Starting an antidepressant is often the first real step in depression care, and for many people it helps. For others, a medicine brings some relief but not enough, or it does little at all after a fair trial. If that has happened to you, the next stage can feel hazy. You may have heard names like Spravato, TMS, and ketamine and wondered what each one actually involves. This guide walks through those options in everyday terms so you can bring sharper questions to your next visit.
What 'not working yet' usually means
Clinicians describe a medicine that falls short in several ways. Some people feel a little better but not back to themselves. Others notice no change, or find that side effects outweigh any benefit. Before moving on, your doctor will usually ask whether the dose was high enough, whether you took it consistently, and how long you gave it. Those details shape what the next step should be. Writing down how your mood, sleep, and energy shift from week to week gives your clinician a clearer picture than memory alone can offer.
Spravato: a nasal spray given in a clinic
Spravato contains esketamine, a close relative of ketamine, and it comes as a nasal spray. It is dispensed under its REMS program, which means the medicine reaches patients only through approved settings that follow specific rules. Spravato is typically used alongside an antidepressant you already take. After each dose you remain on site for a while so staff can check on you, and because the medicine affects how you feel and think for a period afterward, you will need someone to drive you home. Many people find the in-office routine more manageable than they expected, though the schedule of visits is a real commitment that deserves a frank discussion before you start.
TMS: magnetic pulses without sedation
Transcranial magnetic stimulation (TMS) applies brief magnetic pulses through a coil resting on the head, aimed at regions tied to emotional control. The person lies back in a recliner, puts in ear protection since the tapping noise may be intense, and remains alert throughout. Each appointment tends to be short, and people generally resume their day immediately after. Care comes as a series of sessions across multiple weeks, and a few individuals feel soreness on the scalp or a headache during the first appointments. There is no sedative involved, so driving home on your own is typically allowed, a factor that attracts people balancing job and family. Your provider can outline how a series would be structured for your circumstances.
Ketamine: infusions and what they can and cannot do
Ketamine is an older anesthetic that clinicians have used off-label for depression, often given as an intravenous infusion over a set period. Some people describe a noticeable lift in mood within hours, although the effects tend to fade without ongoing treatment. Because the medicine changes perception and blood pressure during the infusion, staff monitor you closely, and you will need a ride home. The research on ketamine is still developing, and investigators continue to study who tends to benefit and how long any improvement lasts. Treat any relief you feel as useful information about how your brain responds, not as a promise of lasting change.
Matching options to daily life
Practical details often decide which path makes sense. Consider how far you can travel several times a week, whether you can arrange rides, how your work schedule shifts from week to week, and what your insurance covers. Some people need a treatment that fits around childcare or shift work, while others have trouble leaving home for long stretches. None of these factors makes an option good or bad on its own. They simply shape how realistic a plan is over the next few months. Your clinician can weigh medical fit alongside these everyday constraints, so the decision reflects your actual circumstances rather than an idealized version of them.
Bringing these options to your doctor
Going into the discussion with concrete questions makes it more productive. Find out how much time, travel, and money the treatment requires. Learn which side effects occur most often and what the care team does about them. Ask how improvement will be measured, and what the two of you would do if the initial approach falls short of your goals. You might also raise whether combining this with talk therapy fits your situation. Jot your questions down ahead of the appointment so they don't escape your memory once you're there. Nothing needs to be decided during that meeting. Giving yourself a few days to reflect is a standard step in a medical choice, and a careful clinician anticipates it.
Moving past a first medicine is rarely a single decision. It tends to be a series of conversations, adjustments, and check-ins. Knowing the basic shape of each option gives you a stronger footing for those talks, and it lets you speak up about what matters most to you, whether that is how often you can attend, how you feel about the medicine itself, or what a good result would look like in your own words.