From our survey

Esketamine or TMS: a side by side for the unconvinced

When standard antidepressants have not worked, two newer treatments tend to come up: esketamine and TMS. One is a medication. The other involves no medication at all. If you are unconvinced about ketamine-based therapy, it helps to see the two laid out next to each other before a clinician walks you through them.

This comparison is written for skeptical readers across the Midwest. It uses a survey we commissioned this summer for context, and publicly known facts about each treatment for the substance. It is not a recommendation for either. Whether either one fits your situation is for a clinician with your full chart to judge.

Why these two, and why now

Our poll reached 443 adults in ten Midwest states, and both treatments were close to invisible to them. Spravato, the brand name esketamine is sold under, drew a blank from 73 percent. TMS fared little better: 25 percent said they knew it, while 64 percent told us a treatment without drugs mattered to them.

Doubt about ketamine therapy was also common: 21 percent described their first reaction as skeptical and 9 percent as negative. Our figures describe the full sample, and we have not tested whether the doubters and the drug-free crowd overlap. Every figure here is final.

What goes into your body

Esketamine: A medication you spray into the nose. Chemically it is a form of ketamine, and it is a controlled substance.

TMS: Nothing. A coil resting on the scalp sends magnetic pulses toward a brain region involved in mood. There is no drug, no injection, and no anesthesia.

Regulatory status

Esketamine: FDA-approved for treatment-resistant depression. This approval applies specifically to Spravato. Clinics that infuse IV ketamine for depression are using it off-label, and ketamine taken at home belongs to yet another, looser category.

TMS: Cleared by the FDA for adult major depression that antidepressants left unresolved. "Cleared" is the review pathway used for many medical devices. It is not the same as drug approval, but it is a formal FDA review.

Regulatory status matters to many people. Among our respondents, 59 percent rated FDA approval a big or even deciding consideration in trying something unfamiliar.

Where it happens and who watches

Esketamine: Only at a certified healthcare site, under a restricted safety program. You administer the spray yourself while staff watch, then stay at least two hours for observation. No doses go home with you.

TMS: At an outpatient clinic. A trained technician runs the device, with a physician overseeing the treatment plan. There is no post-session monitoring period for sedation, because there is no sedation.

Getting home

Esketamine: No driving until the next day after a dose, so line up a ride home or another way back.

TMS: Most people drive themselves and go straight back to work or errands.

Time commitment

Esketamine: Several visits a week early on, fewer later. Each one runs long because of the monitoring period.

TMS: Nearly daily weekday sessions for several weeks, usually followed by a taper. A session is brief once the settings are dialed in.

Neither is a quick fix in terms of scheduling. In the rural Midwest, the distance to a certified esketamine site or a TMS clinic may be the deciding factor. Our respondents clearly weighed proximity: 43 percent named nearness to home among their two leading priorities for a provider.

Common side effects

Esketamine: Dissociation, meaning a sense of being detached from your body or surroundings, as well as dizziness, nausea, sedation, and a temporary rise in blood pressure. These typically fade during the monitoring period. Because of misuse potential, the program has safeguards.

TMS: Scalp discomfort and headache are most common and often ease over time. Seizures are rare but serious, so clinics screen for risk factors first.

Paying for it

Esketamine: Often covered with prior authorization. Plans usually want evidence that other antidepressants have not worked.

TMS: Also often covered after prior authorization, again usually with documented medication trials.

Coverage was the concern respondents named above all others, with 85 percent listing insurance as one of their two leading priorities. Offered a trade between a covered path with more paperwork and a quicker self-pay start, the covered path won 51 percent, 23 percent took self-pay, and the remaining 26 percent could not decide.

What skeptics tend to ask about each

About esketamine: "Is this the same as the ketamine people misuse?" It is related, which is exactly why a certified clinic keeps every dose under staff supervision. "Will I feel strange?" Many people experience temporary dissociation, and the monitoring period exists partly for that reason.

About TMS: "Is this shock therapy?" No. ECT puts you under general anesthesia and deliberately triggers a seizure; TMS involves neither. "Is it real medicine?" It is FDA-cleared and used in mainstream psychiatric practice, though, like any treatment, it does not help everyone.

What the comparison cannot tell you

It cannot tell you which one would work for you. Both usually enter the picture once ordinary antidepressants have fallen short, and some people use neither and do well with therapy or a different medication. Your medical history, other conditions, and practical constraints all matter.

Nor is it grounds for quitting a medication by yourself. Stay on your current prescription while you explore either option, and let your prescriber map out any switch.

Taking it to your doctor

People in our survey trusted their own doctors more than any other source, by far. Their physician's word was the deciding nudge for 74 percent. The Brain Recovery Centers page on how Spravato treatment sessions are run can help you prepare questions. You might say: "I've seen that esketamine and TMS are both options when antidepressants haven't worked. I'm skeptical of ketamine. Can we talk through both, and whether either fits me?"

Should thoughts of suicide crowd in while you compare options, reach out to 988, the Suicide and Crisis Lifeline, by voice or text at whatever hour. Nobody there will ask you to have a treatment plan first.

Methodology

Pollfish ran this survey (reference 395586438) with consumer-panel members, wrapping up June 23, 2026. The sample is 443 adults, ages 18 through 64, drawn from Minnesota, Nebraska, Illinois, Ohio, Missouri, Oklahoma, Wisconsin, Kansas, Indiana and Iowa; each agreed to a consent screen before answering. For multi-select items we show the share of everyone who picked an answer. Numbers here are validated and final. Funding and commissioning came from the publisher.