What to Do When Medications and Therapy Aren’t Enough
Ritesha Krishnappa • December 29, 2025
Quick overview
When evidence-based talk therapy and medication management don’t bring sufficient relief, Elevium offers advanced, clinically proven options that can help many people regain function and hope:
- TMS (Transcranial Magnetic Stimulation) — a non-invasive, FDA-cleared brain-stimulation therapy for depression and certain other conditions.
- Spravato (esketamine) — an FDA-approved, rapidly acting medication for treatment-resistant depression given in-clinic under a REMS safety program.
- Ketamine (IV/IM/compounded intranasal/oral) — an off-label but increasingly used rapid-acting option with a different regulatory and coverage profile than Spravato.
Each has different mechanisms, logistics, evidence levels, and cost/coverage patterns. Below, we explain how they work, who they help, what to expect, and how Elevium integrates them into personalized care.
First step: careful re-evaluation
Before recommending an advanced therapy, Elevium begins with a comprehensive reassessment: review of diagnosis, co-occurring conditions (anxiety, PTSD, bipolar spectrum, substance use), medication history, prior psychotherapy responses, safety (including suicidal risk), medical history, and relevant labs or imaging. This ensures that the chosen option is medically appropriate and that reversible contributors (such as sleep, thyroid, substance, and medication interactions) have been addressed. Elevium’s medication-management and intake workflows emphasize this structured evaluation and shared decision-making.
TMS: how it helps when meds/therapy aren’t enough
How it works
TMS uses focused magnetic pulses to stimulate brain regions involved in mood regulation (commonly the left dorsolateral prefrontal cortex). It is a non-invasive procedure performed while the patient is awake. Evidence shows TMS can significantly reduce depressive symptoms in many patients who have not responded to multiple medication trials.
Who it’s for
- People with treatment-resistant depression (failed adequate trials of antidepressants) or those who can’t tolerate medication side effects.
- Selected patients with OCD or other indications, when supported by the device/protocol and clinical judgment. (Device-specific approvals and local practice guide candidacy.)
What the course looks like
- Intake & screening: psychiatric evaluation, medical history, and motor-threshold titration.
- Typical course: daily sessions (usually 5×/week) for ~4–6 weeks (about 20–30 sessions). Some accelerated protocols (e.g., iTBS) use much shorter sessions.
- During sessions, patients are awake, can read or relax, and usually resume normal activities afterward. Side effects are most commonly scalp discomfort or headache; seizures are rare with proper screening.
Why does it help when meds fail
TMS offers a non-systemic approach that targets neural circuits directly rather than changing neurotransmitter levels systemically. That means patients who did not respond to medication trials sometimes respond to TMS.
Pros/cons summary
- Pros: FDA-cleared, few systemic side effects, durable responses for many.
- Cons: Time commitment (daily visits), potential for scalp pain/headache, insurance often requires prior authorization and documentation of prior treatment failures.
Spravato (esketamine): a regulated, fast-acting option
How it works
Spravato is a nasal esketamine formulation that modulates glutamatergic signaling (NMDA receptor pathway) and can produce rapid antidepressant effects in patients with treatment-resistant depression. Because of safety risks (dissociation, sedation, blood pressure elevation), it is delivered in-clinic under a REMS program with post-dose monitoring.
Who it’s for
Patients who meet FDA-labeled criteria for treatment-resistant depression (typically after multiple failed antidepressant trials) require careful monitoring. Eligibility depends on clinical history and insurer criteria.
What the process looks like at a clinic
- Evaluation & documentation: psychiatric assessment and documentation of prior treatments to support prior authorization.
- Dosing visits: in-clinic dosing with at least 2 hours of observation after administration; vital signs and mental status are
- monitored until the patient is safe to leave.
- Follow-up: regular psychiatric follow-ups to assess response, side effects, and maintenance plans.
Why Spravato when meds fail
Spravato’s regulated, standardized dosing and FDA approval make it a clear option when conventional antidepressants fail, and a rapid response is desirable. Because it’s delivered under REMS, there is a well-defined safety and monitoring structure that many insurers recognize, which can improve the likelihood of coverage (though prior authorization is commonly required).
