How People Choose Between Ketamine Therapy, TMS, ECT, or Another Medication
Many patients reach a moment when the next step isn’t obvious. Another medication? TMS? ECT? Ketamine therapy? In clinical practice, it’s common to feel torn between speed, safety, and what your real life can hold.
Below are some considerations to help anchor you in this decision-making process, with the note that each situation is unique and should be considered in lock-step with expert care providers.
Four drivers Lumin Health hears most: severity, pace of relief, fatigue with meds, interest in subjective experience
Severity and urgency
If symptoms are immediately dangerous or profoundly impairing – psychosis, catatonia, rapid decline in function – teams often prioritize ECT or hospital‑level support. When risk is lower but depression is still stubborn, options broaden to TMS or ketamine treatment. Part of this is predicated on the increased potential side effect profile of ECT.
Pace of relief
Some people need earlier change. Ketamine therapy may offer quicker shifts for a subset of patients, sometimes within hours to days of initial doses, while TMS often builds across several weeks. Augmentation medications build gradually as well.
Fatigue with meds
After three or four trials, many patients feel weary of daily side effects, slow onset times, and potentially less effective interventions. That pushes some toward in‑clinic interventional care like esketamine (Spravato) or TMS, where the “medicine event” and its impact are contained and monitored.
Interest in subjective experience
Almost all of these options exhibit their own impact on subjective experiences: TMS does not alter consciousness. ECT occurs under anesthesia. Ketamine/esketamine therapy is done awake with staff present. During dosing, some people notice shifts in time, space, or perspective that fade the same day. Personal comfort with that experience matters and should guide choice.
When values compete (speed vs comfort with altered experience)
Trade‑offs are expected when pursuing treatment routes. Here’s one way to look at them:
- If speed is paramount and you’re open to a monitored experience: ketamine for depression may be a fit to try first.
- If you prefer no change in consciousness: consider TMS or a structured medication plan.
- If reliability must trump everything right now: ECT may rise to the top.
Cost, coverage, and scheduling realities (Spravato clinic vs off‑label ketamine vs TMS)
Esketamine (Spravato)
- Where: Only in a certified Spravato administration center like Lumin Health that is equipped with expert staff and the ability to monitor side effects in person.
- Cadence: Often twice weekly for four weeks, then weekly for four weeks, then weekly or every other week - this is called the maintenance phase. Some people take treatments less frequently or even on an as needed basis
- Coverage: Frequently covered for treatment‑resistant depression with prior authorization.
- Logistics: You’ll need a ride home on dose days. No driving until the next day. Many find the structure of Spravato treatment helpful.
- Predictability: roughly 60% of people respond.
Off‑label ketamine
- Where: at Lumin Health with monitoring, similar to esketamine (Spravato).
- Cadence: Varies by program – commonly two sessions per week at the start, then spaced boosters as needed
- Coverage: Variable. Some use out‑of‑network benefits, but most pay out of pocket.
- Logistics: Similar day‑of guidance as Spravato.
- Predictability: roughly 70-80% of people respond.
TMS
- Where: Outpatient center.
- Cadence: Usually five days per week for six to nine weeks.
- Coverage: Often covered with criteria.
- Logistics: No change in consciousness and most people can resume normal activities after treatment, including driving themselves to and from appointments.
- Predictability: roughly 40-60% of people respond.
ECT
- Where: Outpatient and inpatient centers.
- Cadence: Three times weekly for 2-4 weeks with tapering from there.
- Coverage: Covered.
- Logistics: Done under anesthesia, need a ride home, may be difficult to work for the rest of the day.
- Predictability: roughly 80% of people respond.
Medication adjustments or augmentation
- Where: Home dosing with regular medication follow‑ups.
- Cadence: Daily use with gradual titration.
- Coverage: Commonly covered through regular insurance plans.
- Logistics: Minimal visit time, slower signal of benefit.
- Predictability: depends on the medication: 20-40% of people will respond
Realistic plans respect time, transportation, and caregiving. Sustainable schedules support adherence and recovery.
