TMS vs Ketamine for Depression: How to Choose (2026)

Two very different treatments keep appearing in the same conversation: repetitive transcranial magnetic stimulation (TMS, or more precisely rTMS) and ketamine. Both are options that come up when antidepressants have not helped; both are offered by a growing number of European clinics; and both are routinely oversold. This page puts them side by side on mechanism, evidence, availability and cost, not to pick a winner, but so that the conversation you have with your clinician starts from facts rather than clinic marketing. If you have not yet mapped the full set of options at this stage, start with what to do when depression treatment isn't working.

What each one actually is

TMS uses a magnetic coil held against the scalp to induce small electrical currents in the cortex, usually the left dorsolateral prefrontal cortex, a region consistently implicated in depression. It is non-invasive: no general anaesthesia, no sedation, and it is not associated with the characteristic memory effects of ECT; most people can resume usual activities the same day if they feel well. It is still a medical procedure with its own checks: medicines, sleep deprivation and any seizure history are reviewed beforehand, implanted devices are assessed individually, and hearing protection is used during sessions. A course means repeated sessions, typically daily over two to six weeks (NICE IPG542). The most common side effects are scalp discomfort and headache during or after stimulation; the serious one, seizure, is rare, and screening reduces that risk without eliminating it.

Ketamine is a dissociative anaesthetic on the WHO list of essential medicines. The form used in most depression research and off-label treatment is racemic ketamine, given as an intravenous infusion in a clinic under monitoring. It has never been through regulatory approval as an antidepressant, so its use for depression is off-label: legal, but outside its licensed indication. Its close relative, esketamine nasal spray (Spravato), is an approved EU medicine for treatment-resistant depression: a separate route we compare in Spravato vs ketamine infusions and review in full in the esketamine evidence review.

What the evidence shows

TMS: assessed, effective short-term, variable person to person

TMS has the tidier regulatory story. The UK's assessment found no major safety concerns and adequate evidence of short-term efficacy, with clinical response that varies from person to person (NICE IPG542, reissued unchanged in 2025 as HealthTech guidance HTG396). That careful phrasing is worth keeping: the evidence supports offering TMS, and it also records that many people respond partially or not at all, and that the durability of response beyond the course is less well pinned down than the short-term effect.

Ketamine: rapid, real, and short-lived without repetition

Ketamine's core finding is stronger than TMS's on speed and less settled on everything after it. Racemic ketamine, given by intravenous infusion, produces a rapid antidepressant effect that small controlled trials have shown consistently since 2006. But the effect is usually short-lived, repeated infusions are needed to maintain it, and relapse after stopping is common (Zarate et al. 2006; Caddy et al. 2015, Cochrane; Marcantoni et al. 2020). It is used off-label almost everywhere in Europe: it is not an approved antidepressant. Ketamine-assisted psychotherapy is promising but under-evidenced. Repeated use carries bladder-damage, dependence and, less often, liver-injury risks. The full picture (including Norway's 2025 decision to fund IV ketamine publicly for treatment-resistant depression) is in our ketamine evidence review.

Head to head: genuinely unsettled

Direct comparisons are scarce and small. A retrospective study of 24 treatment-resistant depression patients at a Cypriot clinic offering both found improvement in both groups and no significant difference between them, but a retrospective comparison of this size cannot establish causation or predict an individual response (Mikellides et al. 2021). A 2025 network meta-analysis pooling 35 randomised trials of IV ketamine, rTMS and ECT in treatment-resistant depression found no statistically significant differences in response or remission between IV ketamine and rTMS, while rating the confidence in that evidence very low (Terao et al. 2025). Finding no significant difference at very low confidence does not prove the two are equally effective; it means the question is unanswered. The plain summary: current evidence does not establish a reliable overall winner, nobody can tell you which of these two is more likely to work for you, and a clinic that claims otherwise is ahead of the data.

Availability in Europe

Here the two diverge sharply, and the reason is regulatory, not clinical.

TMS involves no controlled substance and no off-label prescribing, so it has been absorbed into ordinary psychiatric services in many countries: public systems and insurers in parts of Europe cover it, and private TMS clinics operate widely. The practical constraint in much of Europe is simply finding a provider, since availability differs widely between countries and often between cities; a positive national assessment such as NICE's does not guarantee that your local service offers it or that your system reimburses it. Marketing authorisation, professional guidance, lawful off-label prescribing and reimbursement are four separate questions, and each country answers them differently.

Ketamine for depression runs on the opposite logic. Because it is off-label, public funding for IV ketamine remains uncommon and varies by country and specialist pathway; Norway funds it publicly since August 2025, and France opened a narrow compassionate framework in March 2026. Everywhere else, the route is mostly private clinics applying their own criteria, around 45 ketamine and KAP clinics are listed in our directory, against over 200 Spravato centres riding the approved medicine's reimbursement rails. If public funding matters to you, the approved esketamine route, not IV ketamine, is usually the door European systems have actually built; our eligibility check walks through whether it could be open where you live.

What it costs

Published, verifiable figures first. For ketamine, these are named published fees, not a representative European range: in the UK, Oxford Health lists £265 per infusion and Save Minds £595 for repeat infusions (first sessions are priced higher), and in Germany published fees run roughly €200 to 400 per session; a full induction series multiplies any of these by six or more, and assessment, monitoring, any psychotherapy component and maintenance reviews add to the whole-course cost. The breakdown, country by country, is in our ketamine therapy cost guide. For TMS, most European providers do not publish standard prices, and we do not quote unpublished ones; the structural point is that a TMS course means 10–30 sessions, so a per-session fee compounds the same way an infusion series does. Where TMS is reimbursed (as it is within some public systems and insurance schemes), the calculation changes entirely, which is why coverage, not sticker price, is the first thing to check in your country.