Pros/cons summary
- Pros: Rapid onset for many patients; FDA-approved pathway and standardized safety procedures.
- Cons: Must be administered and monitored in a clinic (time burden), dissociation and BP changes are possible, and insurance coverage requires documentation/PA.
Ketamine: flexible, rapid, but usually off-label
How it works
Generic ketamine (racemic) acts on glutamate signaling and can produce rapid antidepressant and anti-suicidal effects in many patients. It’s delivered in different forms (IV infusion is the most studied; IM and compounded intranasal/oral formulations are also used). Ketamine for depression is typically off-label, meaning the drug is not FDA-approved for depression specifically (unlike Spravato).
Who it’s for
Patients needing rapid symptom relief or those who have failed multiple conventional treatments. Because it is off-label, candidacy often requires careful informed consent and discussion of costs/coverage.
What a typical ketamine course looks like
- Screening & consent: medical review, substance-use screening, and informed consent for off-label use.
- Dosing: an acute series of infusions (for IV) over 1–2 weeks, followed by maintenance sessions as clinically indicated. Monitoring during and after dosing is routine to manage dissociation and blood-pressure changes.
- Integration: Many clinics recommend psychotherapy and functional support alongside ketamine to consolidate gains.
Why ketamine when meds fail
Ketamine’s speed of effect (sometimes hours to days) makes it an important option for crises or for patients who need quick symptom relief. However, the lack of standardized regulatory approval for depression means insurance coverage is inconsistent, and many patients pay out-of-pocket.
Pros/cons summary
- Pros: Rapid symptom relief for many, flexible administration routes.
- Cons: Off-label - variable insurance coverage; dissociation and transient BP changes; need for repeated maintenance and more research on long-term outcomes.
How Elevium chooses between these options
Decision factors we weigh
- Severity & urgency: suicidal ideation or severe impairment may favor rapid options (ketamine/Spravato under monitored conditions).
- Prior treatment history: number and adequacy of prior antidepressant/psychotherapy trials.
- Medical comorbidity & contraindications: seizure risk, cardiovascular issues, substance-use history, implants (for TMS).
- Logistics & preference: ability to attend daily TMS vs. preference for medication options; tolerance for clinic monitoring/time.
Insurance & cost: Spravato is often covered with prior authorization; ketamine is frequently self-pay; TMS coverage depends on the insurer and documentation. Elevium helps patients navigate benefits checks and prior authorizations.
Typical pathways
- TMS is often recommended when a patient has documented an inadequate response to medication and prefers a non-drug approach.
- Spravato is chosen when a patient meets labeled criteria and seeks a regulated, clinic-based rapid option.
- Ketamine may be offered when rapid relief is needed, and Spravato is not appropriate/available, with full discussion of cost and evidence.
Integration & ongoing care
Advanced treatments are rarely “one and done” — best outcomes come when these options are integrated with psychotherapy, medication management, and functional supports:
- Combine with psychotherapy: many patients do better when TMS/ketamine/Spravato are paired with ongoing evidence-based therapy to consolidate gains.
- Medication coordination: medication regimens may continue or be adjusted during/after advanced treatments. Elevium’s medication-management workflow supports close coordination.
- Maintenance planning: TMS maintenance schedules, Spravato maintenance dosing, or periodic ketamine sessions may be planned based on response.
Safety, monitoring, and practicalities
- TMS: requires pre-treatment screening for seizure risk and metal implants; most side effects are mild and transient.
- Spravato: administered under a REMS program with at least 2 hours of post-dose monitoring for dissociation/sedation and BP changes; prior authorization is routinely required.
- Ketamine: requires monitoring during infusion/dosing for dissociation and BP changes; because its use for depression is off-label, informed consent and careful follow-up are critical.
Insurance & cost realities
- TMS: many insurers cover TMS for treatment-resistant depression with prior authorization and proof of prior medication trials.
