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.

TL;DR TMS is a non-invasive brain-stimulation procedure — magnetic pulses through the scalp, no anaesthesia, done awake in a chair — with a formal NICE assessment behind it and a course of daily sessions over several weeks. Ketamine is a licensed anaesthetic used off-label for depression: its rapid antidepressant effect is the best-established fact in its field, but the benefit of a single infusion usually fades within one to two weeks, and repeat dosing is needed to hold it. Direct comparisons are few and show no clear winner. TMS is the more widely embedded option in European health systems; ketamine for depression is mostly private and off-label, with esketamine nasal spray the approved alternative. Which one is worth pursuing is a decision to make with a psychiatrist, not from a price list.

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 anaesthesia, no sedation, no memory effects, and you drive yourself home afterwards. 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 excludes people with the main risk factors.

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.

Fact box — TMS vs ketamine at a glance - Type: TMS — non-drug brain stimulation; ketamine — off-label drug infusion (dissociative anaesthetic). - Regulatory status: TMS — assessed procedure (NICE: no major safety concerns, adequate evidence of short-term efficacy); ketamine — licensed anaesthetic, off-label for depression everywhere in Europe. - Onset: TMS — gradual, over weeks of daily sessions; ketamine — hours to a day, fading within one to two weeks without repetition. - Session burden: TMS — daily sessions over two to six weeks; ketamine — a series of infusions (often six over two to three weeks), then maintenance decisions. - Main risks: TMS — headache, scalp discomfort, rare seizure; ketamine — dissociation and blood-pressure rise during infusion; with repeated use, bladder damage and dependence risks. - Driving home: after TMS, yes; after ketamine, no — plan the rest of the day off. - Head-to-head evidence: limited; no clear winner in the small direct studies and network meta-analyses to date.

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 significant improvement in both groups and no significant difference between them (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 significant differences in response or remission between IV ketamine and rTMS — while rating the confidence in that evidence very low (Terao et al. 2025). The plain summary: nobody can currently 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.

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, private per-infusion fees in our verified listings run roughly £265–595 in the UK and around €200–300 per session in much of continental Europe, with a full induction series multiplying that by six or more — 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 screens cardiovascular health, current medicines and psychiatric history before any first dose, and for repeated ketamine programmes should track urinary symptoms over time. A provider that skips screening is a warning sign, whichever treatment is on offer.

Frequently asked questions

Which works faster?

Ketamine, without contest — relief can arrive within hours to a day of an infusion, which is unlike anything else in depression care. The catch is durability: the benefit usually fades within one to two weeks, and repeated infusions are used to extend it. TMS moves in the opposite way: little happens after one session, and improvement, when it comes, builds across weeks of a daily course.

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 shows no clear winner and is rated low-confidence.

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

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.