A psychiatrist has just told you something that sounds like good news and lands like a problem. Several antidepressants have not done enough. You could be a reasonable candidate for either Deep TMS or intravenous ketamine infusions. You are paying out of pocket. Choose.
So you search “TMS vs ketamine for depression,” and most results introduce one rather than compare the two.
We offer both, which does not make us neutral but does mean we have no stake in making the choice look obvious. This article compares them on what you can weigh at our Fort Worth office.
If you are in crisis while you read this, please do not wait for an appointment. Call or text 988 for the Suicide & Crisis Lifeline, available 24/7, or go to your nearest emergency room. Our office line, 817-659-7344, is answered during business hours; it is not a crisis line.
What the research comparing TMS and ketamine actually found
A 2025 systematic review and network meta-analysis in PCN Reports by Terao and colleagues examined intravenous ketamine, whose use for depression is off-label and not FDA-approved, alongside repetitive TMS (rTMS) and electroconvulsive therapy (ECT). rTMS is the family our Deep TMS system belongs to, though most of this research used other devices.
The authors state plainly that “no head-to-head studies comparing IV ketamine and rTMS have been conducted at this time.” Their analysis pooled 35 randomized trials and 2,109 participants with treatment-resistant depression, every comparison between the two was indirect, and the authors downgraded most comparisons to very low confidence for bias and imprecision.
They found no significant difference between IV ketamine, rTMS, and ECT in response, remission, or tolerability. That means the evidence cannot tell them apart, not that they are equal. IV ketamine did score better on acceptability, which tracks dropout rather than benefit, and beat rTMS on continuous symptom change in a secondary analysis the authors themselves treat cautiously.
The nearest thing to a direct comparison, a 2022 Psychiatry Research paper by Chen and colleagues, pooled two separate trials after the fact; nobody was randomized between them. Its conclusion is the useful part: both “must be included in TRD treatment but may be applied in different clinical situations.” The ketamine data in both papers come from off-label use.
One thing comes first. When several antidepressants have not worked, part of the evaluation is confirming the diagnosis. Depression that has not responded is sometimes unrecognized bipolar disorder, and that changes the plan. Bipolar depression is not treated with an antidepressant alone: without a mood stabilizer beside it, an antidepressant can push mood the other way, into mania or hypomania. TMS for bipolar depression is off-label as well. Raise it with your prescriber, and never stop a medication on your own.
Is TMS or ketamine FDA-approved for depression?
The Deep TMS system we use is FDA-cleared, not FDA-approved. Devices are cleared; drugs are approved. Its current indication, from clearance K222196 granted May 31, 2024, covers depressive episodes and decreasing comorbid anxiety symptoms in adults with major depressive disorder who did not improve enough on antidepressants in the current episode.
Ketamine sits elsewhere. Its FDA-approved label lists only anesthesia uses: sole anesthetic agent, induction, and supplement to other anesthetics. Our own ketamine infusion therapy page says the same: intravenous ketamine for depression is off-label and considered investigational by the FDA.
That is not a reason to rule ketamine out. The FDA approves products for specific uses and does not regulate how physicians prescribe, so off-label prescribing is routine and lawful. But know which side of the line you are on.
TMS vs ketamine for depression, side by side: status, driving, and cost
| Deep TMS | IV ketamine infusion | |
| Status | FDA-cleared device for adult MDD | FDA-approved anesthetic; off-label and investigational for depression |
| Getting home | No sedation; driving yourself is usually possible | A responsible adult 18+ must bring you, wait on site, and drive you home |
| Per session, as of publication | $250 to $450, depending on protocol | $700 first infusion, $500 after |
Those figures are as of publication; check our Price List for today’s. We are self-pay.
How many appointments, and who drives you home?
BrainsWay’s FDA clearance documents describe three shapes of TMS course. The original high-frequency protocol runs 20.2 minutes a session, five days a week for four weeks. Theta-burst sessions are much shorter, about three minutes of stimulation. The accelerated protocol cleared in 2025 front-loads treatment instead of shortening it: five sessions a day for six days inside a two-week window, then two sessions a day, once a week, for four more weeks, for a total treatment duration of six weeks.
Those are stimulation times, not appointment lengths, so a short protocol is not a short visit. That accelerated protocol also runs more total sessions than the standard course.
For ketamine the transportation rule is exact: a responsible adult 18 or older brings you, stays in the waiting area throughout, and drives you home. No discharge alone, no rideshare or taxi, no driver who left and came back. Ketamine’s own FDA-approved label advises against driving for 24 hours.
