If you have tried multiple antidepressants without lasting relief, you may be a candidate for one of two breakthrough treatments now available in Miami: Spravato (esketamine) or TMS therapy (transcranial magnetic stimulation). Both are FDA-approved for treatment-resistant depression, but they work through entirely different mechanisms and suit different patients. Understanding the differences can help you and your psychiatrist in Miami decide which path makes the most sense for you.
Spravato is an FDA-approved nasal spray containing esketamine, a derivative of the anesthetic ketamine. It works on glutamate receptors in the brain — a completely different pathway than traditional antidepressants, which target serotonin or norepinephrine. This novel mechanism is why Spravato can produce rapid antidepressant effects, sometimes within hours to days, even in adults whose symptoms have not responded to multiple prior treatments. Spravato is administered in a certified healthcare setting. Adults self-administer the nasal spray under medical supervision and are monitored for at least two hours afterward. Treatment sessions typically occur twice weekly for four weeks, then weekly, then every one to two weeks for maintenance. At Elevate Psychiatry, our Spravato program is available at our Miami clinics for adults 18 and older with treatment-resistant depression or major depressive disorder with active suicidal ideation.
Transcranial magnetic stimulation uses focused magnetic pulses to stimulate underactive areas of the brain associated with mood regulation. TMS does not require anesthesia, sedation, or monitoring after sessions — most adults drive themselves to and from appointments. A standard TMS course involves daily sessions five days per week for six weeks, with each session lasting approximately 20 to 40 minutes. TMS has been FDA-cleared for treatment-resistant depression since 2008 and has accumulated a robust long-term safety record. At Elevate Psychiatry, our TMS program in Miami uses advanced equipment and is supervised by board-certified psychiatrists throughout your treatment course.
The most important difference between Spravato and TMS is the speed of response. Spravato can begin working within hours to days, making it a strong option when rapid symptom relief is a clinical priority — for example, in adults with severe depression or active suicidal thoughts. TMS typically produces gradual improvement over several weeks of daily treatment, with many patients noticing the most significant changes in weeks three through six.
Another key distinction involves how treatment is delivered. Spravato requires you to remain in the clinic for monitoring after each dose due to potential side effects including dissociation, dizziness, and elevated blood pressure. TMS sessions have minimal side effects — typically mild scalp discomfort or headache — and require no post-session monitoring. You can return to normal activities immediately after a TMS session.
Insurance coverage also differs. TMS is covered by most major insurance plans when prior authorization criteria are met, which typically requires documented failure of two or more antidepressants. Spravato received FDA approval in 2019 and is covered by many insurance plans, though prior authorization requirements vary. Our team at Elevate Psychiatry helps verify your benefits before you begin either treatment.
Your psychiatrist will evaluate several factors when recommending Spravato versus TMS. Spravato may be preferred if you need rapid relief, have not responded to TMS in the past, or have been diagnosed with major depressive disorder with suicidal ideation requiring urgent intervention. TMS may be preferred if you want a non-pharmacological approach, prefer not to receive a medication-based treatment, or have scheduling flexibility to attend daily weekday sessions for six weeks.
Some adults with severe treatment-resistant depression benefit from a combination approach — for example, completing a TMS course while also starting Spravato to accelerate early symptom improvement. Your care team will review your full treatment history, current medications, and clinical presentation before recommending any advanced intervention. A comprehensive psychiatric evaluation is always the starting point.
Elevate Psychiatry offers both Spravato and TMS therapy at our Miami locations — one of a limited number of practices in the area providing both FDA-approved advanced options under one roof. Our board-certified psychiatrists have experience managing complex, treatment-resistant cases and work closely with each adult patient to develop a personalized plan. We also offer medication management and therapy services to complement advanced treatments and support long-term recovery. Adults throughout Florida can access our team via telepsychiatry for evaluation and medication management, though in-person attendance is required for Spravato and TMS sessions.
Before deciding on Spravato, it helps to know exactly what each treatment session involves. Read our full guide: Spravato in Miami: What to Expect at Your Treatment Session.
For a comprehensive overview of all advanced treatment options available for treatment-resistant depression, including medication optimization and ECT, see our complete guide to treatment-resistant depression in Miami.
If you have been struggling with depression that has not responded to standard treatments, you do not have to keep trying the same approaches. Both Spravato and TMS represent meaningful advances in psychiatric care that have helped thousands of adults achieve significant improvement. Our team at Elevate Psychiatry is currently accepting new adult patients at our Brickell, Coconut Grove, and Doral offices. Contact us today to schedule a comprehensive evaluation and learn whether Spravato or TMS may be right for you.
If you're deciding between Spravato and other treatment options, our full clinical guide explains how esketamine works and who qualifies: Esketamine for Depression in Miami: How It Works and Who It Helps. >
