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If you need relief within days and can arrange a ride home twice a week, Spravato is usually the faster option. If you want to avoid another medication, need to drive yourself, and can commit to daily visits for about six weeks, TMS is usually the better fit. Both are approved for depression that has not responded to standard antidepressants, and the choice is normally decided by your medical history and your schedule instead of by which one is stronger.
What this page answers
TMS is a device. Spravato is a medication.
TMS uses focused magnetic pulses to stimulate areas of the brain involved in mood. Nothing enters your body, and you stay awake and alert throughout. Spravato is esketamine, a prescription nasal spray you take in a certified clinic while a clinician monitors you afterwards. It is always taken alongside an oral antidepressant, never on its own.
| TMS | Spravato | |
|---|---|---|
| What it is | Magnetic stimulation device | Esketamine nasal spray |
| Taken with an oral antidepressant | Not required | Required |
| Monitoring after each dose | None | About two hours on site |
| Can you drive home | Yes | No, not for the rest of the day |
| Typical schedule | Five days a week for four to six weeks | Twice weekly at first, then tapering |
| Most common side effects | Scalp discomfort, headache | Dissociation, raised blood pressure, nausea |
Spravato generally acts sooner. Improvement is often noticeable within the first week or two of treatment. In the TRANSFORM-2 trial, esketamine plus a newly started oral antidepressant outperformed the oral antidepressant alone in adults with treatment-resistant depression (Popova et al., 2019).
TMS builds more slowly. In a study across 42 United States sites, response and remission were measured at week six, with 58.0 percent responding and 37.1 percent reaching remission (Carpenter et al., 2012). Judging TMS at week two is one of the more common reasons people stop too early.
TMS is ruled out if you have ferromagnetic metal in or near your head. A seizure history calls for closer review before proceeding.
Spravato needs closer review if you have uncontrolled high blood pressure, a history of aneurysm or bleeding in the brain, or a history of psychosis.
This is the part that decides it for most people, and it is worth being honest with yourself about.
TMS is a small commitment repeated often. Sessions run from about three minutes for theta burst up to roughly twenty minutes for standard protocols, five days a week. You arrive, sit in a chair, and leave. Most people go to work afterwards.
Spravato is a larger commitment repeated less often. You are on site for around two hours after each dose while a clinician monitors you, twice weekly at the start. You cannot drive for the rest of that day, so you need a ride and usually need the afternoon free.
Sometimes, and it is a real clinical question with real limits. We cover sequencing, safety and candidacy for combined treatment separately in Can I do Spravato and TMS at the same time?
In practice it comes down to four questions asked in order.
Depression that has not improved after two or more adequate antidepressant trials is generally described as treatment resistant, and remission rates fall with each successive medication step (Rush et al., 2006). That is the point at which this comparison usually becomes relevant.
Not sure which one fits? A psychiatric evaluation answers it properly, including when the answer is neither. You can read more about TMS at Exxceed Wellness or about Spravato at Exxceed Wellness, or check candidacy for TMS and Spravato directly.
Is one of them stronger than the other?
Neither is straightforwardly stronger. They have been studied against placebo and standard care. Large head-to-head trials do not exist, so a direct ranking is not supported by the evidence.
Do I have to stop my antidepressant for either?
No. Spravato requires you to stay on an oral antidepressant. TMS does not require one, and most people continue whatever they are already taking.
Does insurance cover both?
Both are commonly covered for treatment-resistant depression, and both generally require prior authorisation and documented antidepressant trials. Criteria vary by plan.
What if the first one does not work?
That is a normal part of the pathway. Not responding to one does not predict failure with the other, and switching is a routine next step.
This article is educational information and is not medical advice or a treatment recommendation for any individual. Candidacy for TMS or Spravato is determined by psychiatric evaluation. Individual response varies and no outcome is guaranteed. Reviewed by Nefretiri Abat, J.D., PMHNP-BC.
