TMS vs. SPRAVATO: Which Option Makes More Sense for Your Depression

Treatment-Resistant Depression · Hayward, CA

If your depression has not let go after a couple of solid medication trials, two names tend to come up next: TMS and SPRAVATO. They get mentioned in the same breath, which makes them sound like two versions of the same thing. They are not. They work through different parts of the brain, they ask different things of your week, and they suit different people. Picking between them is less about which one is “stronger” and more about which one fits your situation and the kind of depression you actually have.

Here is how to think about the difference, what each one tends to be good for, and the questions a careful consult should be asking before anyone recommends one over the other.

The basic difference

TMS and SPRAVATO are both options for depression that has not improved enough with standard treatment, but they go about it in very different ways.

TMS — transcranial magnetic stimulation — is a non-medication treatment that uses magnetic pulses to stimulate the mood-related circuits of the brain. You stay awake, you do not need anesthesia, and you usually come in for repeated short sessions over several weeks. It is FDA-cleared specifically for depression that has not responded to medication.^[1][3]

SPRAVATO is esketamine nasal spray. It is FDA-approved for adults with treatment-resistant depression — and since January 21, 2025, it can be used on its own, not only as an add-on to an oral antidepressant.^[2] It is given in a monitored clinic setting because it can cause sedation, dissociation, blood pressure changes, and other temporary effects, so you are watched for a stretch after each dose and you cannot drive yourself home.^[2]

Depression that may fit TMS better

TMS often makes sense when depression is persistent, low-energy, emotionally flat, or just stuck — especially for someone who would rather not add another medication to the pile.

It tends to appeal to people who have had a hard time with medication side effects, who are sensitive to sedation or dissociation, or who want a treatment that does not involve taking a psychoactive medication during the session itself. The tradeoff is consistency. TMS works through repeated stimulation over time, so the schedule matters — the standard course runs five days a week for several weeks.^[1] If getting to frequent appointments is going to be a struggle, that is worth naming early.

Depression that may fit SPRAVATO better

SPRAVATO comes into the conversation when depression is clearly treatment-resistant and a different biological pathway than the usual antidepressants may be what is needed.

Because esketamine acts on glutamate signaling rather than serotonin, it is often discussed in terms of neuroplasticity — the brain’s ability to form new patterns.^[2] That framing tends to matter most when depression feels severe, rigid, or hard to shift after several medication trials. The tradeoff here is the session itself. Because of the monitoring requirement and the after-effects, the dosing visits ask more of your day, and for anyone with panic sensitivity, the dissociation or intense body sensations may need some preparation beforehand.

What a consult should actually weigh

A good provider does not choose based on which treatment sounds more impressive. The decision should come out of your actual clinical picture, not a default.

That means looking at your treatment history and what each past medication did or didn’t do, your side-effect experience, how you are functioning day to day, any suicidal thoughts, whether anxiety or panic is in the mix, how realistically you can attend frequent appointments, how comfortable you are with altered sensations, what your insurance will cover, and whether the depression is tangled up with trauma, bipolar symptoms, substance use, or a medical issue. These details matter because the “best” treatment is the one that fits your situation and that you can safely see through to the end.

The takeaway

TMS and SPRAVATO are not interchangeable. TMS may fit someone looking for a non-medication, circuit-based treatment that builds gradually over repeated sessions. SPRAVATO may fit someone with treatment-resistant depression who could benefit from esketamine’s different biological pathway and can safely tolerate monitored dosing visits. The goal is not to win an argument about which is better in the abstract. It is to match the treatment to the person and to the particular shape of the depression. If you want help thinking it through, that is exactly what a consult is for — and we have also written about how TMS compares with another round of medication and how to choose between SPRAVATO and TMS.

By Nefretiri Abat, JD, PMHNP-BC — Founder, Exxceed Wellness, Hayward CA. This article is for general education and does not substitute for individualized medical care. If you are having thoughts of harming yourself, call or text 988 (the Suicide & Crisis Lifeline) or go to your nearest emergency department. Decisions about TMS, SPRAVATO, and other treatments should be made with a licensed clinician who knows your history.