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TMS vs. Esketamine for Treatment-Resistant Depression

TMS vs. Esketamine for Treatment-Resistant Depression

Treatment-resistant depression, or TRD, is a frustrating condition that can leave a patient feeling as if they have few options. Fortunately, the psychiatric community now has a range of options to consider in treating TRD, including esketamine and transcranial magnetic stimulation, or TMS.

What are the differences between these two TRD interventions, and which is the right choice for you? Let’s discuss the details on each and look at how these two popular options compare.

FDA Approval Status

Before we dive into the scientific differences between these two treatments, it’s important to cover the medical safety behind them.

The U.S. Food and Drug Administration (FDA) has approved both esketamine and TMS in the treatment of specific behavioral health conditions. In fact, the behavioral health community has been impressed with the patient outcomes and efficacy of treatments like esketamine.

What is TMS and how does it work?

TMS targets the brain’s nerve cells in a region that affects mood. An electromagnetic coil is placed in a specific location on the scalp and creates a small local magnetic field. This field stimulates an area in the frontal cortex of the brain, ultimately affecting emotional and behavioral patterns. Treatments are generally done daily for at least two weeks and often longer.

TMS treatment is non-invasive and done on an outpatient basis in your doctor’s office. It has been shown to benefit those with TRD; according to some research, TMS can improve symptoms in up to 60 percent of patients. It is also an FDA-approved treatment for depression.

What is Esketamine and how does it work?

Esketamine, sometimes referred to by the brand name Sravato, is an intranasal spray closely related to ketamine. This FDA-approved nasal spray has proven to be an effective treatment for helping patients with treatment-resistant depression.

Esketamine works by inhibiting a glutamate receptor, and while the exact mechanism by which it helps in depression is not fully understood, it may increase neuroplasticity, or the ability of the brain to make and modify synapses between nerve cells. In short, it uses a different and new mechanism compared to traditional oral antidepressants, which may be why many patients find it to be more effective.

In short, it bypasses a lot of the traditional pathways that standard medication takes by affecting the brain differently, which is why it’s been so effective.

Pros and Cons of TMS & Esketamine

Given the clear benefits of both esketamine and TMS, which therapy should you consider? Both esketamine and TMS have their pros and cons. Weighing these plusses and minuses can help you determine which treatment is right for you.

Length of Treatment

One of the biggest benefits of esketamine that patients love is that it requires far fewer treatment sessions than TMS. This means fewer trips to their psychiatrist, and most times this means esketamine is more cost effective than TMS.

Many patients end up preferring esketamine because TMS requires treatment lasting up to 4-6 weeks, 5 days a week. That’s 20-30 sessions in a month’s time, which can be difficult to fit into most patients’ busy schedules.

Side effects

Side effects are an important consideration when selecting a treatment for depression. If a treatment’s side effects outweigh its benefits, it may not be the right choice for you.

The side effects associated with both esketamine and TMS are minimal. TMS side effects include the following:

  • A tingling sensation in the scalp
  • Lightheadedness
  • Headaches

Esketamine generally has similarly minor side effects, including temporary increases in blood pressure, elevated heartbeat and nausea, all of which are typically short-lived and minor. In order to maintain maximum patient comfort and efficacy, esketamine is administered with the medical supervision of a doctor. Even esketamine’s less common but more serious side effects tend to fade within hours.


Whether or not a therapy is covered by insurance can also affect a decision. Both esketamine and TMS can be covered by your insurance. In order to confirm coverage, you will need to contact your insurance company. Your doctor’s office can also help address your insurance questions and help you determine whether or not you qualify for price reduction programs for esketamine.


When choosing between esketamine and TMS, you also need to look at whether either therapy has contraindications with a medical condition you have. Esketamine is not recommended for those with an allergy to either esketamine or ketamine. It is also not recommended for anyone who has experienced an aneurysm or bleeding in the brain. TMS is not recommended for patients with metal components in their bodies, including aneurysm clips, stents or implants. Patients with facial tattoos that include metallic ink should also avoid TMS.

Which is right for you?

Choosing between esketamine and TMS is an important decision that can greatly affect your experience with TRD. Your best option is to work in close consultation with your psychiatrist or other physician. This medical professional can walk you through the pros and cons of each as they relate to your specific case and help you choose the form of intervention that works best for you. Get in touch with a psychiatric professional today to begin discussing your options.