For the roughly one in three adults whose depression does not lift with standard antidepressants, the past few years have brought real, science-backed options. Two of the most talked-about are TMS and Spravato.
If you have tried medication and therapy and still feel stuck, it does not mean you are out of options or beyond help. It means it may be time to look at treatments designed specifically for depression that has not responded to the usual approaches, what clinicians call treatment-resistant depression.
TMS: gently stimulating the brain's mood circuits
Transcranial magnetic stimulation (TMS) is a non-invasive treatment that uses focused magnetic pulses to stimulate the regions of the brain involved in mood regulation, primarily the prefrontal cortex. It has been FDA-cleared for major depressive disorder since 2008, and the technology and protocols have advanced considerably since.
- It is done in an outpatient setting while you sit in a chair, awake.
- It requires no anesthesia or sedation, unlike older procedures.
- It does not cause the weight changes, fatigue, or other systemic side effects common with some medications.
- Newer accelerated protocols have shortened parts of the treatment course, and TMS is now also cleared for adolescents aged 15 and up.
Spravato (esketamine): a newer, faster-acting path
Spravato is a nasal spray form of esketamine, administered in a certified medical setting where you are monitored afterward. It works differently from traditional antidepressants by targeting the brain's glutamate system, which is involved in learning and brain plasticity.
A significant development came in January 2025, when the FDA approved Spravato as the first and only standalone (monotherapy) treatment for treatment-resistant depression in adults, in addition to its earlier approved use alongside an oral antidepressant. In studies, some people experienced improvement in depressive symptoms quickly, in some cases within the first day, though responses vary from person to person.
How therapy fits alongside these treatments
Medical treatments can lift the weight enough for you to engage with life again, but they work best as part of a fuller plan. Counseling helps you rebuild routines, process what the depression has touched, and develop skills that protect your progress over time. Many people find that the combination, biological treatment plus therapy, gives the most durable results.
Frequently asked questions
What is treatment-resistant depression?
Treatment-resistant depression generally refers to major depression that has not improved after trying at least two different antidepressant medications at adequate dose and duration. About one third of adults with depression do not respond to oral antidepressants alone.
What is TMS and how does it work?
Transcranial magnetic stimulation (TMS) is a non-invasive, FDA-approved treatment that uses focused magnetic pulses to stimulate areas of the brain involved in mood, mainly the prefrontal cortex. It is done in an outpatient setting, requires no anesthesia, and does not cause the systemic side effects of many medications.
What is Spravato (esketamine)?
Spravato is a nasal spray form of esketamine, given in a certified medical setting under supervision. In January 2025 the FDA approved it as the first standalone (monotherapy) treatment for treatment-resistant depression in adults, in addition to its earlier approved use alongside an oral antidepressant. It works on the brain's glutamate system and can improve symptoms quickly for some people.
Do TMS and Spravato replace therapy?
No. They are medical treatments delivered by qualified providers, and they often work best as part of a broader plan that includes counseling and support. Talk therapy helps you build skills and process what is underneath the depression.
How do I know if these options are right for me?
These are medical decisions made with a psychiatrist or other qualified prescriber who can review your history. A counselor can help you understand your options and coordinate care, but does not prescribe these treatments.
Confused about your options? Let's talk it through.
You don't have to figure this out alone. Reach out and we can map a path that fits your situation, including coordinating with medical providers.
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