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Ketamine therapy vs TMS for depression

Both are options for depression that hasn't improved with antidepressants, but they work very differently: ketamine is a drug that can act within hours to days, while TMS uses magnetic pulses over about 4 to 6 weeks of near-daily sessions. Both are given in a clinic.

TMS has had FDA clearance for depression since 2008 and has few side effects. Esketamine (Spravato) is the FDA-approved ketamine-type drug; IV ketamine is off-label. The right choice depends on your history, how fast you need relief, your schedule and your insurance, and a psychiatric clinician should help you decide.

Updated · Facts checked against the sources listed below

At a glance

Your clinician will tailor the plan. Dosing and schedules are decided by your prescriber.
Ketamine or esketamineTMS
What it isA medicine given by IV (ketamine) or nasal spray (esketamine)Magnetic pulses from a coil held against the scalp
FDA status for depressionEsketamine approved; IV ketamine off-labelCleared since 2008; an add-on for teens 15 and older since 2024
Time per visitTreatment plus monitoring; at least 2 hours after esketamineAbout 3 to 40 minutes, depending on the type
Typical courseA series of sessions; benefits may fade without maintenance5 days a week for 4 to 6 weeks; accelerated versions take about a week
How fastSome people improve within hours or daysImprovement often within a couple of weeks
Main side effectsDissociation, nausea, dizziness, raised blood pressure, misuse riskScalp discomfort, headache, facial twitching; seizures are rare

What the evidence shows

NIMH says strong clinical evidence supports TMS for reducing depressive symptoms and that it's generally safe and well tolerated. A 2023 commentary in The Journal of Clinical Psychiatry notes it works better in people with less treatment resistance. Cleveland Clinic notes TMS doesn't cause memory or thinking problems.

For ketamine, the FDA-approved option is esketamine, used for treatment-resistant depression and for depressive symptoms with suicidal thoughts. Ketamine's main advantage is speed: some people feel better within hours. Its benefits can fade within days or weeks, and long-term safety of repeated treatment is still being studied.

There's little head-to-head research between ketamine and TMS, so neither is proven better for everyone. NIMH notes electroconvulsive therapy (ECT) is still the most established option for severe treatment-resistant depression.

Which may fit you

  • TMS may suit you if you can visit a clinic most weekdays for several weeks and prefer a non-drug option with mostly mild side effects. It may not fit if you have metal or electronic implants in the head or neck, or a history of seizures.
  • Ketamine or esketamine may suit you if faster relief matters and you can arrange rides and recovery time after each session. It may not fit if you have a history of psychosis, substance use disorder, uncontrolled high blood pressure or certain heart or blood vessel problems.

If you're thinking about suicide or are in crisis, call or text 988 or call 911 now. ECT and hospital care are options when fast help is needed.

Cost and insurance

TMS: many insurers cover it with prior authorization. A 2023 commentary in The Journal of Clinical Psychiatry found many plans require several failed antidepressants and a course of psychotherapy first, more than the evidence supports. Medicare coverage is set by regional contractors, and some cover TMS after one failed medicine.

Ketamine: esketamine is often covered with prior authorization, while IV ketamine is usually self-pay. Aetna, for example, lists IV ketamine for depression as experimental. See ketamine therapy cost.

Gabriel can help you find and book licensed clinicians who offer either treatment. Gabriel doesn't prescribe ketamine or provide TMS.

Common questions

Is ketamine or TMS better for depression?

Neither is proven better for everyone, and head-to-head research is limited. Ketamine can work faster; TMS usually has only mild side effects.

How long does TMS take compared with ketamine?

Standard TMS is daily sessions 5 days a week for 4 to 6 weeks. Ketamine is a series of sessions, and some people feel better within hours or days.

Can you do ketamine and TMS together?

Research is still working out whether TMS works best alone or combined with other treatments. Ask a psychiatric clinician whether combining makes sense for you.

Is TMS covered by insurance?

Often, with prior authorization. Many plans require several failed antidepressants and psychotherapy first.

Does TMS have side effects?

Usually mild: scalp discomfort, headache and facial twitching. Seizures are the most serious risk and are rare.

Sources

  1. Brain Stimulation Therapies National Institute of Mental Health
  2. Transcranial Magnetic Stimulation (TMS) Cleveland Clinic
  3. Ketamine Therapy Cleveland Clinic
  4. Esketamine Nasal Spray MedlinePlus, U.S. National Library of Medicine
  5. Insurance Coverage of rTMS for Treatment-Resistant Depression: Mismatch of Evidence and Policies The Journal of Clinical Psychiatry
  6. Ketamine for the Treatment of Depression and Other Psychiatric Disorders (CPB 0938) Aetna

This guide is general information, not medical advice. It does not replace a visit with a licensed clinician. Gabriel membership is not health insurance.