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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, most often the left dorsolateral prefrontal cortex, a region that tends to be underactive in depression. 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 works on the glutamate system through the NMDA receptor, a different pathway from the serotonin and norepinephrine systems that most antidepressants act on (McIntyre et al., 2024). Since January 21, 2025 it can be given on its own as a monotherapy for treatment-resistant depression, or alongside an oral antidepressant (Janik et al., 2025). Some insurance policies still ask for a concurrent oral antidepressant even though the label no longer requires one.
One thing worth asking when someone says “TMS”: which kind. The word covers standard 10 Hz repetitive TMS, intermittent theta-burst (the three-minute protocol), Deep TMS with the H1 coil, and the accelerated Stanford protocol (SNT, formerly SAINT) that compresses a course into five days. They share a mechanism and differ in session count, intensity, and how much evidence sits behind them.
| TMS | Spravato | |
|---|---|---|
| What it is | Magnetic stimulation device | Esketamine nasal spray |
| Taken with an oral antidepressant | Not required | No longer required since January 2025; some plans still ask for one |
| 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 for four weeks, then weekly, then every one to two weeks |
| Most common side effects | Scalp discomfort, headache | Dissociation, raised blood pressure, nausea, dizziness |
| Session experience | Awake, no medication, a tapping on the scalp | An altered state for the first hour or two |
| Shape of treatment | A course with an end date | Ongoing maintenance for most responders |
Spravato generally acts sooner. In the trial that supported its approval as a monotherapy, patients showed a statistically significant improvement on the depression rating scale within 24 hours of the first dose compared with placebo (Janik et al., 2025). In the earlier 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). For most people, improvement is noticeable within the first week or two.
TMS builds more slowly. Most patients notice a shift somewhere in weeks two to three of a four-to-six-week course. 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. The exception is the accelerated Stanford protocol, which is designed to compress the whole course into five days; access and insurance coverage for it are still uneven.
This is where the comparison gets honest. There is no large head-to-head trial of Spravato against TMS in treatment-resistant depression. The one published direct comparison is a small retrospective study of forty patients, and it found accelerated TMS responded faster at one month, with the difference between the two gone by six months (Prato et al., 2026). So each treatment has to be judged on its own trials.
Spravato. In ESCAPE-TRD, the largest study against an active comparator, 27.1 percent of the Spravato group reached remission by week eight against 17.6 percent on extended-release quetiapine (Reif et al., 2023). TRANSFORM-2 showed a meaningful but modest four-point advantage on the standard depression scale over antidepressant plus placebo (Popova et al., 2019). An independent re-analysis pooling seven trials found the effect statistically significant but smaller than the manufacturer’s own threshold for clinical significance (Naudet et al., 2025). It works, it is far from a switch, and expectations should be set that way going in.
TMS. In THREE-D, which randomized 414 patients to standard 10 Hz TMS or theta-burst, depression scores fell by roughly half in both groups (Blumberger et al., 2018). The Deep TMS pivotal trial reported 38 percent response and 33 percent remission with active treatment against 21 and 15 percent with sham (Levkovitz et al., 2015). A registry of more than 5,000 patients across 103 sites recorded 58 to 83 percent response and 28 to 62 percent remission depending on the rating instrument (Sackeim et al., 2020). The accelerated Stanford protocol produced the most quoted figure in the field, 86 percent remission in its open-label study (Cole et al., 2020); the sham-controlled follow-up still favored active treatment by a wide margin (Cole et al., 2022), and twelve-week data show about a third of patients still in remission at three months, a more sober number than the headline (Geoly et al., 2025).
Both help a meaningful share of people who have not responded to two or more antidepressants, and the remission rates sit in the same neighborhood. What separates them for an individual patient is almost always the practical side: schedule, driving, how the session feels, and what insurance will approve.
The two treatments have different shapes, and this is one of the most important distinctions on the page.
Spravato is ongoing care. Most people who respond stay on it, with dosing tapering to every one to two weeks for maintenance. In the randomized-withdrawal study SUSTAIN-1, patients who continued Spravato had roughly half the relapse rate of those switched to placebo (Daly et al., 2019), and the long-term extension SUSTAIN-3, with more than 3,700 patient-years of exposure, found about half of patients in remission at the maintenance endpoint with an acceptable safety profile over several years (Zaki et al., 2025). There is no finish line built into it.
