Side effects and safety: Spravato, ketamine and TMS

Spravato (esketamine)

See the Spravato hub, the coverage hub, the coverage checker, treatment comparisons and condition and treatment pages.

Common: dissociation, dizziness, nausea, sedation, feeling drunk, numbness, anxiety, increased blood pressure. Most last under two hours. Serious: the boxed warning covers sedation, dissociation, respiratory depression, and misuse. Blood pressure spikes are why monitoring is mandatory. Do not use with: aneurysm or arteriovenous malformation, history of intracerebral hemorrhage, uncontrolled hypertension, pregnancy. Long term: bladder symptoms and cognitive effects have been seen with heavy recreational ketamine use; they have not appeared at treatment doses in the trials, but clinics ask about urinary symptoms at every visit.

Ketamine (IV, IM, oral)

Same profile as Spravato with dose-dependent intensity. Additional considerations: IV dosing can raise blood pressure more sharply; oral and at-home use carries a higher misuse risk because dosing is less supervised. Liver enzyme elevation is rare. Interactions: benzodiazepines and lamotrigine reduce the effect; MAOIs and stimulants raise cardiovascular risk.

TMS

Common: scalp discomfort and headache during the first week; facial muscle twitching during pulses. Uncommon: hearing changes without earplugs (always wear them), transient mood elevation in people with bipolar disorder. Serious: seizure, roughly 1 in 1,000 patients or less, mostly in people with risk factors. Screening covers epilepsy, brain injury, and medications that lower seizure threshold. Do not use with: non-removable ferromagnetic metal in the head (some aneurysm clips, cochlear implants, certain stents), or implanted devices within 30 cm of the coil.

What good monitoring looks like

• Blood pressure before and after every ketamine or Spravato dose.
• A rating scale at baseline and at intervals, so a treatment that is not working gets stopped.
• Questions about bladder symptoms, substance use and driving at every visit.
• For TMS, motor threshold rechecked if pulses feel different.

Driving and monitoring rules

Federal law requires two hours of observation after Spravato and prohibits driving until the next day. Clinics apply the same rule to ketamine. TMS has no driving restriction. See driving and monitoring rules.