Depression that hasn’t lifted after a couple of medicines leaves you with a hard question, and lately with three answers instead of one. You may have read every TMS vs Spravato comparison already, understood the differences, and still felt stuck. That’s normal. The right choice depends on your treatment history, your insurance, and what your week can actually hold. No article knows those things about you. This page adds the option most comparisons skip: transcranial magnetic stimulation (TMS), a treatment that uses magnetic pulses to stimulate a part of the brain involved in mood, with no medicine and no sedation. At our Manhattan location, all three options are available under one roof, so our clinicians can help you find the right fit rather than push the only thing on the menu. Below, we walk through how the decision really gets made, and who sits with you to make it.
The three options, in plain English
Spravato (esketamine). Spravato is a nasal spray you give yourself, under supervision, at a certified clinic. Esketamine is a form of ketamine delivered through the nose. It’s approved for treatment-resistant depression, which just means depression that hasn’t improved after trying other antidepressants. Insurance often covers it. You stay about two hours afterward so a nurse can monitor how you’re feeling, because it can cause drowsiness and a floaty, detached sensation. Since January 2025, the FDA allows Spravato to be used on its own, not only alongside a daily antidepressant.
IV ketamine. This is a related medicine given slowly through a drip in your arm. Clinicians use it off-label for depression, which means the FDA hasn’t formally approved it for this purpose, though it has been used this way for years. The dose can be adjusted during the session, and a visit runs about ninety minutes. It’s usually paid out of pocket. Like Spravato, it brings on a temporary altered state, so you won’t drive yourself home.
TMS. TMS uses magnetic pulses to gently stimulate the part of the brain tied to mood. There’s no medicine and no sedation. You sit in a chair, awake, feeling a light tapping on your scalp, and you drive yourself home afterward. The trade-off is time: a standard course runs daily sessions, five days a week, for four to six weeks, often totaling about 36 sessions.
Here’s the part most comparisons leave out. Spravato and IV ketamine mean fewer, longer visits with an altered state you recover from before heading home. TMS means many short visits, no altered state, and no ride needed.
How do TMS, Spravato, and ketamine compare side by side?
| | Spravato | IV ketamine | TMS |
|---|---|---|---|
| What it is | Esketamine nasal spray | Ketamine through a drip | Magnetic pulses to the brain |
| How it’s given | You spray it yourself, supervised | Slow infusion in the arm | Coil rests against your scalp |
| Visit length | About 2 hours | About 90 minutes | About 20 minutes |
| Number of visits | Twice weekly, then tapering | Often 6 over 2-3 weeks | About 36 over 6 weeks |
| Can you drive after? | No | No | Yes |
| Insurance usually covers it? | Often | Rarely | Often |
| How fast people notice something | Days to weeks | Hours to days | Two to six weeks |
For a closer look at how Spravato and IV ketamine differ, see our Spravato vs IV ketamine guide.
The four questions that actually decide it
What have you already tried, and for how long? This shapes what you’re eligible for. Spravato is approved specifically for depression that hasn’t responded to other antidepressants, so clinics and insurers will ask what you’ve taken and for how many weeks. The odds of finding relief tend to shrink with each medicine that doesn’t work. In the large STAR*D study, only about one in seven people improved by switching to a third antidepressant after two hadn’t helped. If you haven’t tried much so far, we’d want to look at your history together first.
How is this being paid for? Spravato and TMS are more often billed to insurance, though benefits and out-of-pocket costs vary by plan. IV ketamine is usually paid out of pocket. If cost is a deciding factor, that alone can point you toward one of the covered options. We’d want to check your specific plan before making any promises.
What can your week take? Be honest about your calendar. Spravato is roughly twice a week for a couple of hours at first, then less often. TMS asks more of your schedule up front: about five short visits a week for six weeks, though you can drive yourself and return to your day. If mornings are hard to clear, that matters as much as any clinical detail.
How do you feel about the experience itself? One path involves an altered, dreamlike state for a couple of hours. The other involves sitting in a chair with a tapping sensation on your head and nothing more. Some people feel reassured by the idea of no altered state at all. Others are curious about it, or find it meaningful. There’s no wrong answer, and it’s worth saying out loud in your consultation.
Who helps you choose?
A first consultation at Nushama is a conversation with a licensed clinician (often a physician or psychiatric nurse practitioner) who reviews your history and talks through the options with you. It usually takes 45 to 60 minutes. Many insurance plans cover the visit, and our care team can check yours before you come in.
In that hour, the clinician asks what you’ve tried, how you’re feeling now, and what your days look like. They screen for anything that would make one option safer than another, walk you through what each treatment involves, and answer the questions you didn’t know how to ask. Their job is to be on your side of the table, not to sell a particular treatment. The conversation is unhurried, trauma-informed, and yours to steer.
Honesty matters here. A consultation can end with “none of these yet,” or a referral somewhere better suited to you. Some members also end up doing more than one treatment in sequence, perhaps starting with one approach and adding another later as their needs change. Whatever direction makes sense, the clinical team stays with you through it.
Worth noting: a clinic that offers only one of these three can only recommend the one it offers. Because Nushama’s Manhattan location offers Spravato, IV ketamine, and TMS, your clinician can follow the evidence and your circumstances wherever they lead. A 2025 analysis of individual patient data from two clinical trials found that both TMS and esketamine outperformed simply starting a new antidepressant, so having more than one door open is a real advantage. One thing to know: Spravato carries an FDA boxed warning for sedation, dissociation, respiratory depression, abuse and misuse, and suicidal thoughts and behaviors, and is available only through a restricted program called REMS that requires certified clinic monitoring. That reality sits alongside the benefit, not behind it. At the same time, a long-term extension study published in 2025 confirmed sustained symptom reduction and no new safety concerns over up to 6.5 years of esketamine use.
Bringing it all together
This was never a choice you were meant to make alone with a comparison chart. The differences between TMS, Spravato, and IV ketamine only become a real decision when they meet your history, your coverage, and your calendar. Bring a list of what you’ve tried, a rough sense of your insurance, and any questions that have been on your mind. Whatever the answer turns out to be, you don’t have to figure it out by yourself. Our team walks with you from that first conversation through treatment and integration, adjusting the plan as you go. If you’d like to start that conversation, our Manhattan care team is here to book a consultation whenever you’re ready.
Medically reviewed by the Nushama clinical team. Last updated: August 2026.