Spravato vs. TMS: Comparing Two Major Treatments for Resistant Depression
Spravato vs. TMS is one of the more useful comparisons for someone with treatment-resistant depression, because both treatments are FDA-approved for it, both are covered by major insurers, and both have strong evidence — but they work through completely different mechanisms. The choice often comes down to your specific symptoms, lifestyle, and treatment history.
How each treatment works
Spravato is a medication — esketamine nasal spray, administered in clinic. It acts on the brain's glutamate system through the NMDA receptor. TMS (transcranial magnetic stimulation) uses focused magnetic pulses applied to the scalp to stimulate specific brain regions (typically the left dorsolateral prefrontal cortex). One is biochemical; one is biophysical.
Time commitment per week
Spravato is twice a week for four weeks during induction, then weekly to monthly during maintenance. Each session is roughly 2.5 hours including observation. TMS is typically five days a week for six weeks, with each session lasting 20 to 40 minutes — and no observation period afterward, so patients drive themselves and go straight back to work.
Cost and insurance coverage
Both are covered by Medicare and most major insurers for treatment-resistant depression. Out-of-pocket costs are broadly comparable in our experience — copays per session for commercial plans, deductibles, then sharply lower costs after.
Side effect profile
Spravato can cause dissociation, dizziness, transient BP elevation, and mild nausea. TMS is largely side-effect free — most patients tolerate it without issues, though some report scalp discomfort or mild headache during the first week. Neither carries significant long-term risks at standard treatment doses.
Speed of relief
Many Spravato patients feel a noticeable shift within the first few sessions, sometimes within 24 hours. TMS tends to build more gradually; most responders see clear benefit between weeks two and four of treatment. For someone in acute distress, Spravato's speed can matter.
Who's a candidate for which
TMS is generally easier for patients who can fit short sessions five days a week and prefer a non-medication approach. Spravato fits patients who can manage two longer sessions a week, want the option of rapid effect, or have already tried TMS without success. There are also medical considerations — TMS isn't recommended for patients with seizure history or implanted metal in the head; Spravato has its own contraindications.
Can you combine them?
Yes — there's no inherent conflict. Some patients do Spravato first for rapid initial response, then transition to TMS for maintenance. Others do both concurrently. It's a planning conversation, not a clinical conflict.
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