How the choice usually gets made

What follows describes practice as our evidence and country pages record it, not a recommendation of either treatment.

In systems where TMS is reimbursed and ketamine is not, the sequence often decides itself: guideline options first, TMS where available, and off-label ketamine, or approved esketamine, considered at the specialist stage. People with a cardiovascular history may be steered away from ketamine, whose infusions raise blood pressure and heart rate; people with seizure risk factors or certain metallic implants are screened out of TMS. Someone in a severe episode where speed matters may hear ketamine or esketamine discussed earlier, because rapid onset is their defining property; for the severest cases, guidelines reach past both toward ECT. None of this is a self-serve menu. Both options sit at the point where treatment decisions are specialist decisions, and the most useful thing you can bring to that appointment is a written record of what you have tried, at what dose, for how long, with what result.

One caution applies to both routes equally. A responsible provider assesses before any first dose: for ketamine that means the psychiatric diagnosis itself, any bipolar or psychotic symptoms, suicidality, substance use, physical comorbidity, the possibility of pregnancy and interacting medicines, not just a blood-pressure reading, and the result should be an individual plan; an online eligibility score (ours included) cannot determine clinical suitability. During a ketamine session, a subanaesthetic dose does not remove sedation, respiratory or cardiovascular risk: blood pressure, pulse, oxygen saturation and level of consciousness should be monitored by trained staff with the equipment and capability to manage deterioration, followed by a recovery assessment before discharge. Psychological support complements that monitoring; it does not replace it. For repeated ketamine programmes, urinary symptoms and misuse risk should be reviewed over time. A provider that skips any of this is a warning sign, whichever treatment is on offer.

Two more things belong in the decision. Benefits of either treatment may diminish after an acute course: continuation is individualised, with symptom monitoring, regular benefit-and-risk review and a plan for non-response or relapse, for TMS as much as for ketamine; neither indefinite ketamine treatment nor a fixed number of infusions should be presented as inevitable. And rapid symptom relief does not establish protection against suicide: anyone with acute risk needs a full psychiatric assessment, a safety plan and emergency or inpatient care when indicated, not an outpatient booking.

Frequently asked questions

Which works faster?

Ketamine can reduce symptoms within hours to a day in some patients, which conventional TMS cannot match: there, improvement builds across weeks of a daily course. Two qualifications keep this honest: the ketamine benefit usually fades within one to two weeks without continuation, and accelerated iTBS protocols (such as the Stanford SNT studies) compress TMS to days, though their availability and evidence base differ from standard rTMS. There is no head-to-head trial covering every protocol.

Which has the better evidence?

They are strong on different axes. TMS has a formal health-technology assessment behind it (NICE: adequate evidence of short-term efficacy, no major safety concerns) and no controlled-substance baggage. Ketamine has the more dramatic replicated finding (rapid response since Zarate 2006, confirmed by Cochrane) on a smaller, shakier trial base, with maintenance strategy still unsettled. Head to head, the comparative evidence is rated very low confidence and does not establish a reliable winner, which is not the same as proof that they are equal.

Can I do TMS and ketamine at the same time?

Combination approaches exist in research and in some clinics, but there is no solid trial evidence behind combining them, and this page cannot advise on it. Sequencing and combination at this stage are exactly the kind of specialist decisions to put to a psychiatrist.

Is TMS the same as ECT?

No. TMS uses magnetic pulses, awake, with no anaesthesia and no induced seizure; ECT is a hospital treatment under general anaesthesia that guidelines reserve for severe depression. They are different orders of intervention; see our separate ECT vs ketamine comparison.

Where do I start if I want either?

With the record, then the country. Write down your treatment history (drug, dose, duration, result); that is the key that opens every specialist door. Then check what your national system actually covers: our eligibility check and country guides map the routes, and the directory shows verified providers where the private route is the realistic one.

Sources

1. NICE IPG542 (now HealthTech guidance HTG396) — repetitive transcranial magnetic stimulation for depression
2. Zarate et al. (2006), Archives of General Psychiatry — single-infusion ketamine in treatment-resistant depression
3. Caddy et al. (2015), Cochrane Database of Systematic Reviews — ketamine and other glutamate receptor modulators for depression
4. Marcantoni et al. (2020), Journal of Affective Disorders — meta-analysis of IV ketamine for treatment-resistant depression
5. Mikellides et al. (2021), Frontiers in Psychiatry — ketamine vs rTMS in treatment-resistant depression, retrospective comparison
6. Terao et al. (2025), PCN Reports — network meta-analysis of IV ketamine, rTMS and ECT in treatment-resistant depression
7. NICE NG222 — depression in adults: treatment and management
8. EMA: Spravato (esketamine) — medicine overview and EPAR
9. Nye metoder / Beslutningsforum (2025) — decision on IV ketamine for treatment-resistant depression
10. Cole et al. (2022), American Journal of Psychiatry — accelerated iTBS (SNT) for treatment-resistant depression
11. Rossi et al. (2021) — safety and recommendations for TMS practice
12. Swainson et al. (2021), CANMAT — recommendations on ketamine use in depression
13. MHRA — off-label or unlicensed use of medicines: prescribers' responsibilities
14. Oxford Health NHS FT — published infusion fees and Save Minds — published fees

This guide is for general information only and is not medical advice, a diagnosis, or a recommendation of any treatment. Treatment decisions at this stage are specialist decisions: discuss your options with a licensed clinician who knows your history. If you are in crisis, contact your local emergency number (112 in the EU) or a crisis line immediately.