If antidepressants have not worked, three interventional options usually come up. They get compared as though they are competing versions of the same thing.
They are not. They work by different mechanisms, demand different amounts of your life, and suit different situations.
Ketamine vs TMS vs ECT is a comparison about trade-offs rather than rankings. This page lays out the differences plainly, including where ketamine is the weaker choice.
Ketamine vs TMS vs ECT at a Glance
Ketamine is a medication producing rapid effects over hours to days, given in short sessions, usually not covered by insurance except for Spravato. TMS uses magnetic pulses to stimulate a brain region, requires around thirty daily sessions over six weeks, has minimal side effects, and is FDA-cleared and frequently covered. ECT induces a brief controlled seizure under general anesthesia, has the strongest evidence for severe depression, carries memory side effects, and is usually covered.
Speed favors ketamine. Convenience and side effects favor TMS. Effectiveness in severe illness favors ECT.
Those three sentences are the honest summary.
How Each One Works
Ketamine. A medication acting on glutamate signalling, appearing to prompt growth of new synaptic connections. Given by injection, infusion or nasal spray. Effects can appear within hours. Covered in our post on how ketamine works.
TMS, transcranial magnetic stimulation. A coil placed against the scalp delivers focused magnetic pulses to a region involved in mood regulation, usually the left dorsolateral prefrontal cortex. No medication, no anesthesia, no sedation. You sit in a chair, awake, and drive yourself home afterward.
ECT, electroconvulsive therapy. A brief controlled seizure induced under general anesthesia with a muscle relaxant. Nothing like its portrayal in film. Given two or three times weekly for six to twelve treatments.
ECT has the longest track record of the three and the strongest evidence base for severe and psychotic depression.
Its reputation is a serious barrier to people who might benefit from it, which is worth naming plainly.
Time Commitment and Practicalities
The factor that decides it for many people.
Ketamine
TMS
ECT
Sessions
~6 over 2 to 3 weeks, then maintenance
~30 over 6 weeks
6 to 12 over 3 to 4 weeks
Session length
40 to 90 minutes plus recovery
20 to 40 minutes
5 to 10 minutes plus recovery
Anesthesia
No
No
Yes, general
Can you drive home
No
Yes
No
Time to first effect
Hours to days
2 to 4 weeks
1 to 2 weeks
Work disruption
Half days, several times
Daily but short
Significant
Ongoing treatment
Usually needed
Sometimes
Sometimes
TMS looks demanding at thirty sessions and is the easiest to fit around a job, since you drive yourself and go straight back to work.
Ketamine needs fewer appointments and each one costs you a driver and the rest of the day.
Side Effects Compared
Ketamine. Dissociation during the session, raised blood pressure, nausea, dizziness, tiredness afterward. Effects are confined to the session and the hours after it. Longer-term questions around bladder and cognition relate mainly to high-dose recreational use, covered in our post on long-term safety.
TMS. Scalp discomfort at the treatment site and headache, usually settling after the first sessions. No sedation, no cognitive effects. Seizure is a recognized risk and is rare. The mildest side effect profile of the three by a clear margin.
ECT. Memory effects are the significant one. Confusion immediately afterward, difficulty forming new memories during the treatment course, and gaps in memory for the period around treatment. Most of it improves after the course ends, and some people report lasting gaps. Modern technique has reduced this considerably and has not eliminated it. Anesthesia carries its own small risks.
The memory question is the honest reason people choose TMS or ketamine over ECT even when ECT might work better.
Insurance and Cost
Frequently the deciding factor, and it does not track effectiveness.
TMS. FDA-cleared for treatment-resistant depression and widely covered by insurance and Medicare, usually after documented failure of several antidepressants. Prior authorization required.
ECT. Usually covered, as a long-established hospital-based treatment.
Spravato, esketamine nasal spray. FDA-approved and frequently covered, with prior authorization and a REMS-certified site required. Covered in our post on Spravato.
Ketamine by injection or infusion. Off-label, and so usually not covered. Paid out of pocket in most cases.
That is the uncomfortable summary. The fastest-acting option is the one most likely to come out of your own pocket, and the reason is regulatory rather than clinical.
Our post on ketamine cost and insurance covers what to check with your plan.
Which Situation Suits Which
General patterns rather than rules, and a clinician who has assessed you decides.
Ketamine tends to suit someone needing rapid relief, someone with acute suicidal thinking under clinical supervision, someone unable to commit to daily appointments for six weeks, and someone who has not responded to TMS.
TMS tends to suit someone who can attend daily, wants to avoid medication effects and sedation, needs to keep driving and working normally, is worried about cognitive effects, and has insurance that covers it.
ECT tends to suit severe depression with psychotic features, catatonia, treatment where speed and effectiveness outweigh memory risk, situations where eating and drinking have stopped, and cases where other options have failed.
They are not mutually exclusive. Ketamine and TMS are sometimes used sequentially. Someone may have ECT acutely and maintain with something else.
If a provider offers only one of the three and tells you it is the best option for everyone, weigh that accordingly.
FAQs About Ketamine vs TMS
Is ketamine or TMS better for depression? Neither is better overall. Ketamine acts within hours to days and usually is not covered by insurance except for Spravato. TMS takes two to four weeks, requires around thirty daily sessions, has a milder side effect profile and is frequently covered. The right one depends on urgency, schedule and insurance.
Can I have TMS and ketamine together? They are sometimes used sequentially and occasionally in combination, and it depends on your situation and who is coordinating your care. Discuss it with a clinician managing the whole picture rather than a provider offering only one of them.
Is ECT still used? Yes, and it remains the most effective treatment available for severe depression, particularly with psychotic features or catatonia. It is done under general anesthesia and bears no resemblance to its portrayal in film. Memory effects are the genuine drawback.
Why is ketamine not covered by insurance when TMS is? Since TMS is FDA-cleared for treatment-resistant depression when ketamine by injection or infusion is used off-label. Spravato, the nasal spray, is FDA-approved and is often covered. The difference is regulatory status rather than how well each works.
What if TMS did not work for me? Not responding to one interventional treatment does not predict the others, since the mechanisms differ. Ketamine after unsuccessful TMS is a common sequence. Bring your full treatment history to the assessment.
Talk Through the Options
An assessment covers what you have already tried and which of these fits your situation, including the ones we do not provide.
Call (770) 817-9200 or see our ketamine therapy page.
Atlanta Ketamine Clinic, 5755 North Point Parkway Suite 256, Alpharetta, GA 30022.
Reviewed by Angelo Sambunaris, M.D., Atlanta Ketamine Clinic.This article is general information, not medical advice. If you are having thoughts of suicide or self-harm, call or text 988 to reach the Suicide and Crisis Lifeline, available 24 hours a day.
