Pathway
Device or medication?
TMS uses a device; SPRAVATO and ketamine are medications. That difference changes screening, treatment-day experience, and follow-up.
Side-by-side patient decision guide
SPRAVATO vs TMS vs ketamine for depression
No single option is universally better. The useful comparison is how each treatment changes the setting, schedule, monitoring, transportation, insurance conversation, and questions you need to bring to a clinician.
Start with the distinction that matters
These are different clinical pathways—not interchangeable products.
TMS is noninvasive brain stimulation. SPRAVATO is FDA-approved esketamine nasal spray administered under a REMS program. Ketamine is a related medication, but ketamine products are not FDA-approved for psychiatric disorders.
This page helps organize a clinician conversation. It cannot determine diagnosis, urgency, eligibility, sequencing, or which option is appropriate for one person. Start with a careful reassessment if the diagnosis, prior treatment trials, safety needs, or medical contributors are not yet clear.
Review the treatment-resistant depression pathway →Schedule
Frequent brief visits or longer monitored visits?
TMS usually means repeated weekday sessions. SPRAVATO requires at least two hours of monitoring after each administration. Ketamine varies by route and setting.
Transportation
Can you safely get home?
The current SPRAVATO label prohibits driving until the next day after restful sleep. Ketamine instructions vary. Plan before the first appointment.
Coverage
What exactly will the plan pay for?
Ask about authorization, drug or device coverage, professional visits, monitoring, deductibles, copays, and maintenance—not just whether the treatment is “covered.”
Why FDA status matters
Approval or clearance defines the reviewed use—not a guaranteed outcome.
FDA status helps separate evidence reviewed for a specific drug indication or device protocol from off-label and investigational uses. It also anchors the official dosing or protocol, warnings, contraindications, monitoring, and product-quality requirements.
That status does not guarantee benefit for one person, remove the need for informed consent, or guarantee insurance payment. Ask the treating center to name the exact product, device, protocol, and indication; explain whether the proposed use is FDA-approved, FDA-cleared, off label, or investigational; and verify coverage under the patient's actual benefit before treatment.
SPRAVATO vs TMS
Which differences change the day-to-day decision?
SPRAVATO is a supervised esketamine medication with REMS requirements; TMS is noninvasive brain stimulation delivered through repeated office visits. Neither is automatically better. The useful choice depends on clinical fit, safety, treatment history, time, transportation, access, and the complete cost under your health plan.
Speed and measurement
Do not turn a faster-sounding claim into a promise.
Ask when response will be measured, what improvement should look like, and when the treatment plan will be reassessed. Individual response varies with either option.
Side effects and restrictions
The safety conversations are different.
TMS screening focuses on the device, protocol, seizure risk, implanted metal or devices, and common treatment-site effects. SPRAVATO requires discussion of sedation, dissociation, respiratory and blood-pressure monitoring, misuse risk, and label contraindications.
Time and transportation
The calendar may decide what is realistic.
TMS commonly requires frequent weekday visits during an acute course. SPRAVATO requires supervised administration, at least two hours of monitoring, transportation home, and no driving until the next day after restful sleep.
Cost and insurance
Compare the whole course—not one advertised price.
Verify authorization, network, medication or device coverage, professional visits, monitoring, copays, deductibles, transportation, and possible maintenance before comparing expected cost.
Full comparison
Compare the treatment day, not just the treatment name.
On a smaller screen, scroll the table horizontally to compare all three treatment columns.
