Compare Spravato, ketamine and TMS

IV ketamine delivers a precise dose with a clinician watching your vitals and has the strongest evidence of any generic ketamine route. At-home sublingual ketamine is cheaper and more convenient, absorbs unpredictably, and puts a controlled substance in your home with little supervision. Insurance rarely covers IV ketamine. At-home lozenges are not covered.

Ketamine is a racemic mixture of two mirror-image molecules, S-ketamine (esketamine) and R-ketamine. Esketamine binds the NMDA receptor more strongly, so a lower dose produces a similar effect. Spravato is esketamine formulated as a nasal spray and approved for depression; generic ketamine is the racemic mixture approved as an anesthetic and used off label.

Spravato is FDA approved for depression and is covered by insurance. Generic ketamine is not approved for depression, is used off label, and is almost always cash pay. Both work through the same receptor and both produce a rapid response in a similar share of patients.

Both are FDA approved and insured for treatment-resistant depression. They differ in schedule, side effects, who qualifies, and what maintenance looks like.

TMS is an office procedure with mild side effects; ECT is a hospital procedure under anesthesia with the highest remission rates for severe depression. When each is the right tool.