If medication and therapy haven’t brought enough relief, you may be wondering what comes next. Transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), and esketamine (Spravato) are distinct options, not a simple ranking from “mild” to “strong.” The right fit depends on your symptoms, urgency, health history, preferences, and the treatment setting available to you.
| What to compare | TMS, including Deep TMS | ECT | Esketamine (Spravato) |
|---|---|---|---|
| How it works | Magnetic pulses stimulate targeted brain networks while you remain awake. | A carefully controlled seizure is induced under general anesthesia. | A supervised nasal medication that acts on NMDA-type glutamate receptors. |
| Anesthesia and recovery | No anesthesia; most people resume usual activities afterward. | General anesthesia and muscle relaxant; monitored recovery afterward, with a ride home needed. | No general anesthesia; plan for at least two hours of clinic observation and a ride home. |
| Memory and thinking | Not typically associated with ECT-like memory loss; headache or scalp discomfort can occur. | Temporary confusion and memory effects are possible; some people report longer-lasting memory gaps. | Temporary sedation, dissociation, or impaired attention can occur; driving is restricted until the next day after restful sleep. |
| Monitoring and setting | Clinic-based treatment; the team checks positioning, tolerability, and treatment response. | Hospital or specialized service with psychiatric, anesthesia, and recovery monitoring. | Certified healthcare setting with direct supervision, blood-pressure and respiratory monitoring, and observation. |
| Typical schedule | Often daily visits for about 4–6 weeks; session length varies by system and protocol. | Commonly 2–3 visits weekly, often 6–12 treatments, sometimes followed by continuation care. | Usually twice weekly for weeks 1–4, weekly during weeks 5–8, then weekly or every two weeks as individualized. |
| May be considered when… | You want an outpatient, nonanesthetic option and can attend frequent sessions. | Depression is severe or urgent, including certain cases involving psychosis, catatonia, or inability to eat or drink adequately. | You and your prescriber are considering a supervised medication option and can meet the observation and transportation requirements. |
These are general patterns, not a personal recommendation. Individual protocols and eligibility vary.
First, what does “treatment-resistant” depression mean?
The phrase commonly describes depression that has not improved adequately after trying more than one appropriate treatment, such as antidepressant medication. It does not mean you have failed, or that improvement is impossible. Depression can affect brain circuits involved in mood, motivation, sleep, and concentration. When those circuits feel like gears stuck under pressure, a different treatment approach may help them shift.
Your clinician will review prior treatment, diagnosis, medical history, symptoms, and safety needs before recommending a next step. Severe depression can also occur with bipolar disorder or other conditions, so a careful assessment matters.
TMS: a noninvasive option at the center of this comparison
TMS uses magnetic pulses to influence activity in brain networks involved in mood regulation. It does not require anesthesia or intentionally induce a seizure. Think of it as a targeted signal that may help a sluggish network become more active, not as a cure or a guarantee.
BrainsWay Deep TMS uses an H-coil designed to stimulate broader brain regions. It is one of the most extensively researched Deep TMS systems. In a multicenter, sham-controlled randomized trial, Deep TMS improved depression ratings more than sham treatment; response and remission were also higher in the active-treatment group at the end of the acute phase (Levkovitz et al., 2015). Individual outcomes vary, and a trial result cannot predict exactly how you will respond.
A TMS session is often around 20–40 minutes, depending on the system and settings. Some protocols, including a BrainsWay theta-burst option, can be as short as about three minutes of stimulation; the full appointment may take longer for setup and clinical checks. Treatment often involves repeated visits across several weeks. TMS may suit you if you want to avoid anesthesia and can make frequent appointments. It is not generally the option to rely on as the only response to an immediate psychiatric emergency.
ECT: when a rapid, intensive approach may be considered
ECT is a medical procedure in which a brief electrical stimulus produces a controlled seizure while you are under general anesthesia. It is most often considered for severe depression when other treatments have not worked, cannot be tolerated, or a rapid response is important. The American Psychiatric Association’s ECT information describes its use in situations such as high suicide risk, catatonia, or difficulty eating and drinking.
An acute course commonly involves two or three treatments per week, often six to 12 treatments, but the course is individualized. Each visit includes preparation, anesthesia, and recovery; the complete appointment is much longer than the brief seizure itself. Headache, muscle soreness, temporary confusion, and memory difficulties can occur. Memory effects vary, and some people report gaps in memories from around the treatment period.
