COMPARING YOUR OPTIONS

TMS, Spravato, ECT, or IV Ketamine? An Honest Comparison.

When antidepressants and talk therapy haven’t been enough, you start hearing new names — TMS, Spravato, ECT, ketamine. They’re all real, evidence-backed treatments. But they work in very different ways, ask very different things of you, and suit different people.

Here’s a straight, physician-reviewed comparison — including where each one shines, and why we built our office around IV ketamine and the brain-health work that makes it last.

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WHEN FIRST-LINE TREATMENT HASN’T WORKED

Four Different Doors Out of the Same Room

If two or more antidepressants haven’t brought lasting relief, you’re not out of options — you’re at the point where the more powerful, more targeted treatments come in. TMS (transcranial magnetic stimulation), Spravato, ECT (electroconvulsive therapy), and IV ketamine are the four you’ll most often be offered.

They fall into different families. TMS uses magnetic energy to stimulate the brain from outside. ECT uses a controlled seizure under anesthesia. Spravato and IV ketamine are close cousins — both work on the brain’s glutamate system to reopen neuroplasticity — but they’re delivered very differently.

None of these is “the best” for everyone. The right one depends on how severe things are, how fast you need relief, what you can tolerate, and what your life can accommodate. Here’s the honest version of each.

OPTION ONE

TMS — Transcranial Magnetic Stimulation

What it is. A device holds a magnetic coil against your scalp and sends focused pulses that stimulate the mood-regulating regions of your brain. You’re fully awake, there’s no anesthesia and no medication, and you can drive yourself home afterward. TMS has been FDA-cleared for major depression since 2008 and for OCD since 2018.

What the research shows. In pooled analyses of randomized trials, people are roughly twice as likely to respond to TMS as to a sham procedure, and treatment-resistant patients see meaningfully higher response and remission rates than placebo. Newer accelerated protocols (like Stanford’s SAINT/SNT) show very high short-term remission in small early studies — promising, but still early.

Who it tends to suit. People who want a non-drug, non-sedating option, who can’t tolerate medication side effects, and who can commit the time.

The honest trade-offs. The standard course is demanding on the calendar — around 36 sessions, five days a week for six weeks — and relief builds over weeks rather than hours. Benefit can fade, so some people need maintenance or repeat courses. It’s often covered by insurance after documented failed medication trials, though coverage varies.

OPTION TWO

Spravato — Esketamine Nasal Spray

What it is. Spravato is esketamine — one half of the ketamine molecule (the “S” mirror-image form), delivered as a nasal spray. It works on the same NMDA/glutamate system as IV ketamine and drives the same kind of neuroplasticity. The FDA approved it for treatment-resistant depression in 2019 and for major depression with acute suicidal thoughts in 2020.

What the research shows. In its pivotal trials, Spravato added to a new oral antidepressant improved depression more than the antidepressant alone, and it reduced symptoms quickly in people with active suicidal ideation.

Who it tends to suit. People who specifically want an FDA-approved product for depression, and who value that it’s frequently covered by insurance.

The honest trade-offs. Spravato is only given in a certified office under a federal safety program (REMS): you’re monitored for at least two hours after each dose and can’t take it home. As a nasal spray, absorption averages about 48% and varies with technique and congestion, so the delivered dose is less precisely controlled than an infusion. And because it’s only the S-half of the molecule, it leaves out the R-half that’s present in racemic IV ketamine — a part researchers are still actively studying.

OPTION THREE

ECT — Electroconvulsive Therapy

What it is. Under general anesthesia and a muscle relaxant, ECT delivers a brief, carefully controlled electrical stimulus that induces a short therapeutic seizure. You’re asleep and feel nothing; the muscle relaxant means there’s no visible convulsion. Modern ECT is a world away from its old reputation.

What the research shows. ECT is widely regarded as the single most effective treatment for severe depression. The landmark meta-analysis found it significantly more effective than both placebo and antidepressant medication. For the most severe and dangerous depressions, nothing has a stronger track record.

Who it tends to suit. This is an important, sometimes life-saving option — and often the first choice — for severe depression with psychosis or catatonia, for people who can’t eat, drink, or stay safe, and when a rapid response is essential.

The honest trade-offs. It requires anesthesia at each of a typical 6–12 sessions, given two to three times a week in a hospital or specialized suite. The best-known downside is memory: trouble recalling events around the treatment period. For most people this improves within a couple of months, but a minority report longer-lasting gaps.

OPTION FOUR — AND OUR FOCUS

IV Ketamine — The Full Molecule, Precisely Delivered

What it is. A low, carefully controlled dose of racemic ketamine — the whole molecule, both the R and S mirror-image forms — delivered directly into your bloodstream and monitored the entire time. Like Spravato, it opens the brain’s neuroplasticity window through the glutamate system; unlike Spravato, it delivers the complete molecule at 100% bioavailability, dosed precisely to you.

