Spravato vs TMS Therapy: Which Is Right for Treatment-Resistant Cases?
When traditional antidepressants fail to provide relief, millions of people face the challenging reality of treatment-resistant depression. Two innovative FDA-approved options have emerged as potential solutions: Spravato (esketamine nasal spray) and transcranial magnetic stimulation (TMS). While both treatments show promising results, the “best” choice depends on individual circumstances, severity of symptoms, lifestyle factors, and medical history. Spravato typically works faster – often within hours to days – making it ideal for severe, urgent cases, while TMS offers a non-medication approach with longer-lasting effects and fewer systemic side effects, making it preferable for those seeking drug-free alternatives or concerned about substance-related risks.
Understanding Treatment-Resistant Depression and Mental Health Treatment
Treatment-resistant depression affects approximately 30% of people diagnosed with major depressive disorder. This condition is defined as depression that doesn’t adequately respond to at least two different antidepressant medications tried at adequate doses for a sufficient duration. The impact goes beyond persistent sadness – it can severely impair daily functioning, relationships, work performance, and overall quality of life.
For decades, the primary approach to depression treatment involved trying different combinations and doses of traditional antidepressants, sometimes alongside psychotherapy. While this works for many people, those with treatment-resistant depression often spend years cycling through medications with minimal improvement, experiencing side effects, and losing hope. The introduction of novel treatments like Spravato and TMS has revolutionized the landscape of mental health treatment, offering new pathways to recovery for those who haven’t found relief through conventional methods.
What Is Spravato Nasal Spray?
Spravato (esketamine) represents a fundamentally different approach to treating depressive symptoms. Unlike traditional antidepressants that primarily target serotonin, norepinephrine, or dopamine systems, Spravato works on the glutamate system in the brain. It’s a derivative of ketamine, a medication that’s been used in anesthesia for decades.
The treatment is administered as a nasal spray in a certified healthcare setting. Patients self-administer the spray under medical supervision and must remain at the facility for at least two hours afterward for monitoring. The typical treatment schedule begins with twice-weekly sessions for the first month, then reduces to once weekly, and may later shift to once every two weeks or monthly for maintenance.
Key characteristics of Spravato include:
Rapid onset: Many patients report improvement in depressive symptoms within hours to days, rather than the weeks typically required for traditional antidepressant medication
Supervised administration: Due to potential side effects like dissociation, sedation, and blood pressure changes, treatment must occur in a medical setting
Combination therapy: Spravato can be used alongside an oral antidepressant medication or as a standalone treatment
REMS program: Because of the potential for misuse and serious adverse outcomes, Spravato is only available through a restricted Risk Evaluation and Mitigation Strategy (REMS) program
Understanding TMS Therapy for Depression Treatment
Transcranial magnetic stimulation (TMS) takes an entirely different approach – it’s a non-invasive procedure that uses magnetic fields to stimulate specific areas of the brain associated with mood regulation. The most common target is the left dorsolateral prefrontal cortex, a region often underactive in people with depression.
During a TMS session, patients sit in a comfortable chair while a magnetic coil is positioned against the scalp. The device delivers focused magnetic pulses that pass through the skull and stimulate nerve cells in the targeted brain region. Each session typically lasts 20-40 minutes, and patients are awake and alert throughout the procedure.
The standard TMS protocol involves:
Daily sessions, five days per week, for 4-6 weeks (approximately 20-30 total sessions)
No anesthesia or sedation required
Ability to drive immediately after treatment and resume normal activities
No systemic medication entering the body
Cumulative effects that build over the treatment course
Spravato and TMS: Comparing Effectiveness for Depressive Symptoms
Both treatments have demonstrated significant efficacy in clinical trials for treatment-resistant depression, though they work through completely different mechanisms and timelines.
Spravato’s clinical trials showed that approximately 70% of patients experienced some level of improvement in depressive symptoms, with many experiencing rapid relief. The TRANSFORM-2 study demonstrated that patients receiving Spravato plus an oral antidepressant showed significantly greater improvement compared to those receiving a placebo nasal spray plus an oral antidepressant. However, the durability of response often requires ongoing maintenance treatment.
TMS therapy has shown response rates of 50-60% in treatment-resistant populations, with about one-third of patients achieving full remission. A major advantage of TMS is that improvements tend to be sustained even after the treatment course ends, with many patients maintaining benefits for a year or longer. Some patients may need periodic “booster” sessions, but ongoing treatment isn’t always necessary.
