Ketamine vs. TMS for treatment-resistant depression

TMS (transcranial magnetic stimulation) is slower but often covered by insurance. It means daily sessions over four to six weeks, with effects that build gradually and no drug in your system. Ketamine works faster, often within days, but infusions are typically cash-pay, involve dissociative effects and monitoring, and many people need ongoing maintenance. If you're acutely struggling, speed argues for ketamine. If budget and coverage drive the decision, TMS often wins. Most people are somewhere in between, and that is what the rest of this article is for.

What TMS involves

TMS uses a magnetic coil against the scalp near the left prefrontal cortex, an area of the brain thought to be involved in mood regulation. It's been FDA-cleared since 2008, and many insurers cover it for major depression after documented antidepressant failures; how many failures varies by plan. A standard course is five sessions a week for four to six weeks, roughly 20 to 40 minutes each, sometimes followed by a short taper. Newer protocols (intermittent theta burst) cut sessions to a few minutes, and some centers run condensed schedules. You're awake, you drive yourself home, and the common side effects are scalp discomfort and headache early in the course. Seizure, the serious risk, is rare: a survey of over half a million treatment sessions found about 0.7 seizures per 1,000 patients treated, with a higher rate reported for one deep-TMS coil type than for standard figure-8 coils.

The catch is the calendar. Twenty to thirty appointments over four to six weeks is a real commitment for anyone working or caregiving, and improvement typically emerges gradually over the middle weeks of the course. That is hard when you're barely holding on now.

Where each one is stronger

• Speed: ketamine, clearly. Responders often feel a shift within the first few sessions, sometimes the first. TMS builds over weeks. For someone in acute distress, that difference can settle the question. (In a crisis, neither is the answer. See below.)
• Insurance: TMS, more often than ketamine. Spravato® sits in the middle, often covered with prior authorization and closely related to ketamine. IV ketamine is almost always out of pocket; a full course with a year of maintenance can run five figures. Our cost page has the math. For plan rules, see will my insurance cover Spravato®?
• Response rates: hard to compare directly. In one naturalistic study of 307 patients at 42 U.S. TMS practices, sponsored by the device's manufacturer, 58% responded and 37% reached remission by clinician rating (41–56% and 27–29% on patient questionnaires). Real-world ketamine figures fall in a broadly similar range (detailed here). But the studies use different scales, patients, and time points, and head-to-head trials are scarce. A 2025 exploratory analysis matching patients from one large TMS trial and one esketamine trial suggested TMS was at least as effective over four weeks. Claims that one "beats" the other outrun the evidence.
• Durability: in a 12-month follow-up of a manufacturer-sponsored U.S. registry, about 6 in 10 people who responded to a TMS course were still responding a year later while staying on antidepressants, and about a third of all the patients followed for that year had TMS reintroduced. Ketamine's benefit fades without maintenance for many people. Over a multi-year horizon, that changes both the cost and the logistics.
• Side-effect profile: TMS has no dissociation, no blood-pressure effects, no driving restriction, and no misuse potential. That matters if you have cardiovascular concerns, a substance-use history, or simply don't want a dissociative experience. Ketamine's profile is covered on our safety page.

How people choose between ketamine and TMS

In practice, constraints usually make this decision, and that is fine. If your insurance covers TMS and won't touch ketamine, a covered treatment you can complete beats an uncovered one you'll abandon halfway for cost. If you can't take four to six weeks of daily appointments, ketamine's schedule is more forgiving. If you've already done one without benefit, trying the other is a reasonable next step. They work by different mechanisms, and little research has tested whether not responding to one predicts the other, so ask the prescriber. And if suicidal thinking is part of the picture, tell the evaluating clinician directly. Esketamine is FDA-approved, alongside an oral antidepressant, to treat depressive symptoms in adults with major depression who have acute suicidal thoughts or behavior. Its label says it has not been shown to prevent suicide or reduce suicidal thoughts, and it does not replace hospital care when that is needed. Our conditions page explains what its label says about suicidal thinking.

Whichever direction you lean, ask the same questions of any program: how do you measure response, when do we reassess, and what happens if this doesn't work? The quality signals are the same across modalities, and our clinic guide lists them.

Can you combine ketamine and TMS?

Some people ask about getting both at once. The research on this is early and thin. A 2024 systematic review searched for studies from 2014 to 2024 and found only six. Three were case reports. The others were one retrospective study, one pilot study, and one review.

In those studies, people with treatment-resistant depression improved, and side effects were mostly mild and short-lived. The authors reported better results than either treatment alone. They cautioned that the studies were small and used very different designs, and they called for larger randomized trials. Half the evidence being case reports is another reason to read that result cautiously.

A 2023 review took a different angle. It looked at how the two treatments might work together in the brain. It did not test the combination in patients. It said recent studies suggest the pair may give stronger and longer-lasting results, and it aimed to lay groundwork for future treatment plans. That is a hypothesis for researchers to test. If you want to know whether combining them makes sense for you, ask your psychiatrist.