If an antidepressant hasn't improved how you feel, discussions with your doctor often center on three options: Spravato, TMS, and ketamine. Each works in its own way and places different demands on your schedule. Learning the fundamentals before your appointment can make that talk more productive and less confusing.
What These Options Have in Common
All three are usually discussed when standard medicines and talk therapy have been tried and have not done enough. That judgment is made together with your clinician, based on what you have already tried, how long you tried it, and what got in the way. None of them is a shortcut, and none replaces the rest of your care plan. They are different tools for a different stage of the problem.
It also helps to know that these options are not delivered the same way. Some are given in a clinic over a short series of visits, some follow a longer weekly or daily course, and some are repeated over weeks or months. The practical differences often matter as much as the medical ones, so pay attention to how each option would fit into the days you actually live.
Spravato (Esketamine) Nasal Spray
Spravato is a nasal spray containing esketamine, a close relative of ketamine. The FDA has approved it for treatment-resistant depression when combined with an oral antidepressant. Access is controlled by REMS, a federal program that governs how and where the drug is dispensed. Practically speaking, each dose is taken in a clinic instead of at home, and you typically stay at the office for a while afterward so staff can monitor how you're doing.
Sessions tend to follow a set schedule at the start of treatment, with a plan for what comes next once that initial phase is over. Because you may not be able to drive yourself home after a dose, many people arrange a ride ahead of time. Ask the clinic what its schedule looks like and whether it fits your job and family obligations before you commit.
TMS, the Magnetic Option
A treatment called TMS (short for transcranial magnetic stimulation) places a coil on the scalp that emits brief magnetic pulses toward a brain region tied to mood. You recline in a chair, put on hearing protection since the clicking is loud, and remain alert throughout. Anesthesia isn't needed and there's no downtime, so most people go back to their routine directly after a session.
Treatment is typically given on weekdays over several weeks. That steady rhythm is the main demand. Each session is short, but a run of missed appointments can make it hard to keep momentum, so talk through how the course fits around work or school before you begin. Side effects tend to be mild, such as discomfort or tapping sensations at the coil site or a headache, and they often ease as sessions continue. Describe anything you notice to your team so they can adjust.
Ketamine Infusions and What They Ask of You
Ketamine given by intravenous infusion is used off-label for treatment-resistant depression in many clinics. Off-label use means a medicine is prescribed for something outside its official label, which doctors may do when they judge it reasonable for a particular person. The decision rests on your clinician's judgment and on your informed agreement. Infusions are given in a monitored setting over a brief visit, often as a series of sessions spaced across a few weeks, followed by a plan for maintenance if it seems to help.
Ketamine effects can be short-lived, so ask what the plan looks like after the first series ends. Costs also deserve attention, since coverage for infusions can vary widely from one plan to another. Arrange a driver, ask for the full price in writing, and make sure you understand what happens if you need to pause or stop.
How to Raise It With Your Doctor
The most useful conversation begins with a simple account. Write down which medicines you tried, roughly how long each one lasted, the doses if you know them, and what changed or did not change. Include any side effects that made you stop early, because they shape what comes next. You do not need perfect dates. A rough timeline of what you tried and how it went is enough to start.
Then ask direct questions. Which of these options fits your history? What does a typical week look like on that plan? What will it cost, and what will your insurance need from your doctor? What would show that the plan is working, and what would signal that it is time to change course? If one option sounds appealing but hard to schedule, say so. Your clinician can often build a path around your life rather than asking you to rebuild your life around the treatment.
Finally, remember that choosing a next step is not a verdict on you. It is a shared decision between you and your care team, and it is reasonable to take time to think it over before starting something new.