TMS Vs. Spravato
TMS vs. Spravato: Which Treatment Is Right for Depression?
Depression is not the same for everyone — and neither is the path to recovery.
For many people, antidepressant medications and psychotherapy provide meaningful relief. But for others, depression persists despite trying one or more medications. This is often referred to as treatment-resistant depression (TRD) — a condition that, by clinical definition, means a patient has not responded adequately to at least two antidepressant trials given at adequate dose and duration. Research suggests roughly one-third of adults with major depressive disorder meet this definition at some point.
Fortunately, treatment does not have to stop when conventional antidepressants have not worked. Two important options — Transcranial Magnetic Stimulation (TMS) and Spravato® (esketamine) — offer very different ways of treating depression and can be particularly valuable for people who have not experienced adequate improvement with standard care.
At the Alabama Institute of Mood and Memory (AiMM), we believe the question is not simply, "Which treatment is better?" A more useful question is:
"Which treatment is the better fit for this particular patient?"
What Is TMS?
Transcranial Magnetic Stimulation (TMS) is a noninvasive, FDA-cleared treatment that uses precisely targeted magnetic pulses to stimulate brain networks involved in mood regulation, particularly the left dorsolateral prefrontal cortex. The FDA first cleared TMS for depression in October 2008, for patients with major depressive disorder who had not improved with at least one adequate antidepressant trial.
Unlike medications, TMS does not circulate throughout the body. Treatment is delivered while the patient is awake and seated comfortably in a treatment chair. There is no anesthesia, no IV, and no sedation — patients can talk, read, or listen to music during sessions.
Patients typically leave the office immediately after treatment and return to their usual activities, including driving, working, or spending time with family, with no required recovery period.
What a course of treatment looks like
A standard course of TMS is typically delivered five days a week for four to six weeks — often around 30 to 36 total sessions — followed by a gradual taper of less frequent sessions. Traditional protocols run about 19–37 minutes per session and deliver roughly 3,000 magnetic pulses; newer accelerated protocols, such as intermittent theta-burst stimulation, can complete a session in as little as three minutes while remaining comparably effective. The most common side effect is mild scalp discomfort or headache during the treatment course, which typically fades over the first week or two.
How well does it work?
In naturalistic clinical practice (outside of tightly controlled trials), response rates for TMS are commonly reported in the range of 50–60%, with roughly one-third of patients achieving full remission of symptoms. Among those who do respond, follow-up research has found that about 60% maintain that response at 12 months.
Who may benefit from TMS?
TMS may be especially attractive for people who:
Have depression that has not adequately improved with antidepressant medication
Have experienced troublesome medication side effects
Prefer a treatment that does not involve adding another systemic medication
Want to avoid sedation or anesthesia
Need to drive or return to work immediately after treatment
Are able to attend treatment regularly over several weeks
Have previously responded well to TMS and are experiencing a recurrence of depression
For some patients, one of the greatest advantages of TMS is its non-systemic nature. Because the treatment is directed at specific brain networks rather than delivered throughout the body, it generally does not produce the systemic side effects (weight change, sexual side effects, GI upset, etc.) associated with many antidepressant medications.
What Is Spravato?
Spravato® (esketamine) is a prescription nasal spray, FDA-approved in March 2019, used in conjunction with an oral antidepressant for adults with treatment-resistant depression. It was the first depression medication with a genuinely new mechanism of action since Prozac's approval in the late 1980s. Esketamine is the S-enantiomer of ketamine and works as an NMDA-receptor antagonist, affecting the brain's glutamate system rather than the serotonin and norepinephrine pathways targeted by traditional antidepressants.
Because of its potential for misuse and its acute effects, Spravato is a Schedule III controlled substance, available only through a restricted FDA program (the Spravato REMS), and must be administered in a certified healthcare setting rather than taken home. After each dose, patients are monitored because temporary effects can include sedation, dizziness, altered perception, dissociation, and increases in blood pressure.
What a course of treatment looks like
Spravato follows a structured dosing schedule:
Induction phase (weeks 1–4): twice-weekly doses of 56 mg or 84 mg
Maintenance phase (weeks 5–8): once-weekly dosing
Week 9 and beyond: dosing individualized to once weekly or once every two weeks, at the lowest frequency that maintains response
Patients remain at the treatment center for at least two hours of observation after each dose, with blood pressure checks before and after. Current prescribing guidance advises against driving or operating machinery until the next day, after a full night's sleep — not simply for the rest of the treatment day — so transportation arrangements need to cover that full window.
How well does it work?