- Spravato: often covered when label criteria are met and REMS procedures are followed; still often requires PA.
- Ketamine: commonly considered investigational for depression by payers; many patients pay out-of-pocket.
Elevium helps by performing benefits checks, submitting prior authorizations, and estimating likely out-of-pocket costs.
How fast do these treatments work?
- TMS: many patients notice improvement after 2–4 weeks, with fuller benefit by the end of a standard course.
- Spravato: can act quickly (days to weeks) for many patients.
- Ketamine: often rapid, sometimes within hours to days. Response times vary.
Are these treatments safe?
All carry specific risks and require screening and monitoring. TMS has low systemic risk; Spravato and ketamine require clinic monitoring for dissociation and BP changes. Your clinician will review risks and monitoring plans.
Will insurance cover them?
Coverage varies: TMS and Spravato are frequently covered with prior authorization when criteria are met; ketamine for depression is usually off-label and often self-pay. Elevium performs pre-treatment benefit checks to clarify costs.
Share Article
Quick takeaway Yes - TMS can be an effective option for some people with obsessive–compulsive disorder (OCD). In particular, deep TMS (dTMS) has received FDA clearance for OCD and is provided using specific, evidence-based protocols. At Elevium, TMS for OCD is offered as part of an integrated care plan that pairs neuromodulation with therapy, medication management, and careful clinical oversight. How TMS treats OCD - the basic idea TMS uses focused magnetic fields to change activity in brain circuits involved in mood and compulsive thinking. For OCD, clinicians target the networks thought to underlie obsessive thoughts and repetitive behaviors. Deep TMS (dTMS) uses a specialized coil to reach deeper brain structures implicated in OCD and is the modality that has been FDA-cleared for this indication. Clinical protocols are standardized so clinicians can safely and reliably deliver therapeutic stimulation. FDA approvals & what they mean The FDA has cleared specific dTMS systems for the treatment of OCD , which means there is a regulatory basis and controlled clinical evidence supporting its safety and effectiveness for eligible patients. FDA clearance also helps establish standardized treatment protocols and safety monitoring that clinics follow. Typical protocols & what a course looks like Intake & screening: A full psychiatric and medical evaluation is performed to confirm the OCD diagnosis, review prior treatments (therapies and medications), and screen for contraindications (for example, certain implants or seizure risk). Treatment schedule: OCD TMS protocols are typically delivered as a course of daily sessions over multiple weeks. The length of each session and the total number of visits depend on the specific dTMS protocol used and the patient’s clinical response. Monitoring & follow-up: Symptoms are tracked with standardized scales; clinicians adjust the plan and recommend complementary therapies (e.g., ERP — exposure and response prevention) as needed. Elevium’s guidance emphasizes standardized protocols and close outcome tracking to optimize results. Success rates & evidence (what research and clinic experience show) Clinical trials and real-world clinic reports show that many patients with OCD experience meaningful symptom reductions after a full course of dTMS, and some achieve remission. Outcomes vary by individual factors (severity, duration of illness, prior treatment response). Elevium’s TMS for OCD materials summarize published evidence and emphasize honest, individualized expectations during the consent process.