| Question | TMS | SPRAVATO / esketamine | Ketamine |
|---|---|---|---|
| What it is | Noninvasive brain stimulation delivered through a device placed against the scalp. | A prescription esketamine nasal spray administered under direct healthcare supervision. | A medication available in several products and routes. Psychiatric use of ketamine is off label. |
| FDA status | Devices and protocols are cleared for specific indications. Ask which device, protocol, and indication apply. | FDA-approved for treatment-resistant depression in adults as monotherapy or with an oral antidepressant. The label includes another adult MDD indication with different requirements. | Ketamine is FDA-approved as an anesthetic—not for a psychiatric disorder. Compounded ketamine products are not FDA-approved. |
| How treatment is delivered | Magnetic pulses are delivered while the patient is awake in a clinical or office setting; anesthesia is not typically required. | The patient uses the nasal spray in a REMS-certified healthcare setting under direct observation. | The product, route, dose, setting, and monitoring plan vary. Ask for each one in writing. |
| Typical schedule | A typical rTMS course is delivered five days per week for four to six weeks, but session length and newer protocols vary. | For adult TRD, the label starts with twice-weekly treatment, then reduces frequency based on phase, response, and tolerability. | There is no FDA-approved psychiatric dosing schedule for ketamine. The plan varies by route and clinician. |
| Monitoring and time onsite | Screening, device setup, symptom measurement, and side-effect monitoring depend on the protocol. Typical sessions may last several minutes to about 40 minutes. | Each session includes supervised administration and at least two hours of monitoring, including respiratory-status monitoring. | Monitoring needs depend on the exact product and route. Do not assume an at-home or compounded model is equivalent to monitored clinic care. |
| Driving and transportation | Plan for repeated visits and ask whether your protocol or medical history changes driving or work guidance. | Do not drive or operate machinery until the next day after a restful sleep. Transportation must be planned. | Instructions vary. Ask whether a driver is required and when it is safe to resume driving, work, or caregiving. |
| Safety discussion | Ask about headache or scalp discomfort, hearing protection, seizure risk, implanted devices, medications, and the exact protocol. | Discuss sedation, dissociation, respiratory depression, blood-pressure changes, abuse or misuse risk, and label contraindications. | Discuss sedation, dissociation, blood-pressure and respiratory effects, abuse or misuse risk, urinary symptoms, and the risks of unsupervised or compounded products. |
| Insurance and cost questions | Coverage may depend on diagnosis, prior treatment documentation, device or protocol, network, and authorization rules. | REMS participation does not guarantee insurance coverage. Verify the drug, visit, monitoring, and follow-up portions of the benefit. | Psychiatric use is off label, so coverage can differ by product, route, clinician, and plan. Request a written estimate before starting. |
| Follow-up | Ask how response is measured, what happens after the acute course, and whether maintenance treatment may be discussed. | The label calls for ongoing evaluation and the least frequent dosing needed to maintain response or remission. | Ask what outcome is being measured, when continuation is reconsidered, and who owns medication and safety follow-up. |
| Best question to bring | Why does this specific device and protocol fit my diagnosis, history, and practical schedule? | Why does the current SPRAVATO label fit my diagnosis, and how will monitoring, transportation, and continuation work? | What exact ketamine product and route are proposed, why is off-label use being considered, and what safety system surrounds it? |
Schedules, device protocols, labels, coverage rules, and individual instructions can change. Confirm current details with the treating clinician, facility, insurer, and official product information.
TMS conversation
Ask which device, protocol, target, and treatment course are proposed.
“TMS” is not enough detail. Ask how the protocol fits the diagnosis, what screening is required, how response is measured, and what happens after the acute course.
Read the TMS guide →SPRAVATO conversation
Use the current label—not an older summary—as the starting point.
Ask which labeled indication applies, what the REMS-certified setting provides, how blood pressure and respiratory status are monitored, and how transportation will work.
Read the SPRAVATO guide →Ketamine conversation
Product, route, setting, off-label status, and monitoring must be explicit.
Do not let the word “ketamine” hide meaningful differences. Ask who evaluates, administers, monitors, manages adverse effects, and owns follow-up.
Read the ketamine guide →A commonly blurred distinction
SPRAVATO and ketamine are related, but they are not the same care model.
SPRAVATO has a specific FDA label, nasal-spray device, REMS program, certified-setting requirement, and monitoring rules. Ketamine used for depression is off label, and its product, route, dosing, setting, and safeguards vary.
