Spravato® vs. TMS: Which Treatment Is Right for Treatment-Resistant Depression in New York?

If standard antidepressants haven’t worked for your depression, you’ve likely started researching what comes next. Two treatments come up consistently: Spravato® (esketamine) and TMS (transcranial magnetic stimulation). Both are FDA-approved for treatment-resistant depression. Both are available in New York. But they are not identical — and understanding the differences can help you have a more informed conversation with your psychiatrist.

This article explains both treatments clearly so you can better understand your options and decide which approach may fit your situation.

What TMS Is

Transcranial magnetic stimulation (TMS) is a non-invasive procedure that uses repetitive magnetic pulses to stimulate areas of the brain involved in mood regulation — most commonly the dorsolateral prefrontal cortex. It does not involve medication. During treatment, patients sit awake while a magnetic coil is placed against the scalp.

TMS received FDA clearance for major depressive disorder in 2008 and has been used for over 15 years. It has a well-established evidence base and is a widely used treatment for patients who have not responded to antidepressants.

The practical considerations of TMS:

• Typically requires sessions 5 days per week for 4 to 6 weeks (20–30 treatments total)

• Each session lasts about 20 to 40 minutes

• Many patients begin noticing improvement after 2 to 4 weeks of treatment

• Response and remission rates are meaningful, though not all patients benefit

• Maintenance sessions may be recommended to sustain improvement

TMS can be a strong option, particularly for patients who prefer to avoid medication-based treatments or cannot tolerate systemic side effects.

What Spravato® Is — and How It Differs

Spravato® (esketamine) is an FDA-approved nasal spray that works through the glutamate system, specifically as an NMDA receptor antagonist. This is a different mechanism from traditional antidepressants, which primarily target serotonin or norepinephrine.

Because it acts on a different neurobiological pathway, Spravato® may be helpful for patients who have not responded to multiple prior medications.

Key considerations for Spravato®:

• FDA approval: Approved in 2019 for treatment-resistant depression and for major depressive disorder with acute suicidal ideation or behavior

• Onset of effect: Some patients report improvement within days, though individual responses vary

• Treatment schedule: Typically twice weekly for the first 4 weeks, then spaced out over time

• In-clinic administration: Each session includes a 2-hour monitoring period due to potential temporary side effects such as dissociation or increased blood pressure

• Transportation: Patients cannot drive themselves home after treatment

Spravato® works at the neurochemical level and is designed to help improve synaptic function and plasticity — processes that are often disrupted in depression.

Comparing Spravato® and TMS

Patients often want a direct comparison when considering these treatments:

Speed of response

• TMS: Improvement often begins after several weeks

• Spravato®: Some patients experience earlier changes even within days of the first treatment, though timelines vary

Mechanism

• TMS: External stimulation of targeted brain regions

• Spravato®: Neurochemical effects through the glutamate system

Acute suicidal ideation

• Spravato®: FDA-approved for this indication

• TMS: Not FDA-approved for acute suicidal ideation

Time commitment

• TMS: Daily weekday sessions for several weeks

• Spravato®: One to two visits a week but longer in-clinic sessions

Side effects

• TMS: May include scalp discomfort or headache

• Spravato®: May include temporary dissociation or blood pressure changes during sessions

Long-term management

• Both treatments may require maintenance to sustain results

Which One Is Right for You?

There is no one-size-fits-all answer. The right choice depends on your medical history, treatment preferences, symptom severity, and how your depression has responded to prior interventions.

Spravato® may be considered for patients who:

• Have not responded to multiple antidepressants

• Are looking for a treatment with a different mechanism of action

• Need closer clinical monitoring due to symptom severity

TMS may be preferred for patients who:

• Want a non-medication-based approach

• Have contraindications to certain medications

• Prefer shorter, more frequent sessions

A comprehensive evaluation with a psychiatrist is essential to determine the most appropriate option.

Accessing Spravato® in New York

Spravato® must be administered at a certified treatment site under the FDA’s REMS program. Not all psychiatric practices offer it, so it’s important to confirm that your provider has experience with both evaluation and ongoing management.

At Aurora Wellness, our team of board-certified psychiatrists, PMHNPs, and PA-Cs provides comprehensive evaluations for treatment-resistant depression. We offer Spravato® treatment at our Brooklyn and White Plains locations, along with ongoing psychiatric care and therapy to support patients throughout the process.

If you’ve been through multiple antidepressants without adequate relief, discussing advanced treatment options with a qualified provider can be an important next step.