You’ve done what your doctor asked. You tried the first antidepressant, gave it eight weeks, adjusted the dose. Then a second one. Maybe a third. The side effects came and went, but the depression mostly stayed. At this point, you’ve qualified, clinically, for a label nobody wants: treatment-resistant depression.
The good news is that “resistant” doesn’t mean “out of options.” Two of the most effective next steps, Spravato and TMS, work in completely different ways, and comparing Spravato vs TMS side by side can make an overwhelming decision feel a lot more manageable.
What “Treatment-Resistant” Actually Means
In practice, treatment-resistant depression usually means your depression hasn’t responded adequately to at least two different antidepressants, taken at an adequate dose for an adequate length of time. It’s a clinical threshold, not a judgment about how hard you’ve tried or how “bad” your depression is.
Reaching that threshold is also exactly what opens the door to Spravato and TMS. Both are typically considered once standard antidepressants haven’t done enough, and both are FDA-approved specifically for this situation.
How TMS Works
Transcranial Magnetic Stimulation uses focused magnetic pulses, similar in nature to what’s used in an MRI, to stimulate the dorsolateral prefrontal cortex, a region of the brain that tends to be underactive in depression. Over a series of sessions, this repeated stimulation appears to help restore healthier activity patterns in mood-regulating brain circuits.
A typical TMS course runs five days a week for about four to six weeks, with each session lasting roughly 20 minutes. There’s no sedation involved. You stay fully awake, can drive yourself to and from appointments, and return to normal activities immediately afterward.
Real-world data on standard TMS protocols generally shows response rates in the range of 50 to 60 percent, meaning a meaningful reduction in symptoms, with somewhere around a third of patients reaching full remission. Newer, more intensive accelerated protocols have pushed those numbers considerably higher in clinical trials, though standard protocols remain the most widely used approach.
How Spravato Works
Spravato is the brand name for esketamine, a nasal spray derived from ketamine and FDA-approved for treatment-resistant depression, as well as for major depressive disorder with acute suicidal thoughts or behavior. Rather than working on serotonin or dopamine like traditional antidepressants, esketamine targets the brain’s glutamate system, which appears to trigger a rapid strengthening of connections between brain cells involved in mood regulation.
Each Spravato session takes place in a clinical setting under direct supervision. You self-administer the nasal spray, then stay for about two hours while staff monitor your blood pressure and how you’re feeling, since temporary dizziness, sedation, or a sense of detachment are common in the hours after dosing. You cannot drive yourself home afterward.
Treatment typically starts at twice a week for the first month, then tapers to weekly and eventually every two weeks for maintenance. Clinical trial data shows roughly 70 percent of patients experience at least a 50 percent reduction in symptoms, with remission rates in published studies generally falling between about 35 and 46 percent.
Speed vs. Staying Power
If there’s one factor that most often decides between the two, it’s timeline. Spravato tends to work fast. Many patients notice a shift in mood within hours to days of an early dose, which matters enormously for someone in acute distress or experiencing suicidal thoughts. If you or someone you know is currently having thoughts of suicide, the 988 Suicide & Crisis Lifeline is available by call or text, any time, before or alongside starting any treatment plan.
TMS works on a slower timeline. Most people notice initial changes somewhere between weeks two and four of a course, with benefits continuing to build afterward as the brain consolidates the changes from treatment. What TMS tends to offer in exchange for that slower start is durability. Several studies suggest TMS produces longer-lasting remission for a meaningful number of patients compared to esketamine, which more often requires ongoing maintenance dosing to sustain its effects.
Comparing the Practical Details
A few other differences worth weighing with your psychiatrist:
- Time commitment looks different for each. TMS requires daily weekday visits for four to six weeks, while Spravato requires twice-weekly visits initially, dropping to weekly and then biweekly over time.
- You can drive yourself home after TMS. You cannot drive after a Spravato dose, so you’ll need someone to take you home each time.
- TMS is typically used as a standalone treatment, often alongside existing medication. Spravato, by contrast, is FDA-approved for use in combination with an oral antidepressant, not as a replacement for one.
- Side effects differ in kind, not just degree. TMS side effects are generally mild and localized, most commonly a headache or scalp discomfort near the treatment site, while Spravato’s side effects are more systemic: temporary dissociation, dizziness, nausea, and blood pressure changes, which is why the two-hour monitoring window is required.
- Eligibility rules out different people for different reasons. Spravato generally isn’t recommended if you have uncontrolled high blood pressure, certain vascular conditions, a history of brain bleeding, or if you’re pregnant. TMS has its own screening requirements, including caution around certain seizure risks and non-removable metal implants near the head.
What About Cost and Insurance?
Both treatments are typically covered by major insurance plans once you meet the clinical criteria for treatment-resistant depression, though the documentation requirements differ slightly. TMS approval generally requires records showing at least two antidepressant trials without adequate relief, and most practices, including ours, handle that pre-authorization paperwork directly so you’re not stuck chasing records between providers.
Spravato coverage works similarly but often involves closer coordination with your pharmacy benefit, since it’s dispensed and administered on-site rather than picked up like a standard prescription. If you’re uninsured or your plan doesn’t cover one of these options, ask about self-pay rates and payment plans before ruling anything out based on cost alone.
A Few Other Questions Patients Often Ask
Can I try both at some point, or do I have to pick one? You’re not locked into a single path. Some patients start with one treatment and add or switch to the other later, depending on how they respond and what’s happening in their life at the time.
Does either option replace my current antidepressant? Not automatically. Spravato is specifically approved for use alongside an oral antidepressant. TMS is often used alongside existing medication too, though your psychiatrist may adjust your regimen as treatment progresses.
What happens if neither treatment works well enough on its own? It happens, and it isn’t the end of the road. Your team can reassess, adjust protocols, consider combining approaches, or explore other options like ketamine infusion therapy or pharmacogenetic testing to better match medication to your biology.
Neither Choice Is Permanent, and Neither Is a Last Resort
It’s worth saying plainly: needing Spravato or TMS doesn’t mean standard psychiatric care has failed you. Roughly one in three adults with depression don’t get adequate relief from the first couple of medications they try, which is precisely why these therapies exist and why they’re backed by FDA approval rather than treated as experimental.
Some patients also move between the two over time, trying TMS first and adding Spravato later if a crisis emerges, or the reverse. Your psychiatric team can help you sequence these options rather than treating the decision as one-and-done.
How Kalamazoo TMS & Behavioral Health Approaches This Decision
Because our practice offers both Spravato and Transcranial Magnetic Stimulation under one roof, our team isn’t limited to recommending whichever treatment happens to be available. Your evaluation looks at your specific history, including how urgent your symptoms are, your medical eligibility for each option, your schedule, and what’s realistic for your life over the coming weeks.
For some patients, the answer is obvious quickly. Someone in acute crisis with suicidal thoughts may benefit most from Spravato’s faster onset. Someone who can’t take time off for daily visits, or who wants to avoid the two-hour monitoring window entirely, may lean toward TMS. Many patients simply want a knowledgeable team to walk them through the tradeoffs before deciding.
Take the Next Step
You don’t have to figure out Spravato vs TMS on your own, and you don’t need to arrive with a decision already made. A thorough evaluation is designed to help you leave with a clear, personalized recommendation instead of two brochures and more questions than you started with.
Schedule a Spravato consultation at Kalamazoo TMS & Behavioral Health, or ask about TMS during the same visit. Call (269) 381-6950 or request an appointment online to get started.