At Elevium, we believe there’s no one-size-fits-all answer to mental health care. Every treatment has strengths, limitations, and a best-fit patient. Below is a clear, patient-friendly comparison to help readers weigh their options and see how Elevium integrates treatments into individualized plans. At a glance - Quick Comparison Table
What is TMS (Transcranial Magnetic Stimulation)? TMS uses focused magnetic pulses to stimulate targeted areas of the brain (most commonly the left dorsolateral prefrontal cortex for depression). Pulses are delivered with a coil placed on the scalp; treatment is done while awake and does not require anesthesia. Variants: Standard rTMS: sessions ~30–45 minutes. iTBS (intermittent theta burst stimulation): accelerated protocol with much shorter sessions (often 3–10 minutes) that can produce similar clinical results in many patients. Safety & Side Effects: The most common side effects are mild scalp discomfort or headache, which typically resolve. Serious events (seizures) are rare when patients are properly screened and protocols followed. Who is a candidate for TMS? TMS is typically considered when: A patient has major depressive disorder that has not responded adequately to multiple antidepressant trials or therapy. Medication side effects are intolerable, or the patient prefers a non-drug option. The patient can attend frequent sessions and has no contraindications (e.g., certain metal implants near the head, unshielded intracranial hardware, or an active condition that raises seizure risk). For teens: certain devices have adolescent indications — candidacy is determined by device labeling and clinician judgment. Typical pre-treatment evaluation includes: psychiatric assessment, medical history, medication review, seizure risk evaluation, and review for metal implants. A baseline symptom scale (PHQ-9, etc.) is often used to track progress. What to expect during treatment (timeline & session flow) Evaluation & prep Initial consult / intake (60–90 minutes): psychiatric history, prior treatments, informed consent, and screening. Motor threshold titration: first appointments set the stimulation intensity based on each patient’s motor threshold (a quick calibration). Treatment course Frequency: Most standard protocols are 5 sessions per week (Mon–Fri). Duration: Typical acute course is 4–6 weeks (totaling ~20–30 sessions). Some protocols extend to 6 weeks or include additional sessions for partial responders. Session length: Traditional rTMS sessions 20–45 minutes; iTBS sessions about 3–10 minutes. Maintenance: Some patients have periodic maintenance TMS (weekly or monthly) if symptoms recur. During a session You’ll sit comfortably. The technician positions the coil and runs the protocol. You’re awake and alert and can read, use your phone, or relax. Most patients return to normal activities immediately after (unlike treatments that require post-procedure monitoring or sedation).
Quick overview Medication management at Elevium is a collaborative, medical approach to treating mood, anxiety, and related conditions. It’s not just “getting a prescription” - it’s an ongoing process of assessment, careful medication selection, safety monitoring, and coordination with therapy and other supports. Elevium’s medication management workflow is designed to be evidence-informed, patient-centered, and transparent about costs and logistics.
Quick answer If you’re a parent looking at TMS (transcranial magnetic stimulation) or Spravato (esketamine nasal spray) for a teen with depression, the biggest takeaway is this: TMS has FDA-cleared options for some adolescents (ages 15–21) as an adjunct treatment for major depressive disorder, depending on the specific TMS system and clinical scenario. Spravato is not established for pediatric patients (safety/effectiveness in people under 18 hasn’t been established in labeling). Spravato also requires in-clinic administration and at least 2 hours of monitoring each session due to risks like sedation/dissociation and respiratory depression. Below is a parent-friendly guide: eligibility, safety data, FAQs, and what options a clinic like Elevium may offer for younger patients. What are these treatments? TMS (Transcranial Magnetic Stimulation) TMS uses a magnetic coil placed on the scalp to stimulate brain circuits involved in mood regulation. It’s non-invasive, done awake, and doesn’t require anesthesia. In youth research, the most common side effects are typically headache and scalp discomfort, and serious adverse events are uncommon when safety guidelines are followed. Spravato (Esketamine) Spravato is a controlled substance nasal spray administered under supervision in a certified healthcare setting with monitoring because of risks like sedation/dissociation and respiratory depression. It is not dispensed for home use. Spravato. For pediatric use, labeling states that the safety/effectiveness has not been established. Eligibility: Who might be a candidate? TMS eligibility (typical teen considerations) A teen may be considered when: Depression is moderate to severe and significantly impairing. Symptoms haven’t improved enough with evidence-based first-line care (therapy and/or medication), or there’s a reason meds aren’t a good fit. The teen can attend frequent sessions and cooperate with treatment. No contraindications (for example, certain metal implants near the head). Important age note: Some TMS devices now have FDA-cleared indications for adolescents 15–21 as adjunct treatment for MDD. Spravato eligibility for teens In practice, most reputable programs treat Spravato as an adult-focused option because pediatric safety/effectiveness is not established in the labeling. If a clinic considers ketamine/esketamine-type therapies for youth at all, it’s usually in highly specialized contexts with careful risk/benefit review and parent/guardian involvement.