Randomized sham-controlled ECT studies are limited and historically varied. In the Northwick Park randomized trial, clinician-rated improvement favored real ECT at four weeks, while both real and simulated treatment groups improved; the result is one reason to interpret older trial findings carefully rather than treating them as a direct comparison with modern TMS or Spravato (Johnstone et al., 1980).
Spravato: a supervised medication with a required observation period
Spravato is intranasal esketamine, a medication that affects NMDA glutamate receptors. For adults with treatment-resistant depression, current FDA labeling allows it as monotherapy or together with an oral antidepressant. A phase 3 randomized trial found greater improvement in depressive symptoms with esketamine plus a newly started oral antidepressant than with an oral antidepressant plus placebo nasal spray by day 28 (Popova et al., 2019).
The nasal administration itself is brief, but the appointment is not: treatment must take place under direct supervision in a certified setting, with at least two hours of observation. The team monitors for effects such as sedation, dissociation, changes in blood pressure, and breathing concerns. Dosing is commonly twice weekly for four weeks, then weekly for weeks five through eight, with later dosing individualized. You’ll need transportation home and must not drive or operate machinery until the next day after restful sleep.
How can you choose among TMS, ECT, and Spravato?
The differences are practical as well as clinical:
- TMS avoids anesthesia and has a relatively brief recovery, but usually means frequent clinic visits over several weeks.
- ECT involves anesthesia and more involved recovery, but may be considered when depression is especially severe or a rapid response is needed.
- Spravato avoids general anesthesia, but requires supervised dosing, extended observation, transportation, and repeated visits.
These treatments have not all been compared head-to-head in the same kinds of patients. For example, an important randomized comparison of ECT and ketamine studied intravenous racemic ketamine, not Spravato nasal spray; its results should not be presented as proof that Spravato is equivalent or superior to ECT. Your clinician can help weigh benefits and risks in light of your diagnosis, urgency, prior treatments, and preferences.
Getting support in New Haven, and planning for cost
At Light-tunnel Behavioral Health Services Inc. in New Haven, psychiatric care includes personalized evaluation and treatment planning. Dr. Omolola Aragbada, PMHNP-BC, is one of the practice’s psychiatric providers. Learn about the practice’s TMS services, psychiatric evaluations, and providers. Ask the care team which treatment options are appropriate and available for your situation.
If you are self-pay, you can still ask for a psychiatric evaluation and discuss whether TMS, medication management, therapy, or other services fit your needs. Before starting, request a written estimate that explains evaluation fees, treatment costs, any maintenance visits, and expected out-of-pocket expenses. If you have insurance, confirm benefits and authorization requirements directly with your plan and the practice; coverage varies by service and policy. The practice’s accepted insurance information may help you start that conversation.
If depression feels urgent: what to do and what to avoid
Do:
- Tell your clinician plainly if you have thoughts of suicide, feel unable to stay safe, or cannot manage basic needs such as eating or drinking.
- Ask a trusted person to stay with you and help contact care if you are at immediate risk.
- Call or text 988 in the U.S. for the Suicide & Crisis Lifeline. If there is immediate danger or a medical emergency, call 911 or go to the nearest emergency department.
Avoid:
- Waiting for a routine appointment if you or someone else may be in immediate danger.
- Stopping prescribed medication or changing doses without contacting the prescriber.
- Assuming an outpatient treatment visit can replace emergency evaluation or hospitalization when those are needed.
Safety note: This article is for general education, not a diagnosis or treatment recommendation. TMS, ECT, and Spravato require individualized assessment by qualified healthcare professionals. Spravato is not proven to prevent suicide or replace hospitalization when clinically needed. If you may harm yourself or someone else, call or text 988; call 911 for immediate danger.
References
- Johnstone EC, et al. “The Northwick Park electroconvulsive therapy trial.” The Lancet. 1980;2:1317–1320. Trial article.
- Levkovitz Y, et al. “Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial.” World Psychiatry. 2015. Full article.
- Popova V, et al. “Efficacy and safety of flexibly-dosed esketamine nasal spray combined with a new oral antidepressant in treatment-resistant depression.” American Journal of Psychiatry. 2019. Article.
- U.S. Food and Drug Administration. Spravato prescribing information.
Continue the Series
Next: What to Expect During Spravato Treatment: A Step-by-Step Guide to Esketamine Therapy in New Haven.