TMS requires no anesthesia, which the National Institute of Mental Health notes explicitly, so people generally drive themselves, though Cleveland Clinic notes your provider may suggest someone drive you to and from your first appointment. If you cannot name a person for every ketamine appointment, that is real information about fit.
How long do the results last?
For ketamine, an off-label and investigational use for depression, our service page is unglamorous: many treatment-resistant patients benefit, not everyone does, and improvements are often short-term, commonly around two weeks.
A 2016 meta-analysis in Psychological Medicine by Kishimoto and colleagues covered nine trials of a single infusion in 234 adults. The effect peaked at day one and lost superiority over placebo by days 10 to 12. That is why ketamine gets called fast-acting. TMS works the other way, building over a course rather than after one session.
For TMS the durability picture comes mostly from open-label follow-up rather than randomized maintenance trials, so any single number would claim more than the design supports. BrainsWay’s original 2013 clearance includes an optional twice-weekly maintenance phase, and a repeat course is sometimes part of the plan.
Side effects: what each one asks your body to tolerate
Our Deep TMS page calls the treatment generally painless, though some people notice mild to moderate scalp discomfort or tapping in the first few sessions. Headache is common. Seizure is a recognized but rare risk. In a 2019 survey in Clinical Neurophysiology, Lerner and colleagues counted 24 seizures across an estimated 318,560 sessions. Only four occurred when TMS was delivered within published guidelines to people without recognized risk factors, which is how they reach “fewer than 1 seizure per 60,000 sessions.” Risk rises with a seizure disorder or with medications that lower the threshold, which a TMS evaluation screens for.
TMS also has a hard eligibility limit. Cleveland Clinic lists non-removable metal or electronic hardware in or near the head as unsafe around a magnetic pulse: aneurysm clips or coils, cochlear implants, implanted brain stimulators, metal plates, certain clips or wires. Cardiac pacemakers and defibrillators are on the same list. Metal elsewhere, including dental fillings and joint replacements, is generally fine. Tell us about any implant; screening settles it before scheduling.
The short-term effects we publish for ketamine are dizziness, nausea, temporary increases in blood pressure, vivid dreams or perceptual changes, confusion, mood changes, or increased libido. These usually begin during or soon after the infusion and improve within about 80 minutes. Ketamine is also a Schedule III controlled substance with misuse potential, part of why it is given and monitored in the office.
That is why cardiovascular screening comes first. Ketamine’s FDA-approved label says it is contraindicated in patients for whom a significant elevation of blood pressure would be a serious hazard. Uncontrolled hypertension, unstable heart disease, or a history of aneurysm are possible reasons not to proceed. Bring your readings and medication list. You sign a consent form first and can withdraw it at any time, including mid-infusion.
What to ask at your evaluation
At a consultation about treatment-resistant depression, the conversation turns on what your weeks can absorb and how fast you need movement. Bring these:
- Which would you start with, and how many appointments over how many weeks?
- Who in my life can meet the escort requirement, every time?
- What would tell us early that this is not working, and what then?
- Does my diagnosis change what you recommend?
Frequently asked questions
Is TMS or ketamine better for depression?
No one can answer that from evidence. A 2025 network meta-analysis in PCN Reports found no head-to-head studies comparing IV ketamine and rTMS, and rated its indirect comparison as very low certainty. IV ketamine for depression is off-label and investigational; it tends to act quickly and fade, while TMS builds over weeks.
Which one is FDA-approved for depression?
Neither, in the way people usually mean it. The Deep TMS device is FDA-cleared for adults with major depressive disorder after an inadequate response to antidepressants. Ketamine is FDA-approved as an anesthetic, and its use for depression is off-label and investigational per the FDA.
Do you offer Spravato?
No. We provide intravenous racemic ketamine, the standard form of the drug, given in our office. Spravato (esketamine) is a separate, FDA-approved nasal spray dispensed only through its own restricted REMS program, and it is not a treatment we offer.
Which one costs less out of pocket?
That depends on how many sessions you need, which is why we do not print a course total and why multiplying a per-session rate by a guessed number of visits misleads. Per-session self-pay rates for both are on our Price List, and they change.
The bottom line
No evidence base supports declaring a winner between TMS and IV ketamine. What differs is everything else. TMS is a cleared device, a weeks-long schedule, no sedation, usually your own car, and a screen for implanted hardware. Ketamine is an off-label, investigational use of an approved anesthetic, fewer but longer visits, a cardiovascular screen, and another adult who drives you home. Choose on fit, not on a percentage in a table.
