling, are the whole reason for the two-hour monitoring window, and they generally fade before you leave. TMS's most common side effect is mild scalp discomfort or a light headache near the treatment area that usually eases after the first few sessions. Serious side effects are rare with both, which is a big reason they are used so widely. Each also has situations where it is not appropriate: certain blood pressure or medical conditions for Spravato, and certain metal implants in or near the head for TMS. A qualified provider screens for all of that before you start.
Cost and insurance in Missouri
Because both are FDA-approved treatments rather than experimental, they are covered by many insurance plans when a person meets the criteria, and some clinics in the St. Charles County area accept most insurance, including MO HealthNet. Coverage always depends on your specific plan, so the practical move is to ask a clinic to verify your benefits before anything begins. Our FAQ answers more of the common cost and insurance questions.
So which should you ask about?
There is no formula that picks for you, but a few patterns help. People who want to avoid adding another medication often lean toward TMS. People who need relief sooner, or who cannot commit to daily visits for six weeks, sometimes lean toward Spravato. Many people are genuine candidates for either, and the deciding factor comes down to their medical history and their own doctor's read on the situation. Research consistently finds that a recommendation from your own doctor is the single biggest thing that moves people to try a new treatment, so the most useful step is not choosing on your own. It is asking a provider, "Between Spravato and TMS, which one fits me, and why?"
If you are not yet sure you have reached this stage, start with our guide on when antidepressants aren't working, which explains what treatment-resistant depression means. If your low mood traces back to something you lived through, our page on PTSD and trauma may fit better, and if you are still wondering whether what you feel is depression at all, begin with the everyday signs of depression.
This article is general information for the St. Peters and St. Charles County, MO community. It is not medical advice. Please talk with a licensed provider about your own care.