When antidepressants have not worked well enough, it can feel like you have run out of options. You have not. Several evidence-based treatments are available for treatment-resistant depression, and each one works differently.
This guide compares four of the most common next steps: TMS, Spravato (esketamine), IV ketamine and electroconvulsive therapy (ECT). It covers how each is given, how much time it takes, common side effects and what to consider when deciding with your provider.
What is treatment-resistant depression?
Depression is often called treatment-resistant when symptoms have not improved enough after at least two adequate trials of antidepressant medication. It does not mean treatment cannot work. It means a different approach may be needed. Read more in depression help when medications don’t work.
TMS (transcranial magnetic stimulation)
How it works: A magnetic coil placed against the head delivers focused magnetic pulses to areas of the brain involved in mood regulation.
Time commitment: About 36 sessions, usually five days a week for around six weeks, followed by a short taper. Each session takes about 19 to 37 minutes.
Side effects: The most common is scalp discomfort at the treatment site, which usually fades after the first week. Some people get mild headaches. There is a rare risk of seizure (less than 0.1% per patient). TMS does not require anesthesia or medication, so you can drive yourself and return to work right after a session.
Evidence: In a large real-world registry of patients treated with NeuroStar, 83% of those who completed treatment showed a clinically meaningful response and 62% reached remission, based on clinician ratings (Sackeim et al., 2020).
Insurance: Covered by most major insurers, Medicare and TRICARE for adults with major depressive disorder who meet criteria.
Spravato (esketamine nasal spray)
How it works: Spravato is a nasal spray form of esketamine, a medication related to ketamine. It is FDA-approved for adults with treatment-resistant depression, either on its own or together with an oral antidepressant.
Time commitment: Doses are taken at a certified treatment center, typically twice a week for the first four weeks, then weekly, and later weekly or every other week. After each dose, you must be monitored for at least two hours.
Side effects: Common effects include dissociation (feeling disconnected), dizziness, nausea, sleepiness and a temporary rise in blood pressure. Because of these effects, Spravato is only available through a restricted safety program, and you cannot drive until the next day after a restful sleep.
Insurance: Often covered with prior authorization.
IV ketamine infusions
How it works: Ketamine is an anesthetic that, at lower doses, can rapidly reduce depression symptoms for some people. IV ketamine is not FDA-approved for depression, so it is used off-label.
Time commitment: A typical series is several infusions over two to three weeks, each lasting about 40 minutes plus recovery time, with possible booster infusions later.
Side effects: Dissociation, nausea, raised blood pressure and drowsiness during and shortly after the infusion. You will need someone to drive you home.
Insurance: Usually not covered, so most people pay out of pocket.
Electroconvulsive therapy (ECT)
How it works: Under general anesthesia, a brief electrical stimulation triggers a controlled seizure in the brain.
Time commitment: Usually two to three treatments a week, often for 6 to 12 treatments, sometimes followed by maintenance sessions.
Side effects: Anesthesia-related effects, headache, confusion and memory problems, especially for events around the time of treatment. You need someone to drive you home after each session.
When it is used: ECT is one of the most effective treatments for severe depression, including depression with psychosis or when rapid improvement is critical. It is generally covered by insurance.
Side-by-side comparison
| TMS | Spravato | IV ketamine | ECT | |
|---|---|---|---|---|
| Anesthesia | No | No | No (low-dose) | Yes, general |
| Drive yourself home | Yes | No, not until the next day | No | No |
| Time per visit | 19 to 37 min | 2+ hours with monitoring | About 1 to 2 hours | Several hours including recovery |
| Memory side effects | No | No lasting effects reported | No lasting effects reported | Possible |
| Usually covered by insurance | Yes, with criteria | Often, with criteria | Usually not | Yes |
Which option is right for you?
There is no single best treatment for everyone. The right choice depends on how severe your symptoms are, how quickly you need relief, your medical history, your schedule and your preferences about medication and anesthesia. Many people also continue talk therapy alongside any of these options.
TMS is often a good fit for people who want a non-drug treatment without anesthesia and who can commit to daily sessions for several weeks. If your depression is severe, if you are having thoughts of suicide, or if you need rapid improvement, talk with your provider about which approach is safest for you. If you are in crisis, call or text 988 to reach the Suicide & Crisis Lifeline.
Explore TMS in Albuquerque
If medications have not given you enough relief, a consultation can help you understand whether TMS makes sense for you. Learn more about treatment-resistant depression treatment in Albuquerque and TMS therapy in Albuquerque.
Contact Mediterra Mindful Care to schedule a consultation.