The FDA warns that compounded ketamine products are not FDA-approved and highlights additional risks when treatment occurs without onsite monitoring. If a clinic or telehealth service proposes ketamine, ask whether the product is FDA-approved or compounded, which route is used, who is physically present, how vital signs and mental status are monitored, and what emergency capability exists.
Prepare for a real evaluation
Four steps make the comparison more useful.
- 1
Confirm the clinical question.
Ask whether the working diagnosis, current safety needs, bipolar symptoms, substance use, sleep, medical contributors, and level of care have been reassessed.
- 2
Bring the treatment record.
List medications, doses, duration, benefit, side effects, psychotherapy, hospital care, and any prior TMS, esketamine, ketamine, or ECT.
- 3
Name the exact treatment.
Record the device or medication, protocol or route, FDA status, proposed schedule, monitoring plan, and why it fits the clinician’s evaluation.
- 4
Verify the full practical pathway.
Confirm transportation, time away from work or caregiving, authorization, total expected cost, progress measurement, follow-up, and what happens if symptoms worsen.
Another option may belong in the discussion
This three-way comparison does not cover every advanced treatment.
Depending on diagnosis, severity, psychosis, catatonia, urgency, prior response, medical factors, and patient preference, a clinician may discuss ECT, medication or psychotherapy changes, a different level of care, or another pathway instead.
Read the ECT guide →Common comparison questions
Answers that preserve the clinical decision.
Is SPRAVATO (esketamine) or TMS better?
There is no universal winner. TMS is a noninvasive device-based treatment, while SPRAVATO is a supervised medication with REMS requirements. Diagnosis, urgency, safety, treatment history, schedule, transportation, preference, access, and insurance can all change the decision.
How quickly can TMS or SPRAVATO work?
Response timing varies, and neither treatment guarantees rapid improvement. TMS is delivered over a course of repeated sessions, while SPRAVATO follows an induction and maintenance schedule defined in its current label. Ask when the clinician will measure response, what counts as meaningful improvement, and when the plan will be reconsidered.
Is SPRAVATO cheaper than TMS?
There is no reliable universal price comparison. Coverage can depend on diagnosis, prior treatment documentation, authorization, network, the exact TMS device or protocol, the SPRAVATO medication benefit, professional visits, monitoring, deductibles, and maintenance. Request a written estimate for the complete course rather than comparing one session price.
How long do most people stay on SPRAVATO?
The current label uses induction and maintenance phases and calls for the least frequent dosing needed to maintain response or remission. The appropriate duration is an individual prescribing decision based on benefit, tolerability, safety, and ongoing evaluation—not a fixed website rule.
Is SPRAVATO the same as ketamine?
No. SPRAVATO is the brand name for FDA-approved esketamine nasal spray and has a defined label and REMS program. Ketamine is a related medication, but ketamine products are not FDA-approved for psychiatric disorders. Product, route, dose, monitoring, and coverage can differ substantially.
Can TMS and SPRAVATO be used together?
A clinician may sometimes discuss sequencing or combining treatments, but that is not a standard website decision. The care team should explain the evidence, safety plan, treatment goal, monitoring, insurance implications, and who coordinates the full depression-care plan.
Do I need a ride home after treatment?
For SPRAVATO, plan transportation and do not drive until the next day after a restful sleep. Ketamine instructions depend on the product, route, and setting, so confirm them in advance. TMS usually does not involve anesthesia, but follow the treating center's instructions for your protocol and medical situation.
What can rule out or delay one of these treatments?
The answer depends on the treatment and patient. A clinician may review diagnosis, current safety needs, blood pressure and cardiovascular history, seizure risk, implanted metal or devices, pregnancy, substance-use history, medications, prior response, and ability to complete monitoring and transportation requirements. Ask for the treatment-specific reason in your case.
Primary sources
Check the current public guidance
- NIMH: Brain Stimulation Therapies
- DailyMed: Current SPRAVATO prescribing information (updated March 2026)
- FDA: Risks associated with compounded ketamine for psychiatric disorders
This page is educational. It does not diagnose, prescribe, recommend a personal treatment, replace informed consent, or establish a clinician-patient relationship.