TMS and Spravato Treatment: Side Effects and Safety Considerations
Understanding the side-effect profiles is crucial when choosing between these FDA-approved options.
Spravato side effects include:
- Dissociation or feeling detached from reality (very common, especially initially)
- Dizziness and sedation
- Increased blood pressure
- Nausea
- Anxiety or perceptual disturbances
- Potential for misuse or dependence (though risk appears low in supervised clinical settings)
- Bladder problems with long-term use
TMS side effects include:
- Scalp discomfort or headache at the treatment site (usually mild and decreases over time)
- Facial twitching during treatment
- Lightheadedness
- Extremely rare risk of seizure (approximately 1 in 30,000 treatments)
TMS has minimal systemic side effects because it doesn’t involve medication entering the bloodstream. This makes it particularly appealing for patients who have experienced problematic side effects from antidepressant medication or who have medical conditions that complicate medication use.
Who Is the Right Candidate for Each Mental Health Treatment?
Spravato may be more appropriate for:
- Patients experiencing severe depression with acute suicidal thoughts (given its rapid action)
- Those who can commit to supervised treatment sessions and the required monitoring period
- Patients without a personal or family history of substance use disorders
- Individuals without uncontrolled hypertension or cardiovascular concerns
- Those who haven’t responded to TMS or aren’t candidates for it
TMS may be more suitable for:
- Patients seeking a medication-free option or who want to reduce antidepressant medication
- Those with substance use concerns or history
- Individuals who prefer accumulating benefits over time rather than acute intervention
- Patients who can commit to daily weekday sessions for 4-6 weeks
- Those without magnetic-sensitive metal implants in the head or implanted medical devices (contraindications for TMS)
Practical Considerations: Cost, Access, and Lifestyle Impact
Both treatments require significant time commitments and can involve substantial costs, though insurance coverage has expanded for both.
- TMS requires daily clinic visits for several weeks, which can be challenging for those with demanding work schedules or limited transportation. However, sessions are relatively short, and patients can return to normal activities immediately. Most major insurance plans now cover TMS for treatment-resistant depression, though prior authorization is typically required.
- Spravato sessions are less frequent but longer when the mandatory two-hour monitoring period is included. Patients cannot drive after treatment and need someone to accompany them home.
Can You Combine or Switch Between These Depression Treatment Options?
Some patients may benefit from trying both approaches, either sequentially or in combination, though this should always be discussed with a psychiatrist.
It’s not uncommon for patients to try TMS first, given its favorable safety profile and non-medication approach. If TMS provides only partial improvement, adding Spravato might offer additional benefits. Conversely, some patients start with Spravato for rapid symptom relief, then transition to TMS for longer-term maintenance.
The decision to combine treatments should take into account potential increases in costs, time commitments, and the complexity of managing multiple interventions simultaneously.
Final Thoughts: TMS vs Spravato
The choice between Spravato vs TMS therapy ultimately depends on your unique mental health journey, the severity of your depression symptoms, and your personal circumstances and preferences. Both represent groundbreaking FDA-approved treatment options that have transformed outcomes for people who haven’t found relief through traditional treatments like talk therapy and conventional antidepressants.
- A typical TMS treatment course offers a non-medication approach through transcranial magnetic stimulation therapy that allows patients to resume daily activities immediately after each session, making it ideal for those seeking drug-free options or managing multiple mental health conditions.
- Spravato, available in nasal spray form, provides an alternative for those with severe symptoms who need rapid intervention, though it requires supervised administration and monitoring. Your healthcare provider can help determine which treatment plan aligns best with your medical history, lifestyle, and treatment goals, considering factors like pregnancy status – as pregnant women require special consideration with any intervention – and whether you have comorbidities, such as anxiety or obsessive-compulsive disorder.
Regardless of which path you choose to treat depression, remember that seeking innovative treatments demonstrates courage and commitment to better mental health. Neither Spravato nor TMS works for everyone, and some people may need to try both or combine them with other therapies to achieve optimal results.
The important message is that treatment-resistant depression is not a dead end – these advanced options provide real hope for relief when conventional approaches fall short. Work closely with a psychiatrist experienced in these treatments to develop a comprehensive treatment plan tailored to your needs, maintain open communication about your progress and any concerns, and remember that finding the right treatment often requires patience and persistence. With the expanding landscape of FDA-approved treatments for depression, more people than ever are finding pathways to recovery and reclaiming their lives from the grip of treatment-resistant depression.
About the Author
Rhonda Richardson, PMHNP-BC
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