Have you tried lifestyle changes, talk therapy, and traditional antidepressants, but nothing seems to help your mental health?
When depression lingers or returns despite trying multiple medications, it’s considered treatment-resistant depression. That’s where alternative mental health treatments like TMS, ketamine (IV ketamine therapy), and Spravato enter the conversation.
While these treatments all fall under “advanced depression treatment options,” they work differently and serve distinct types of patients. This guide explains the differences of ketamine vs TMS vs Spravato, and how we help determine the best treatment for depression or other mental health conditions.
How They Work – A Quick Guide
- TMS (Transcranial Magnetic Stimulation): Uses magnetic pulses on the scalp to stimulate underactive mood circuits in the brain. No anesthesia or medication.
- Ketamine: Modulates the NMDA receptor in the glutamate system, helping the brain form new neural connections and often improved mood within hours.
- Spravato (Esketamine): A nasal spray version of ketamine which is FDA-approved for treatment-resistant depression and major depression with suicidal ideation.
What Comes First?
Before recommending a treatment plan, clinicians look at:
- How many antidepressants were tried and at what dose/duration
- Whether medications failed to work or caused significant side effects
- The urgency of suicidal thoughts or other conditions
- Co-occurring conditions (anxiety, OCD, PTSD, bipolar disorder, etc.)
- Health history or family health history
Generally speaking, TMS is an early consideration if the patient wants a non-drug, well-tolerated approach. However, ketamine or Spravato are often an early choice when rapid relief is needed, especially for suicidal thoughts.
Who Is a Good Candidate?
TMS is often ideal for people who have already tried at least two antidepressants without success, prefer a non-medication option, and want longer-lasting results rather than quick but temporary relief. It’s also a strong fit for those who want to avoid dissociation or sedation, have a history of substance use, or can’t safely take ketamine for other medical reasons.
Ketamine can be particularly helpful for patients who need rapid symptom relief, especially when suicidal thoughts are present. It’s also a strong option for those who haven’t responded to standard antidepressants and are still open to a medication-assisted treatment.
Spravato tends to be the best fit for patients who meet insurance criteria for treatment-resistant depression and prefer an FDA-approved form of ketamine (esketamine) rather than off-label IV ketamine. It is well suited for individuals who need rapid symptom relief but feel more comfortable with a standardized and regulated medical approach.
Who Is NOT a Candidate?
Identifying who isn’t a good fit for each treatment is just as important as knowing who is. Safety considerations, medical history, and existing conditions all play a role in treatment selection.
TMS is generally avoided in people with a history of seizures or with certain metal implants in or near the skull that aren’t MRI-safe.
Ketamine is usually not recommended for people with active psychosis, uncontrolled high blood pressure, heart problems, pregnancy, or those who are breastfeeding. Providers are also cautious with patients who have a history of substance misuse.
Spravato is mostly avoided in people with a history of aneurysm or brain bleed, uncontrolled high blood pressure, psychosis, or severe liver issues. Like IV ketamine treatment, clinicians check for a history of substance misuse before prescribing it.
Timeline & Durability
TMS takes a bit longer to work (usually a few weeks), but the results can last well beyond the treatment course. Ketamine and Spravato are much faster acting, sometimes improving symptoms within hours or days, but they usually need ongoing maintenance to sustain the benefits. For this reason, some patients start with ketamine or Spravato for rapid relief and then move to TMS for longer-term stability.
Side Effects
Side effects also play a role in choosing the right treatment. TMS tends to have mild effects such as headache or scalp discomfort, but does not require sedation or cause general side effects. Ketamine and Spravato, on the other hand, can involve dissociation, dizziness, nausea, or changes in blood pressure; thus, patients are always monitored in-clinic for safety after treatment.
How Clinicians Decide
There’s no universal best treatment for depression. Instead, the real question is: “What depression treatment is right for me?”
Clinicians look at several factors when deciding which treatment makes the most sense for each individual.
If someone has urgent symptoms or suicidal thoughts, ketamine or Spravato may be the best fit because they work quickly. If the goal is longer-term stability, TMS tends to be the better fit. Patients who don’t tolerate medications well may prefer TMS since it’s not drug-based.
Other conditions like bipolar disorder, anxiety, PTSD, or another health concern can help guide the decision, too. Insurance coverage can also play a role in the treatment course, as TMS and Spravato can often be covered by insurance while IV ketamine is largely uncovered.
And, while you know your body best, at the end of the day, it is important to defer to your care provider for their knowledge and expertise of advanced treatment methods.
Contact Us Today
Ready to explore alternative mental health treatments for treatment-resistant depression? Our team can help guide the next step.