What the research shows. IV ketamine has been studied in randomized trials for treatment-resistant depression, PTSD, and anxiety, and it can lower suicidal thoughts within hours — far faster than antidepressants. In the largest head-to-head trial, ketamine was non-inferior to ECT for non-psychotic treatment-resistant depression — without anesthesia and without ECT’s memory effects.

A note on FDA status — stated plainly. Ketamine is an FDA-approved anesthetic that we use off-label for mood and trauma disorders. “Off-label” doesn’t mean unproven or unusual; it’s a common, legal, evidence-guided practice. It does mean it’s usually paid out of pocket rather than billed to insurance.

SIDE BY SIDE

The Four Options at a Glance

	IV Ketamine	Spravato	TMS	ECT
How it works	NMDA/glutamate pathway → neuroplasticity (whole molecule)	Same NMDA/glutamate pathway (S-half only)	Magnetic pulses stimulate mood-regulating cortex	Brief therapeutic seizure under anesthesia
How it’s given	IV infusion, monitored in-office	Nasal spray, 2-hr monitored visit (REMS)	Coil on scalp, awake, no anesthesia	Under general anesthesia + muscle relaxant
FDA status	Approved anesthetic; off-label for depression	Approved for TRD (2019) & MDD w/ suicidality (2020)	Cleared for MDD (2008), OCD (2018)	Long-established standard for severe depression
Typical course	~6-infusion series + maintenance	Twice weekly, then tapering; ongoing	~36 sessions, daily over ~6 weeks	6–12 sessions, 2–3×/week
Onset	Hours to days	Hours to days	Builds over weeks	Days to weeks; rapid in severe cases
Best suited for	TRD, PTSD, anxiety; want rapid, titratable care with integration	Those wanting an FDA-approved, often-insured option	Those wanting a non-drug, non-sedating option	Severe, psychotic, catatonic, or life-threatening depression
Main trade-off	Off-label; usually out of pocket	Variable absorption; repeated monitored visits	Big time commitment; slower onset	Anesthesia; temporary memory effects

Simplified for comparison. Every claim above is sourced in the references below and individualized to you at consultation.

OUR APPROACH, HONESTLY

Why We Built Our Office Around IV Ketamine

We respect all four of these treatments — and we’ll tell you when one of the others is the better fit for you. But when we designed how we’d help people, we chose IV ketamine as our primary tool. Three reasons, plainly:

The whole molecule, dosed to you. An infusion delivers both halves of the ketamine molecule at full, predictable bioavailability, titrated to your body in real time — not a fixed nasal dose absorbed at roughly half strength. Some meta-analytic research even suggests IV racemic ketamine may be at least as effective as intranasal esketamine, though there’s no head-to-head trial yet, so we hold that view carefully.

Fast, without anesthesia or memory cost. Relief often comes in hours to days, and in direct comparison ketamine held its own against ECT for non-psychotic depression — while letting you stay awake, drive yourself home, and keep your memories intact.

It opens a window — and we don’t waste it. This is the real reason. Ketamine opens a period of heightened neuroplasticity when the brain can more easily form new, healthier patterns. The infusion alone doesn’t do the lasting work; what you do with that window does. That’s why every series includes our integration work — so the change holds.

And we’re looking ahead. Ketamine is the first psychedelic medicine to reach mainstream psychiatric care — it won’t be the last. Our team is already certified in psychedelic-assisted therapy, and as new treatments earn FDA approval and become legally available, we intend to be at the forefront of bringing them to Indiana — with the same physician-led safety and integration we build around ketamine today.

BEYOND THE CHAIR

The Part Most Offices Skip

A ketamine infusion that isn’t paired with real integration is a window left open with no one walking through it. Our whole model is built to change that.

Brain Health Reboot is the integration curriculum included with every IV ketamine series — how to use the neuroplasticity window well, from your first infusion to after your sixth. ROOT is our ongoing brain-health membership that keeps the work going, built on four pillars: Regulate your nervous system, Overcome the biology working against you, Open neuroplasticity into daily habits, and Transform the emotional patterns underneath.

Our goal isn’t to keep you coming back forever. It’s the opposite — to help your brain hold its own gains so you need us less over time. Healing, not escape. Explore Beyond the Chair →

STRAIGHT TALK

When We’d Point You Somewhere Else

Choosing us should mean it’s genuinely right for you. IV ketamine isn’t the answer for everyone, and we’ll say so:

If your depression includes psychosis or catatonia, or you’re in a life-threatening crisis, ECT has the strongest evidence and is often the right first step. If having an FDA-approved, insurance-covered treatment for depression matters most to you, Spravato or TMS may fit better. If you want to avoid medication entirely, TMS is worth a serious look. And ketamine isn’t appropriate for people with certain heart, blood-pressure, or psychiatric conditions — which is exactly what a consultation is for.

If you’re in crisis right now, call or text 988 any time. An outpatient series is not a substitute for emergency care.

Not Sure Which Is Right for You?

Start with a free, no-pressure consultation. We’ll listen, walk you honestly through your options — including the ones we don’t offer — and help you find the right next step.