In the pivotal clinical trials supporting FDA approval, patients who continued Spravato alongside an oral antidepressant were about 51% less likely to relapse than those on placebo plus an oral antidepressant. Manufacturer estimates have suggested the medication can help somewhere in the range of 30–40% of patients who have not responded to standard antidepressants, though individual response varies.
Who may benefit from Spravato?
Spravato may be considered for appropriate adults who:
Have treatment-resistant depression
Have experienced inadequate improvement despite antidepressant treatment
Need a treatment that works through a different biological pathway from conventional antidepressants
Are comfortable receiving treatment in a medically supervised setting
Can arrange transportation for the day of treatment (and avoid driving until the following day)
Can accommodate the required post-treatment monitoring period
Spravato also carries an additional FDA indication for adults with major depressive disorder who have acute suicidal ideation or behavior, based on the ASPIRE I and ASPIRE II trials. That said, the medication's effectiveness in preventing suicide specifically has not been established, and treatment decisions in these situations require careful psychiatric assessment and appropriate safety planning.
So, Which One Is Better?
There is no universal winner.
TMS may be the better fit for someone who wants a non-medication treatment, has struggled with medication side effects, needs to remain fully functional immediately after treatment, or prefers not to experience the potential psychoactive effects associated with esketamine.
Spravato may be the better fit for someone with significant treatment-resistant depression who is an appropriate candidate for esketamine and can accommodate transportation and monitoring requirements — including the full next-day driving restriction.
For some patients, the decision may also depend on previous medication trials, severity and urgency of symptoms, medical history, other psychiatric conditions, insurance coverage, transportation, work schedule, and personal preference.
And importantly, TMS and Spravato should not necessarily be viewed as competing treatments. Modern interventional psychiatry provides multiple options because different patients respond to different approaches. A patient who does not respond adequately to one intervention may still benefit from another.
What If My Depression Has Not Improved With Medication?
One of the most discouraging experiences for someone with depression is trying medication after medication and beginning to believe that nothing will work.
Data from the landmark STAR*D trial found that only about 28–33% of patients achieve remission after their very first antidepressant trial — a reminder that needing more than one approach is common, not unusual. An inadequate response to several medications does not mean that treatment options have been exhausted.
Instead, it may be time to reconsider the treatment strategy.
Interventional psychiatry expands treatment beyond the traditional cycle of simply switching from one antidepressant to another. Depending on the individual, options may include TMS, Spravato, psychotherapy, medication optimization, combination approaches, and — in appropriately selected patients with severe illness — electroconvulsive therapy (ECT).
The key is matching the intensity and mechanism of treatment to the individual patient's illness.
Choosing Treatment Should Start With the Patient, Not the Procedure
At the Alabama Institute of Mood and Memory (AiMM), our approach begins with a comprehensive psychiatric evaluation.
Before recommending TMS, Spravato, or another intervention, we consider questions such as:
What treatments have already been tried? Were they given at adequate doses and for adequate durations? Did they help partially or not at all? Were side effects the reason treatment was stopped? How severe is the current depression? How is it affecting work, relationships, sleep, cognition, and daily functioning? Are there medical or psychiatric factors that make one treatment more appropriate than another?
These details matter.
The goal is not simply to provide a treatment. The goal is to determine which treatment offers the most appropriate balance of effectiveness, safety, tolerability, and practicality for each individual patient.
There Are More Options for Depression Than Ever Before
Depression that has not responded to medication can feel frustrating and exhausting, but today's psychiatric treatments extend well beyond conventional antidepressants.
TMS offers a noninvasive, non-sedating approach that directly targets brain networks involved in depression.
Spravato offers a medication-based approach with a different mechanism from traditional antidepressants, administered in a closely monitored clinical setting.
Both represent important advances in the treatment of depression.
If you have tried antidepressants without adequate improvement, the next step does not always have to be "try another medication."
Sometimes, it is worth asking a different question:
"Is it time to consider a different type of treatment?"
Considering TMS or Spravato in Huntsville, Alabama?
The Alabama Institute of Mood and Memory (AiMM) provides comprehensive psychiatric care and interventional treatment options for adults with depression, including TMS and Spravato® evaluation and treatment.
Treatment recommendations are individualized following psychiatric evaluation and consideration of your symptoms, previous treatments, medical history, preferences, and treatment goals.
Alabama Institute of Mood and Memory (AiMM) Because Every Mind Matters.
Learn more or request an appointment at aimmhealth.com
This article is intended for general educational purposes and does not replace individualized medical advice. TMS and Spravato are not appropriate for every patient. Response rates, protocols, and side effect profiles cited here are drawn from published clinical trial data and prescribing information and may not reflect every patient's experience. Indications, contraindications, potential risks, benefits, and alternative treatments should be discussed with a qualified healthcare professional.