TMS is a course you complete. Of patients who responded during the acute course, 62.5 percent were still maintaining that response at one year, and a meaningful share of those who relapsed responded to a second course (Dunner et al., 2014).
If you want a treatment with an ending, TMS gives you one. If you are comfortable with ongoing maintenance and want the fastest acute response, Spravato delivers that.
TMS is ruled out if you have ferromagnetic metal in or near your head. A seizure history calls for closer review before proceeding. Seizure during treatment is a real but very rare risk, well under one in a thousand per course with current protocols and proper screening.
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, hear a tapping from the coil, feel it on your scalp, and leave. Scalp tenderness and a mild headache are the usual complaints early on, and both tend to fade within the first week. Most people go to work afterwards. The friction is time: people with rigid schedules or long commutes often cannot make four to six weeks of weekday visits work.
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, which comes to about eight visits in the first month before it tapers. The first ninety minutes after dosing is a noticeably altered state for many people, with dizziness, nausea, mild sedation and a temporary rise in blood pressure around the forty-minute mark among the common effects (Wajs et al., 2020). You cannot drive for the rest of that day, so you need a ride and usually need the afternoon free. The two-hour observation is a federal safety requirement rather than a clinic preference.
On insurance: both are commonly covered for treatment-resistant depression, and both generally require prior authorization with documented antidepressant trials, usually one to four depending on the plan. Spravato is dispensed through specialty pharmacy and must be given in a REMS-certified clinic. The accelerated five-day TMS protocol is the one place coverage lags; many plans have not integrated it yet and many patients pay out of pocket for it.
For some patients this question settles the choice before anything else does. Spravato’s main session effects, dissociation, sedation, anxiety and a rise in blood pressure, are listed as important risks on the FDA label and should be screened for directly rather than minimized. A quarter to a third of patients report some version of dissociation each session, and it generally fades by the end of the observation window (Wajs et al., 2020). If panic sensations escalate quickly for you, or altered states and sudden internal shifts feel frightening, Spravato may still be possible but it needs preparation, and TMS may simply be the easier treatment to sit through.
The trade runs the other way on schedule. TMS asks for near-daily attendance for several weeks, and some patients find the scalp stimulation uncomfortable in the first sessions. So TMS may be easier psychologically for someone who fears dissociation and harder practically for someone who cannot manage frequent appointments.
| Leans TMS | Leans Spravato | |
|---|---|---|
| Panic-prone | Often the better fit; no psychoactive session experience | Possible with extra preparation for panic sensations |
| Dissociation tolerance | No dissociation; easier if altered states feel frightening | Dissociation is expected during monitored dosing |
| Schedule | Demanding: near-daily visits for several weeks | Fewer visits; easier if a frequent schedule is unrealistic |
| Severity | A steady, circuit-based build over time | A different biological pathway when depression is severe or rigid |
| Driving | Drive yourself to and from each session | No driving after dosing; you need a ride home |
Which one first, if both are on the table? Spravato often comes first when the TMS schedule is unrealistic, when depression is severe, or when a monitored treatment through a different pathway is the goal. TMS often comes first when avoiding a psychoactive session experience matters more, or when the patient wants to feel like themselves before adding a medication. Neither order is automatically right.
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.
A careful consult also goes through your treatment history and what each past medication did or did not do, how sensitive you have been to sedation or dissociation, how you are functioning day to day, any thoughts of self-harm, whether anxiety or panic is in the mix, how comfortable you are with altered sensations, and whether the depression is tangled up with trauma, bipolar symptoms, substance use or a medical issue. The right treatment is the one that fits your situation and that you can safely see through to the end.
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, and the one small direct comparison found the two had converged by six months, so a direct ranking is not supported by the evidence.
Do I have to stop my antidepressant for either? No. Spravato can now be given with or without an oral antidepressant, though some plans still require one for coverage. 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 authorization 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.
Can TMS be repeated if depression comes back? Yes. A meaningful share of people who relapse after a first course respond to a second one (Dunner et al., 2014).
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. If you are having thoughts of harming yourself, call or text 988 or go to your nearest emergency department.
And if you have already tried both without adequate relief, that is not the end of the pathway: see what to do if neither Spravato nor TMS works.
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