TMS vs. Ketamine Therapy: Which Is Right for You?

If antidepressants haven't worked for you, the two treatments you'll hear about most are transcranial magnetic stimulation (TMS) and ketamine therapy. They're genuinely different — in mechanism, evidence, cost structure, and daily-life logistics — and quite a few clinics now offer both. Here's an honest comparison.

The short version

• TMS uses magnetic pulses to stimulate the brain's mood circuits — no drugs, no dissociation, no ride home needed. It's FDA-cleared for depression and OCD, and widely covered by insurance after documented medication failures. The catch: a demanding schedule — typically sessions five days a week for about six weeks.
• Ketamine works chemically and fast — often within days rather than weeks. Generic ketamine is off-label and usually cash-pay; the nasal-spray form Spravato is FDA-approved and often covered. Sessions are fewer but each involves dissociation, monitoring, and no driving afterward.

Evidence and effectiveness

Both have solid evidence in treatment-resistant depression, and neither is universally better:

• TMS: large trials and decades of clinical use show meaningful response in roughly half of patients with treatment-resistant depression, and remission in roughly a third. Newer accelerated protocols (like SAINT-style theta-burst) are shortening the calendar.
• Ketamine: rapid antidepressant effects — often within 24 hours — with response rates in a similar range for the initial series. Durability is ketamine's weak spot: without maintenance sessions or follow-on care, effects commonly fade over weeks.

Two practical differences matter more than the headline numbers. Speed: if you're in a severe episode, ketamine acts in days; TMS builds gradually over weeks. Durability: a successful TMS course often holds for many months without further treatment, while ketamine usually requires ongoing boosters.

Insurance and cost — often the deciding factor

• TMS is the insurance-friendly option: most commercial plans and Medicare cover it after (typically) two to four failed antidepressant trials. Out of pocket without insurance it's expensive — often $6,000–$12,000 for a full course.
• Ketamine infusions are almost never covered — expect $400–$800 per session, $2,400–$4,800 for the initial series, plus maintenance.
• Spravato threads the needle: ketamine-class treatment with insurance coverage for qualifying diagnoses.

If your insurance covers TMS and not ketamine, TMS is often the sensible first move — trying it doesn't close the ketamine door later.

Side effects and experience

• TMS: scalp discomfort and headache early in the course, which usually fades. You're fully alert; you drive yourself home. The serious risk — seizure — is very rare.
• Ketamine: dissociation during sessions (the point, arguably), transient blood pressure elevation, nausea, and misuse potential. You need a ride home and screening for cardiovascular and psychiatric contraindications. See what a session feels like.

TMS also has fewer psychiatric exclusions — it's an option for people with psychosis history or blood-pressure issues where ketamine usually isn't.

The time-commitment reality

This is where lives diverge. TMS asks for ~30 clinic visits in six weeks — short sessions, but every weekday. Ketamine asks for ~6 longer visits in two to three weeks, each consuming half a day once you count monitoring and recovery, then periodic maintenance. People with rigid work schedules often find ketamine's schedule easier; people who can't arrange rides or childcare for impaired afternoons often prefer TMS.

How to actually decide

1. Check insurance first. Covered TMS vs. cash-pay ketamine changes the math entirely; so does Spravato eligibility.
2. How urgent is relief? Severe, acute suffering argues for ketamine's speed.
3. Which schedule can you sustain? An abandoned course of either is wasted money.
4. Any exclusions? Metal implants near the head rule out TMS; uncontrolled hypertension or psychosis history rules out ketamine.
5. Ask about sequencing. These aren't mutually exclusive — many patients try one, then the other, and some clinics combine approaches.

Clinics that offer both — like several in our directory — are worth prioritizing for this conversation, since they have less incentive to steer you toward the only thing they sell. Our guide to choosing a clinic covers the questions to ask either way.