TMS and esketamine: high efficacy for patients with treatment resistant depression

Author: Daniel Fischer, M.D., medical director, outpatient and interventional psychiatry, Providence Portland and Providence St. Vincent medical centers

About 30-50% of patients with major depression find they do not respond well to various medications. Searching for an effective treatment is a source of frustration for patients, family members and providers.

Providence’s Outpatient Interventional Psychiatry Program offers both transcranial magnetic stimulation (TMS) and esketamine (brand name is Spravato) at Providence Portland Medical Center. TMS also is available at Providence St. Vincent Medical Center.

Both treatments have the same medical indications and efficacy. When we talk to patients who are severely depressed, we discuss both TMS and esketamine as options. The treatments are available only for adults.

Program overview
Both types of treatment are highly effective in 70-75% of my patients. It’s really fulfilling to me as a psychiatrist – as well as for my Providence St. Vincent colleague, outpatient psychiatrist Kelly Harrington, M.D. – since many conventional treatments often don’t work nearly as well as we would like.

For our program, both TMS and esketamine require a referral from a provider – it can be a primary care doctor, psychiatrist, psychologist, PA, NP or therapist. The patient must have a diagnosis of major depressive disorder and have attempted at least two medications unsuccessfully. Patients can continue to take their medications in conjunction with both types of treatments.

In keeping with the Providence mission, we are honored to accept patients with Oregon Health Plan, Medicare and most private insurance. We began offering the treatments in January 2021 and are the only clinical providers of esketamine in Oregon that accept OHP.

Below are details about both types of treatments:

Transcranial magnetic stimulation
TMS is a noninvasive, nonmedication alternative treatment for major depression that has been cleared by the FDA since 2008. It is very well studied and safe, with similar results as electroconvulsive therapy (ECT) but is much safer.

TMS uses a large magnet similar to an MRI and pulses rapidly over the dorsolateral prefrontal cortex, which is shown to be low functioning when people are depressed. The pulsing generates a brief electrical field using magnetic energy.

The patient sits in a chair, with a coil containing the magnet resting over the top of their head. It is painless, although the patient will feel a tapping sensation. Each session lasts 20 minutes and the patient can drive, work and go about their day immediately afterward. There is a time commitment involved – patients must come into the clinic Mondays through Fridays for 36 treatments, which is the FDA-approved protocol.

Insurance requires that patients must attempt two or three antidepressants and therapy before the treatment will be covered. After that, insurance typically is very good about paying for the treatment, each of which is comparable to the cost of an office visit.

The FDA approved the use of esketamine for major depressive disorder in 2019. It should not be confused with its parent compound, ketamine, which has received a lot of media attention recently. Esketamine is half of the original molecule and is designed to have less dissociative side effects than racemic ketamine.

We adhere to FDA-approved protocols, in contrast to private clinics prescribing off-label ketamine with varying levels of psychiatric expertise and evidence to support their practices in a way that can be exploitive to patients who are desperate for relief. 

While more expensive than TMS, eskestamine often is covered by insurance and patients with OHP or Medicare typically pay nothing. Treatments are administered twice a week for the first month and once a week for the second month. There is a total of 12 treatments over two months, and effects are cumulative over a period of several weeks.

Each session lasts two hours, and patients cannot drive themselves immediately afterward. The patient administers the esketamine themselves via a nasal spray and must be monitored by clinical staff for the remainder of the session. Many patients bring a family member into the room, listen to music and can relax in a darkened space. Most people seem to really like the treatments and think they’re interesting – with experiences and memories that are helpful in processing the past, which often has kept people stuck in their depression.

Esketamine is considered a type of anesthesia, though at a lower dose than in a surgical setting. As required by the FDA, we carefully log and report any side effects during sessions, including blood pressure increases, headaches, nausea and rare cases of dissociation.

Contraindications for esketamine include patients for whom hypertension would be dangerous, since about 20% of patients experience an increase in blood pressure during each session. Patients with a history of aneurisms or some types of cardiovascular disease also are not good candidates.

Final reminders
For providers who would like to refer patients, please remember that they must be coded with a diagnosis of major depressive disorder to be covered by insurance, including OHP. The two types of treatments will not be covered by insurance for patients with anxiety without depression, bipolar disorder psychosis and certain other behavioral health diagnoses.

As a psychiatrist, it’s immensely gratifying to see how well these treatments work for patients who have struggled with major depression – often for years – and who have tried medications and talk therapy, with limited or no success. It’s a privilege to help people who previously thought they had nowhere else to go.

To refer a patient

  • Call Providence Outpatient Psychiatry (for both the east side and west side clinics) at 971-345-5060.
  • East side location: Providence Portland Medical Center, 5228 NE Hoyt Street, Building B, Suite 300, Portland, 97213
  • West side location: Providence St. Vincent Medical Center, 9155 SW Barnes Road, Suite 333, Portland, 97225.


About the Author

The inScope content team focuses on bringing you the latest in clinical news from our team of world-class medical providers and physician leaders.

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