Quick answer Spravato (esketamine) - more likely to be covered by insurance for treatment-resistant depression or certain labeled indications because it is FDA-approved for those uses and provided under a REMS (safety) program. Coverage usually requires prior authorization and is commonly billed through the medical benefit (clinic/office administration), though specifics vary by insurer. Ketamine (racemic or other formulations) given for depression (IV, IM, oral, compounded intranasal) is generally off-label for psychiatric indications. Most commercial and government payers treat ketamine for depression as experimental/ investigational and do not routinely cover it, so patients commonly pay out-of-pocket. Exceptions can occur on a case-by-case basis. Below is a patient-friendly but practical breakdown to help you understand the differences, benefits, and when each option might be preferred. How insurers think about these two treatments 1. FDA approval & labeling (big insurer signal) Spravato (esketamine): FDA-approved specifically for treatment-resistant depression (and for depressive symptoms in certain cases). Because it’s approved and regulated (REMS), payers have a clear precedent for coverage policies — though they still typically require documentation of prior treatment attempts and a prior authorization. Ketamine (IV/IM/oral/compounded intranasal): Ketamine as an anesthetic is FDA-approved, but not specifically approved for depression except for esketamine. Using ketamine for depression is off-label, so most insurers label it “investigational” and don’t cover it routinely. 2. Delivery setting & billing pathway Spravato: Administered in a certified clinic with monitoring (because of REMS). Charges are generally billed under the medical benefit (clinic visit/drug administration/observation). In some systems, parts may route through the pharmacy/medical split — check your plan. Ketamine: Often given via IV infusion in outpatient infusion clinics/medical offices. Since this use is off-label, some insurers will not cover the drug or the infusion visit; even when they do, coverage is inconsistent. Ketamine given for anesthesia (unrelated uses) is covered in its approved context, but that does not imply coverage for depression treatment. 3. Evidence & guidelines Spravato has randomized trials, an FDA label, and published REMS safety requirements — this strengthens the case for insurer coverage. Ketamine has growing evidence showing rapid antidepressant effects but lacks a universal regulatory approval for depression (outside esketamine), so guidelines and payer policies are uneven. Benefits of each treatment (clinical perspective) Spravato (esketamine) Standardized, FDA-approved formulation and dose. REMS program requires safe administration and monitoring, which some insurers view positively. Good evidence for treatment-resistant depression and a clear pathway for prior authorization. Administered under supervision with structured follow-up — easier to document for insurers. Ketamine (IV/IM/oral/compounded) Flexible routes of administration (IV, IM, oral, intranasal) — IV infusions may produce rapid effects. Often faster & flexible protocols in experienced clinics (some patients respond when other treatments fail). Potentially lower direct drug cost (depending on formulation), but overall cost can still be high because of clinic fees and repeat sessions. Clinical experience: Many providers and clinics report beneficial outcomes, particularly for acute suicidal ideation or rapid symptom relief; however, standardization and long-term data vary.
For many patients, Spravato (esketamine nasal spray) represents a lifeline when traditional antidepressants fall short. However, no treatment is without risk, and you may have stumbled upon online stories that read “Spravato ruined my life.” In this article, we’ll explore: Why some patients have negative experiences Common and rare side effects of Spravato How to minimize risks When to seek help What makes treatment at Elevium different
Transcranial Magnetic Stimulation (TMS) is FDA-approved and widely considered a safe, effective treatment for depression, OCD, and other mood disorders. But, as with any therapy, individual experiences vary - and online, you may have come across forums or articles claiming “TMS made me worse.” At Elevium , we believe in open, honest communication about both the benefits and the potential challenges of treatment. In this article, we’ll cover: Why some patients report negative experiences The most common side effects How Elevium minimizes risk and enhances outcomes What to do if symptoms worsen How to make an informed, confident decision about TMS
When to Expect Results and Side Effects from Spravato
How Much Does Spravato Cost? Understanding Pricing, Insurance, and Treatment Options
