If you’re struggling with treatment-resistant depression (TRD) and traditional medications haven’t provided relief, advanced treatments like Transcranial Magnetic Stimulation (TMS) or Spravato (esketamine) may be the solution. At McLean Neuropsychiatric Treatment Center (NTC) in McLean, Virginia, we specialize in both of these treatments.
This blog will help you understand the differences between TMS and Spravato so you can make an informed decision about which one is best for you.
What is TMS and How Does it Work?
Transcranial Magnetic Stimulation (TMS) is a non-invasive therapy that uses magnetic pulses to stimulate specific areas of the brain involved in depression. It’s approved by the U.S. Food and Drug Administration (FDA) for treating depression, especially for those who haven’t found relief with traditional medications. TMS is also used to treat conditions like obsessive-compulsive disorder (OCD), migraines, and smoking cessation, and it is also being studied for epilepsy treatment.
In cases of depression, Transcranial Magnetic Stimulation (TMS) is used to target the left dorsolateral prefrontal cortex (DLPFC), a brain region crucial for mood regulation and cognitive functions. TMS may enhance neuroplasticity in this area, which refers to the brain’s capacity to form new neural connections. By promoting neuroplasticity, TMS may help “re-wire” dysfunctional cognitive patterns associated with depression.
What is Spravato and How Does it Work?
Spravato is the brand name for esketamine, a nasal spray made of one of ketamine’s derivatives. Spravato was developed specifically for the treatment of depression and has been approved by the FDA for TRD and major depressive disorder (MDD) with suicidality.
Like TMS, Spravato is thought to increase neuroplasticity. However, Spravato is thought to enhance neuroplasticity across multiple brain regions, potentially leading to broader effects in treating depression than TMS. Studies show esketamine increases measures of neuroplasticity across the whole prefrontal cortex. Ketamine, which has a similar mechanism to esketamine, also increases neuroplasticity in the hippocampus, an area implicated in memory and emotional regulation.
Whereas TMS increases electrical activity in the brain through magnetic pulses, Spravato increases activity by affecting chemical signaling between nerve cells. Spravato blocks NMDA receptors on certain neurons. This blockage causes an increase in the chemical messenger glutamate, which increases excitatory transmission in the brain.
Key Differences Between TMS and Spravato
Treatment Efficacy
In a randomized controlled trial, 63% of TRD patients experienced a significant reduction in depression symptoms after completing a full course of Transcranial Magnetic Stimulation (TMS). By the end of the study, just over 40% of patients achieved remission.
Spravato has shown similar effectiveness. An analysis of real-world data on TRD patients using Spravato found that 64% had a major reduction in symptoms after their treatment, with 40% of them reaching remission.
Treatment Administration and Regimen
Transcranial Magnetic Stimulation (TMS) treatment involves having a magnetic coil placed on the front/left area your head where your dorsolateral prefrontal cortex is. As the magnetic pulses are delivered, you may hear clicking sounds and feel a tapping sensation. Each TMS treatment, once you are sitting in the TMS chair and your technician has placed the coil and started the machine, lasts 18 minutes and 27 seconds. A full series of TMS treatment consists of 36 total daily sessions”. Patients can typically taper their last six sessions, doing 2 or 3 sessions per week for the last two or three weeks.
For Spravato treatment, your starting and maintenance doses will either consist of two or three nasal spray devices, administered under clinical supervision with a five-minute break between doses. Once you have administered your Spravato dose, you are monitored for at least two hours in-office. Our staff will monitor your vital signs periodically to ensure safety and before you leave, the staff will ensure the drug’s effects have worn off enough for you to be discharged. The initial course involves twice-weekly sessions for four weeks, followed by weekly sessions for another four weeks.
Whether you choose TMS or Spravato, at McLean NTC, you’ll receive close clinical support to ensure your safety and maximize the treatment’s benefits.
How Long Do the Effects Last?
TMS generally has longer-lasting effects than Spravato. Studies have reported that the antidepressant effects of TMS can persist for several months after the treatment course has ended. On the other hand, the sustained antidepressant effects of Spravato tend to last around a week.
Maintenance treatments are often recommended for both TMS and Spravato to prolong and sustain their therapeutic benefits. The frequency of maintenance doses will differ depending on the patient’s responses but tend to be once every one or two weeks for Spravato and once every month for TMS. The frequency of maintenance doses may decrease over time.
