Spravato vs TMS: which fits your depression?
Spravato and TMS are both treatments for depression that hasn't responded to antidepressants, and both are covered by most insurance. The biggest practical difference is time: TMS is usually a short session every weekday for about six weeks, while Spravato is a longer visit twice a week, then less often. They work in different ways, and some people try one after the other.
Spravato vs TMS in one table.
| Spravato (esketamine) | TMS | |
|---|---|---|
| What it is | A nasal spray medicine you take yourself in our office | Magnetic pulses delivered to the scalp by a device |
| How it works | Acts on glutamate, the brain's main signalling chemical | Stimulates the mood-regulating area at the front of the brain |
| Time each week | Twice a week, about 2.5 hours a visit, in month one; weekly or every other week later | Usually five weekday sessions a week for about six weeks, typically 20 to 40 minutes each |
| Common side effects | Dissociation, drowsiness and a blood pressure rise, confined to the two hours you rest with us | Scalp discomfort and headache during sessions |
| After a session | Someone drives you; you drive again the next day | You can usually drive yourself |
| After the first course | Maintenance visits continue to protect the response | The course ends; some people need repeat courses later |
| Insurance | Covered by most plans with prior authorization | Covered by most plans with prior authorization |
Spravato details from the SPRAVATO® Prescribing Information. TMS schedule from standard FDA-cleared protocols; individual clinics vary.
Is Spravato or TMS more effective?
No trial has compared Spravato and TMS head to head, so no one can say plainly that one works better. Both have strong evidence on their own. What usually decides it is your life: whether you can get to a clinic every weekday for six weeks, or whether two longer visits a week fit better, and how you feel about a medicine versus a device.
Which takes less time each week?
TMS sessions are shorter but come every weekday. Spravato visits are longer but come twice a week, and after the first two months they thin out to weekly or every other week. Many working people find two evening or Saturday visits easier than 30 weekday appointments.
Here's the Spravato schedule, set against a pill every day.
30 doses
Every day.
Side effectsEvery single day: sedation, dry mouth, sexual side effects, weight gain.
8 visits
Twice a week.
4 visits
Down to once a week.
2–4 visits a month
Down to once a week or every other week. Dashed: weeks you may or may not need.
Side effectsMostly gone by the end of each visit.
Can you do TMS and Spravato together?
Some people do TMS and Spravato together or one after the other, but it isn't standard to start both at once, because it makes it hard to tell which is helping. If TMS didn't work for you, that's no reason to think Spravato won't: it works on a different system entirely. We'll talk through your history at your evaluation.
You're far from alone.
Many of the people we see tried TMS first, and a lot of them tell us it didn't help much. We see a skewed group, of course: people TMS helped don't come looking for Spravato. But if TMS didn't work for you, it says nothing about how you'll do on Spravato.
A treatment that didn't work isn't a verdict.
Spravato is approved for depression that hasn't responded to at least two antidepressants. What you've already tried doesn't predict how you'll do on Spravato. It's what qualifies you for it.
Who tends to fit Spravato, and who tends to fit TMS?
Spravato may fit better if you:
- can't get to a clinic every weekday, but can manage two visits a week
- want a treatment that can start working within days: in its approval trial, people on Spravato were doing better than the comparison group from day 2 (Popova et al., 2019)
- have depression with suicidal thoughts, Spravato's second FDA-approved use (more on that)
- have metal implants in or near the head that rule out TMS
TMS may fit better if you:
- would rather not take another medicine
- need to drive yourself to and from every session
- have a condition that rules out Spravato, such as certain blood-vessel conditions or a past bleed in the brain (the full list)
- can commit to daily weekday sessions for about six weeks
What is a Spravato session like compared with a TMS session?
A Spravato session
You take the spray yourself, then rest in a recliner for at least two hours. Many people feel floaty or detached for part of the first hour, which eases before you leave; music and an eye mask help. A Sherpa stays close, and someone else drives you home. What Spravato feels like.
A TMS session
You sit awake in a chair while a magnetic coil rests against your head and delivers rapid tapping pulses. Many people find the tapping uncomfortable at first and get used to it. Afterward you can usually drive and go straight back to work.
Thirty thousand Spravato treatments.
We focus on Spravato, and we've given more than 30,000 treatments across our four New Jersey offices, top ten nationally by volume. That experience is why your two hours are uneventful: our team has already seen whatever your first session turns out to be.
Find out if Spravato is an option for you.
Answer a few questions about your history. We'll tell you whether Spravato is likely to fit, and talk through TMS with you too if you'd like.
Name, date of birth and insurer. We check your plan and call you back. No commitment.
Check my coverageRegister once, and our team starts your insurance check and reaches out to schedule your evaluation.
Request an evaluationWhat people ask about Spravato and TMS.
What is the difference between Spravato and TMS?
Spravato is a nasal spray medicine taken in a certified office twice a week to start. TMS uses magnetic pulses from a device, usually every weekday for about six weeks.
Which is better, Spravato or TMS?
No head-to-head trial exists, so neither has been shown to be better. The right choice usually comes down to your schedule, your history and your preferences.
Can Spravato work if TMS didn't?
Yes, it can. Spravato works on glutamate signalling, a different mechanism from TMS, so a TMS course that didn't help doesn't predict how you'll respond.
Which works faster, Spravato or TMS?
Spravato can start working within days: in its approval trial, people on it were doing better than the comparison group from day 2. TMS usually builds over several weeks of daily sessions. No trial has compared the two directly.
Should I try TMS before Spravato?
There's no required order. Both are options for depression that hasn't responded to antidepressants, and which comes first usually depends on your schedule, your health and your insurance.
Does insurance cover Spravato and TMS?
Most plans cover both with a prior authorization. We handle the Spravato approval for you.