The past decade has seen meaningful advances in psychiatric treatment for conditions that were previously considered difficult to treat with precision. Two of the most significant developments sit at the intersection of neuroscience and clinical psychiatry: esketamine, the FDA-approved intranasal formulation of a ketamine derivative for treatment-resistant depression, and transcranial magnetic stimulation adapted for ADHD. Both represent departures from the medication-first model that has dominated psychiatric practice for decades, and both are increasingly available at outpatient practices across the country.
This article explains what esketamine is, how it differs from standard ketamine, and what the current evidence says about TMS for ADHD. Whether you are looking into esketamine for treatment-resistant depression or exploring whether TMS might address your ADHD symptoms, the goal here is to give you a clear, accurate picture of what these treatments involve and what to look for in a provider. Village TMS offers both esketamine and TMS in New York City within a psychiatrically supervised outpatient setting.
Understanding Esketamine and How It Differs from Ketamine
Esketamine and ketamine are closely related but not identical. Ketamine is a racemic mixture, meaning it contains equal parts of two mirror-image molecular forms, known as enantiomers. The S-enantiomer, esketamine, has been found to have greater affinity for the NMDA receptor that is the primary target of ketamine’s antidepressant effects. Esketamine is effectively a more refined version of ketamine that isolates the component most responsible for its therapeutic activity.
Spravato, the FDA-approved intranasal esketamine product, was approved in 2019 for treatment-resistant depression in adults who have not responded to at least two antidepressant medications. It received a subsequent approval for major depressive disorder with acute suicidal ideation. Unlike ketamine infusions, which are administered intravenously using an off-label anaesthetic formulation, Spravato is a purpose-built psychiatric medication with a specific FDA approval and an established clinical evidence base.
The practical distinction matters for several reasons. Spravato is covered by most major commercial insurance plans and Medicare for qualifying patients, making it significantly more financially accessible than ketamine infusions for many people. It is administered as a nasal spray rather than an IV, which some patients find less medically intensive. And it carries the regulatory accountability that comes with FDA approval, including post-market safety surveillance and a required Risk Evaluation and Mitigation Strategy programme that governs how it is prescribed and administered.
What Esketamine Treatment Involves
Esketamine must be administered in a certified healthcare setting under the supervision of a healthcare provider. Patients self-administer the nasal spray under supervision and are then monitored for at least two hours to assess for sedation, dissociation, and blood pressure changes, which are the most common side effects during and immediately after administration.
The initial treatment phase involves twice-weekly sessions for four weeks, followed by weekly sessions in months two, and then either weekly or every-two-weeks maintenance dosing depending on clinical response. Most patients who respond to esketamine show measurable improvement within the first four weeks, often with a meaningful lift in mood within 24 to 48 hours of the first few sessions.
According to the National Institute of Mental Health, brain-based treatments that work through mechanisms distinct from conventional antidepressants, including both ketamine-derived treatments and brain stimulation therapies like TMS, represent an important frontier in addressing the substantial population of patients who do not achieve adequate relief from standard pharmacological approaches.
Patients cannot drive after esketamine sessions and must arrange transport home. This is a logistical consideration that should be planned before beginning treatment, as it affects every session throughout the treatment course.
TMS for ADHD: What the Evidence Shows
Transcranial magnetic stimulation for ADHD is a different application of the same technology used for depression. ADHD involves dysregulation of executive function, attention, and impulse control, which are mediated by prefrontal cortical networks. TMS applied to the right dorsolateral prefrontal cortex, which is involved in inhibitory control, and other prefrontal regions has been studied as a non-pharmacological approach to improving the attentional and executive function deficits that characterise ADHD.
The evidence base for TMS for ADHD is growing but is not yet as extensive as the evidence for TMS in depression. Several controlled trials have demonstrated significant improvements in ADHD symptom severity, attention, and executive function following TMS treatment, with effect sizes that are clinically meaningful in a subset of patients. Deep TMS in particular has been studied specifically for ADHD with promising results, using H-coil technology that reaches deeper prefrontal structures than standard figure-eight coils.
TMS for ADHD is most likely to be considered for adult patients who have not responded well to stimulant or non-stimulant medication, those who experience significant side effects from ADHD medications, those who prefer a non-pharmacological approach, and those who have co-occurring depression or anxiety where TMS’s established efficacy for depression may provide dual benefit.
It is important to note that TMS for ADHD does not currently carry an FDA clearance specifically for that indication in the same way it does for depression and OCD. Providers offering TMS for ADHD are using the technology in an off-label context supported by clinical evidence. A reputable provider will be transparent about this distinction and will discuss realistic expectations based on the current evidence.
Combining Esketamine and TMS
An emerging area of clinical practice involves combining esketamine or ketamine with TMS, particularly for patients with severe or treatment-resistant depression. The theoretical basis is that ketamine’s promotion of neuroplasticity may enhance the brain’s responsiveness to TMS stimulation, and that the two treatments working through complementary mechanisms may produce additive or synergistic effects.
Clinical experience at practices offering both treatments suggests that some patients who are partial responders to either treatment alone show enhanced and more durable responses when the two are combined. This combination is still being studied formally and is not yet a standardised protocol, but it represents the direction that integrative psychiatric practices are exploring for their most challenging cases.
Finding Esketamine Near You
Esketamine, dispensed as Spravato, is available only at healthcare settings certified in the Spravato REMS programme. When searching for esketamine near you, verify that the practice is REMS-certified, has psychiatric oversight in place, and can coordinate esketamine treatment with your broader mental health care.
Ask specifically about the practice’s experience with esketamine, how they monitor response, what their protocol is for patients who show partial response, and whether they offer additional treatments like TMS that can complement or follow on from an esketamine course.
Final Thoughts
Esketamine and TMS for ADHD both represent significant advances in the range of options available to patients for whom conventional psychiatric medication has not provided adequate relief. Neither is appropriate for every patient, and both require thorough evaluation and qualified clinical oversight to deliver their full benefit.
The most important step in accessing either treatment is finding a provider with the psychiatric expertise, the clinical infrastructure, and the honest communication to guide you through an evaluation, set realistic expectations, and deliver treatment with appropriate monitoring and follow-up.