Talk with us
If you are in Fort Worth or the surrounding North Texas area and what you have read here sounds familiar, we would be glad to talk it through with you. The Institute for Advanced Psychiatry is an outpatient practice at 6800 Harris Parkway, Suite 100, treating adults 18 and older. You can request an appointment or call 817-659-7344.
If you are in crisis or thinking about harming yourself, please do not wait for an appointment. Call or text 988 to reach the Suicide & Crisis Lifeline, available 24/7, or go to your nearest emergency room.
Sources
- Terao I, et al. “Comparative efficacy and safety of intravenous racemic ketamine, repetitive transcranial magnetic stimulation and electroconvulsive therapy for Stage 2 or higher treatment-resistant depression: A systematic review and network meta-analysis.” Psychiatry and Clinical Neurosciences Reports. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12206548/
- Chen MH, et al. “Comparative study of low-dose ketamine infusion and repetitive transcranial magnetic stimulation in treatment-resistant depression: A posthoc pooled analysis of two randomized, double-blind, placebo-controlled studies.” Psychiatry Research. 2022;316:114749. https://pubmed.ncbi.nlm.nih.gov/35940087/
- U.S. Food and Drug Administration. “510(k) Summary: Brainsway Deep TMS System, K122288.” 2013. https://www.accessdata.fda.gov/cdrh_docs/pdf12/k122288.pdf
- U.S. Food and Drug Administration. “510(k) Summary and Indications for Use: BrainsWay Deep TMS System, K222196.” 2024. https://www.accessdata.fda.gov/cdrh_docs/pdf22/K222196.pdf
- U.S. Food and Drug Administration. “510(k) Summary: BrainsWay Deep TMS System (with iTBS Protocol), K203735.” 2021. https://www.accessdata.fda.gov/cdrh_docs/pdf20/K203735.pdf
- U.S. Food and Drug Administration. “510(k) Summary: BrainsWay Deep TMS System (accelerated iTBS protocol), K251449.” 2025. https://www.accessdata.fda.gov/cdrh_docs/pdf25/K251449.pdf
- DailyMed / U.S. Food and Drug Administration. “KETALAR (ketamine hydrochloride) injection, CIII – full prescribing information.” Label revised 03/2026. Accessed 2026-09-02. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=14e8f864-8b8a-4e7e-8439-e510d3107063
- Kishimoto T, et al. “Single-dose infusion ketamine and non-ketamine N-methyl-d-aspartate receptor antagonists for unipolar and bipolar depression: a meta-analysis of efficacy, safety and time trajectories.” Psychological Medicine. 2016;46(7):1459-1472. https://pubmed.ncbi.nlm.nih.gov/26867988/
- Lerner AJ, Wassermann EM, Tamir DI. “Seizures from transcranial magnetic stimulation 2012-2016: Results of a survey of active laboratories and clinics.” Clinical Neurophysiology. 2019;130(8):1409-1416. https://pubmed.ncbi.nlm.nih.gov/31104898/
- National Institute of Mental Health. “Brain Stimulation Therapies.” Accessed 2026-09-02. https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies
- Cleveland Clinic. “Transcranial Magnetic Stimulation (TMS).” Accessed 2026-09-02. https://my.clevelandclinic.org/health/treatments/17827-transcranial-magnetic-stimulation-tms
- U.S. Food and Drug Administration (Janssen Pharmaceuticals). “SPRAVATO (esketamine) nasal spray, CIII – full prescribing information.” Label revised 01/2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/211243s016lbl.pdf
- Institute for Advanced Psychiatry. “Ketamine Infusion Therapy.” Accessed 2026-09-02. https://www.psychiatryfortworth.com/services/ketamine-infusion-therapy/
- Institute for Advanced Psychiatry. “TMS (Transcranial Magnetic Stimulation).” Accessed 2026-09-02. https://www.psychiatryfortworth.com/services/tms-transcranial-magnetic-stimulation/
- Institute for Advanced Psychiatry. “Price List.” Accessed 2026-09-02. https://www.psychiatryfortworth.com/price-list/
Medical disclaimer
This article is for general education and is not medical advice, a diagnosis, or a treatment recommendation for any individual. Reading it does not create a physician-patient relationship. Treatment decisions, including whether any medication or procedure is appropriate for you, should be made with a qualified clinician who knows your history. Do not start, stop, or change a psychiatric medication without talking to your prescriber. If you are experiencing a medical or mental health emergency, call 911 or 988.