If a doctor has raised treatment-resistant depression with you, or you have started reading about it on your own, you have probably seen both of these names. They are often mentioned together because both are FDA-supported options for depression that has not responded to standard care. But they work in different ways and feel different to go through. Neither is better in the abstract. The right choice depends on your history, your preferences, and what your clinician recommends.
What each one is
TMS (transcranial magnetic stimulation)
TMS is a non-invasive, FDA-cleared treatment that uses focused magnetic pulses to stimulate areas of the brain involved in mood regulation. There is no medication and no anesthesia. You sit in a chair, fully awake, while a coil rests against your head and delivers pulses.
Esketamine (Spravato)
Esketamine is an FDA-approved nasal-spray medication derived from ketamine. It works through a different brain system (the glutamate system) than SSRIs and SNRIs, which is part of why it can help people who have not responded to those. It is given under medical supervision in a certified clinic and used together with an oral antidepressant, not usually on its own.
What a course of treatment looks like
The two schedules feel quite different day to day:
- TMS: Typically short sessions on most weekdays over roughly four to six weeks. You can drive yourself and return to normal activities right after each session, since nothing sedating is involved.
- Esketamine: Given in the clinic, usually twice a week at first and then tapering to less frequent visits. Because it can cause drowsiness or a dissociated feeling, you are monitored for about two hours after each dose and you cannot drive yourself home that day.
Side effects, in plain terms
Both are generally well tolerated when delivered by an experienced clinic, but the side-effect profiles differ. With TMS, the most common effects are scalp discomfort or a tapping sensation at the treatment site and occasional headache, which often ease as sessions continue. With esketamine, people may feel temporary dizziness, a floating or dissociated sensation, nausea, or a short rise in blood pressure during the monitoring window. These effects are the reason the observation period exists, and they typically fade before you leave the clinic. Your clinician will review your full history, since certain conditions make one option more suitable than the other.
How people and clinicians choose
There is no universal winner. A clinician weighs factors like your medical history, how urgent your symptoms are, whether you can arrange rides to appointments, your insurance coverage, and your own comfort with each approach. Some people prefer TMS because it involves no medication and no post-dose monitoring. Others are drawn to esketamine because some people notice improvement relatively quickly. Coverage varies by plan and by clinic, so it is worth asking directly what your insurance will approve.
Questions worth asking a clinic
- Based on my history, do you think TMS or esketamine is the better starting point, and why?
- What does the full schedule look like, and how will I get to and from appointments?
- What side effects should I plan around?
- What will my insurance cover, and what would I owe?
- How will we measure whether it is working?
The bottom line
TMS and esketamine are two different tools for the same problem: depression that standard antidepressants have not resolved. If you are weighing them, that is a good sign, because it means you are looking past more of the same and toward a real next step. Bring these questions to a doctor or a specialty clinic and let your own history guide the choice. If you want the wider picture first, our overview of depression treatment options and our guide on what to do when an antidepressant is not working both give helpful context.