Onset of Action
Spravato is more rapid-acting than TMS, with users experiencing relief of depressive symptoms within two hours after administration. In comparison, the therapeutic effects of TMS are usually noticed after 2 to 4 weeks of regular treatment sessions.
Safety
| Side effects of TMS | Side effects of Spravato |
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Spravato is more psychoactive in its effects than TMS. If you use Spravato, you may experience dissociation, which involves feeling disconnected from your body and thoughts and experiencing time and space differently. Though these effects can be unpleasant and disorientating for some, they can benefit and be pleasurable for others. These dissociative effects typically wear off within 45-60 minutes after onset.
Because of these psychoactive effects, Spravato also has an abuse potential. People may seek out Spravato or ketamine, which has the same dissociative effects as Spravato, outside of their treatment sessions. This could lead to chronic use and result in long-term health complications.
Who is a Candidate for Spravato and TMS
When comparing the two treatments, esketamine may be more suitable for patients requiring rapid intervention, particularly those with acute suicidal ideation. Spravato’s fast-acting nature is a significant advantage, especially in more acutely severe cases.
On the other hand, TMS may be more appropriate for patients seeking a non-pharmacological option with a longer-term treatment strategy, particularly those who may be concerned about the side effects associated with medications like esketamine.
These different treatments also have different patient eligibility. People with a history of seizures are generally not eligible to receive TMS because it lowers seizure thresholds.
Those with psychosis or a close family history of psychosis are unable to receive Spravato because it may exacerbate symptoms due to its psychological effects. However, each person is unique and can gauge candidacy through an evaluation appointment with our psychiatrist.
If you have a pre-existing heart condition, you may be at higher risk while using Spravato because of its potential because of its potential to increase blood pressure at the time of treatment, though these effects typically subside within the 2-hour monitoring period.
Deciding Between TMS and Spravato
TMS and Spravato are both effective treatments for treatment-resistant depression, but they differ in how they work and how quickly results are seen. TMS is a non-invasive, longer-acting option that uses magnetic pulses, while Spravato is a fast-acting nasal spray that affects neurotransmitters.
Deciding between TMS and Spravato depends on your medical history, treatment goals, and preferences. Both treatments have been effective for treatment-resistant depression (TRD), but TMS is a non-drug option, while Spravato may offer faster symptom relief. By booking a consultation with McLean NTC, our specialists can help determine whether TMS or Spravato suits you and which treatment would best suit your needs. Our team will carefully review your personal and medical history and, if eligible, will help devise a personalized care plan to help you maximize the benefits of either treatment.
FAQs about TMS and Spravato
Q: How long do the effects of TMS and Spravato last?
A: The duration of these treatments will vary from individual to individual. If you choose to have a treatment with McLean NTC, you will work with one of our providers, who can help determine the most appropriate maintenance schedules based on your treatment response and needs.
Q: Does insurance cover Spravato?
A: Many insurance plans, including Medicaid, cover Spravato for TRD. Our team can help you verify your insurance coverage.
Q: Is TMS painful?
A: TMS is not painful, though some patients may experience mild discomfort during the procedure, like tapping on the scalp.
Q: Can I drive myself to and from a Spravato treatment?
A: No, you cannot drive yourself home after a Spravato treatment. Federal regulations for Spravato prohibit driving afterward due to the treatment’s side effects, which include dizziness, sedation, dissociation, and impaired coordination that may last for several hours. While you may drive yourself to your appointment, you must arrange for someone else—such as a friend, family member, or rideshare—to drive you home to ensure safety for yourself and others.
Q: How long does each TMS session last?
A: Your first TMS appointment will be about an hour long. Dr. Haq will explain all the nuances of the treatment and answer any questions you may have, and he will then map your motor cortex and measure your motor threshold so that your treatment power and placement can be identified. Each subsequent appointment will last about 30 minutes in the office.
Q: Do I need someone to accompany me to a TMS treatment?
A: No, you do not typically need someone to accompany you to a TMS session. TMS is a non-invasive procedure with minimal side effects, and patients can generally resume normal activities, including driving, immediately after treatment. However, this could be made possible if you feel more comfortable having a partner, close friend, or family member with you in the session.
Sources
- https://pubmed.ncbi.nlm.nih.gov/36326400/
- https://www.spravato.com/
- https://pubmed.ncbi.nlm.nih.gov/36793329/