Stubborn Depression? TMS or Spravato treatment may be the solution

Edited/wirtten by Brittany Albright MD, MPH

Depression that does not respond to 2 or more antidepressant medications of therapeutic dose for at least 6 weeks is what I call “sticky depression” or more formally, treatment resistant depression. Luckily it does not have to be treatment resistant anymore because I have 2 major weapons against “sticky depression” - Transcranial Magnetic Stimulation (TMS) and Spravato (esketamine nasal spray). Luckily, both are very safe, FDA approved/cleared, and are covered by most major insurance plans. Often, the biggest challenge is deciding which treatment is best for my individual patient because most patients are great candidates for both treatments.

Deciding between Spravato (esketamine nasal spray) and Transcranial Magnetic Stimulation (TMS) for treating depression involves several considerations, and the choice should be made in consultation with your healthcare professional. Here are some factors to consider:

1. Type and Severity of Depression:

   • Spravato: Approved for treatment-resistant depression and Major Depressive Disorder (MDD) with acute suicidal ideation or behavior. It's often considered when 2 or more other antidepressants haven't worked.

   • TMS: Typically used for treatment-resistant depression. It's a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain.

2. Mode of Administration:

   • Spravato: Administered as a nasal spray in a REMS certified Spravato treatment healthcare setting under the supervision of a healthcare provider for at least 2 hours.

   • TMS: Involves multiple brief 18 minute sessions (approximately 36) over several weeks - typically Monday through Friday, where a magnetic coil is placed against your scalp.

3. Side Effects:

   • Spravato: Can cause dissociation, dizziness, nausea, sedation, increased blood pressure, and vomiting. Requires monitoring for at least two hours after administration.

   • TMS: Common side effects include headaches, scalp discomfort, and lightheadedness. Extremely rarely, it can cause seizures.

4. Effectiveness:

   • The effectiveness can vary based on individual factors. Some people may respond better to one treatment than the other. Typically, both of these methods are significantly more effective than antidepressant medications alone.

5. Insurance Coverage and Cost:

   • Coverage and out-of-pocket costs can differ significantly between the two treatments but most are covered by most major insurance companies.

6. Personal Medical History:

   • Your health history, including any other mental health disorders, can influence which treatment is more suitable.

   • Spravato: Contraindications include history of stroke, uncontrolled high blood pressure, pregnancy, lactation, and active substance abuse.

   • TMS: Contraindications include history of seizures and metal in head.

7. Preference and Lifestyle:

   • Considerations like treatment frequency, duration, transportation (can drive to and from TMS appointments but can’t drive home after Spravato treatments) and the ability to adhere to treatment schedules are important.

It's crucial to have a detailed discussion with your psychiatrist or healthcare provider to understand the best option for your specific situation, taking into account your medical history, the severity of your depression, your response to previous treatments, and your personal preferences.

Feel free to call Sweetgrass Psychiatry located in Mount Pleasant, SC today at (843) 800-1303 if you would like to have a consult with one of our TMS or Spravato experts.