What Patients Should Know Before Considering TMS, Spravato, or ECT

Treatment-Resistant Depression · Hayward, CA

When depression has not improved enough with standard medication or therapy, the next step should not be random. A good evaluation asks a few specific questions: How severe is the depression? How urgent is the situation? What has already been tried? And what kind of treatment can you safely tolerate?

Three higher-level options that may come up are TMS, SPRAVATO, and ECT. They all affect the brain, but they do it in very different ways — and the right choice depends far more on your situation than on which one sounds the most powerful.

TMS: targeted, but schedule-heavy

TMS uses magnetic pulses to stimulate the specific brain circuits involved in mood. Compared with ECT, it is more targeted — almost like using a scalpel instead of a whole-system intervention. You stay awake, there is no anesthesia, and it does not intentionally cause a seizure.

But TMS is not casual. A standard acute course for depression usually means daily weekday sessions, five days a week, for about four to six weeks — often totaling 20 to 30 sessions.^[1][2] It may fit someone who wants a non-medication option, has had medication side effects, or wants to avoid sedation and dissociation. It can be harder for someone whose schedule, transportation, or symptoms make near-daily visits unrealistic. Common side effects include scalp discomfort, headache, nausea, dizziness, fatigue, and sometimes temporary anxiety or irritability. Worsening symptoms should be reported, not silently pushed through.^[1]

SPRAVATO: neuroplasticity, but not a magic button

SPRAVATO is esketamine nasal spray, FDA-approved for treatment-resistant depression. It is given in a monitored clinical setting because it can cause sedation, dissociation, dizziness, nausea, anxiety, blood pressure increases, and other temporary effects.^[3]

SPRAVATO is often discussed in relation to glutamate and neuroplasticity — the brain’s ability to form and update patterns. That can be useful when depression feels rigid or stuck. But neuroplasticity still needs direction. Our team usually recommends pairing SPRAVATO with therapy, behavioral activation, better sleep rhythm, and structured daily habits. The medication may open a window for change, but what gets practiced during that window still matters. The tradeoff is the session experience: patients are monitored after dosing and should not drive or do anything requiring full alertness until the next day after restful sleep.^[3] For people with panic sensitivity, dissociation or intense internal sensations can feel frightening, so preparation matters.

ECT: broader, more intensive, sometimes urgent

ECT uses an electrical current to intentionally produce controlled seizure activity while the patient is under anesthesia. It is one of the longest-used and most studied brain stimulation therapies for serious depression, with a substantial evidence base supporting its efficacy in severe depressive illness.^[4]

ECT is usually considered when depression is severe, urgent, psychotic, catatonic, life-threatening, or has not responded to other treatments. Compared with TMS, it is less like a scalpel and more like a whole-system reset. That can be powerful, especially when speed matters, but it also comes with more medical intensity. It requires anesthesia and can involve memory or cognitive side effects, so the decision deserves careful discussion.^[4]

How the choice is usually made

The question is not, “Which treatment is strongest?” The better question is: which treatment fits the depression, the risk level, and your ability to complete it safely?

TMS may fit someone who wants a targeted, non-medication treatment and can commit to frequent sessions. SPRAVATO may fit someone with treatment-resistant depression who can tolerate monitored esketamine sessions and use the neuroplastic window intentionally. ECT may fit when depression is severe, dangerous, psychotic, catatonic, or needs a faster intervention. None of these should stand alone — therapy, sleep, structure, behavioral activation, trauma work when relevant, and social support still matter.

The takeaway

TMS, SPRAVATO, and ECT are not interchangeable. TMS is more targeted and usually less medically intensive. SPRAVATO may create a neuroplastic window, but it needs support and structure. ECT is broader and more intensive, often considered when severity or urgency is high. The goal is not just to escalate treatment — it is to choose the right level of care for the kind of depression in front of you.

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. Severe depression, suicidal thoughts, psychosis, catatonia, and treatment-resistant symptoms require individualized evaluation by a licensed clinician. 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 ECT should be made with a licensed clinician who knows your history.