Spravato vs TMS: how to choose

The short version

Spravato acts fast and requires ongoing sessions with dissociation and a two-hour observation each time. TMS takes six weeks of short daily visits with no drug effects and often no maintenance for a year or more. Insurance covers both after two failed antidepressants. See the coverage hub, the Spravato hub, and the coverage checker.

Side by side

| | Spravato | TMS | |---|---|---| | Mechanism | Esketamine nasal spray, NMDA receptor | Magnetic stimulation of prefrontal cortex | | Speed of response | Days to 2 weeks | 3 to 4 weeks | | Schedule | 2 per week for a month, then weekly or biweekly ongoing | Daily for 6 weeks plus taper, then usually done | | Visit length | 2.5 hours | 20 to 40 minutes | | Side effects | Dissociation, nausea, blood pressure rise, sedation | Scalp discomfort, headache | | Driving | Not until the next day | No restriction | | Oral antidepressant | Required by most insurers | Not required | | Exclusions | Uncontrolled hypertension, aneurysm, pregnancy, psychosis | Seizure disorder, metal in head | | Insured cost per session | 0 to 50 | 0 to 0 | | Maintenance | Ongoing sessions | Re-treatment only on relapse |

Choose Spravato when

You need a fast response (severe symptoms, suicidal thoughts), you can commit to regular clinic visits with a ride, and you tolerate dissociation. It is also the choice when you cannot have TMS because of metal implants or seizure history.

Choose TMS when

You want a course with an end date, you drive yourself, you prefer no drug effects, or you have cardiovascular issues that make ketamine-type drugs risky. It is also easier to fit around work.

Doing both

Many clinics offer both, and some patients use Spravato for rapid relief while starting TMS for durability. Insurers evaluate each authorization separately; they do not generally pay for both at the same time without a clinical rationale.

Find clinics offering Spravato or TMS, and check your plan on the coverage hub.