A standard course of repetitive transcranial magnetic stimulation (TMS) for depression means coming to the clinic five days a week for four to six weeks, roughly 20 to 36 sessions. That is because response depends mainly on the number of sessions delivered, not on calendar time.
Esketamine (Spravato) carries a different but equally demanding logistical load. Under its FDA safety program, known as a Risk Evaluation and Mitigation Strategy (REMS), each dose is self-administered only at a certified center. Patients must be monitored on site for at least two hours after dosing, and they cannot drive until the next day.
Both treatments work. But both were built around a model that assumes the patient can get to a downtown medical center, over and over, on someone else’s schedule.
Geography decides who gets treated
For patients in the outer suburbs and rural areas, that assumption quietly decides who gets treated. In a retrospective cohort of U.S. adults with treatment-resistant depression, the likelihood of ever starting esketamine fell steadily with distance from a certified center. Compared with patients living within 9 miles, it was down about 51 percent at 20 to 29 miles and nearly 93 percent at 50 or more miles. Patients who did start but lived farther away were significantly more likely to interrupt treatment.
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A separate analysis found that living more than roughly 7 miles from a center, or in a rural area, independently lowered the odds of starting treatment, while greater distance predicted earlier discontinuation. These are not patients who turned down effective care because they doubted it. They turned it down, or dropped out, because the geography made it impossible to sustain.
A distribution problem, not an efficacy problem
The answer is to bring interventional psychiatry to where patients already are, through community practices, regional clinics, and satellite sites, rather than concentrating it in a handful of urban academic centers. Two trends make that increasingly feasible:
- Shorter sessions: Intermittent theta-burst stimulation now delivers a TMS session in about 3 minutes rather than the traditional 30 to 40. That lowers the chair time and staffing burden that kept smaller practices out.
- Shorter courses: Accelerated protocols that compress a full course into days rather than weeks are under active study. They could turn an impossible six-week commute into a short, intensive visit.
Smaller and solo practices, still a large share of psychiatry, have historically balked at the space, staffing, and reimbursement uncertainty these services require. That is exactly why deliberate investment in distributed capacity matters.
Not standalone procedures
One caution should travel with any expansion: These are not standalone procedures. TMS and esketamine perform best as part of ongoing medication management and psychotherapy, not as a one-off intervention a patient receives at a specialty storefront and then leaves. Both have consistently outperformed simply switching to another antidepressant in treatment-resistant depression, and both were studied alongside continued oral antidepressant treatment.
Relapse after a successful course is a real concern. Sustaining the gain depends on continuity of care: maintenance planning, symptom monitoring, and the medication and therapy relationship that interventional treatment is meant to augment, not replace.
Bringing these treatments closer to home only helps if what patients find there is integrated psychiatric care, not an isolated machine or a monitored room.
Ravi Singareddy is the founder and medical director of Empower Psychiatry & Sleep in north metro Atlanta, where he leads an interventional psychiatry practice offering transcranial magnetic stimulation (TMS) and Spravato (esketamine) for treatment-resistant depression. Double board-certified in psychiatry and sleep medicine, he brings more than two decades of clinical and academic experience to patients who haven’t found relief with medications alone. He is affiliated with Emory Healthcare.
His interest in neuromodulation dates back to his years as associate professor of psychiatry at Penn State College of Medicine. There, he taught annually on vagus nerve stimulation and novel depression therapies, and he published on long-term combined electroconvulsive therapy and vagus nerve stimulation in the American Journal of Psychiatry. He has authored numerous peer-reviewed papers on sleep disorders, insomnia, anxiety, and depression, with work appearing in Sleep, the Journal of Clinical Sleep Medicine, and Psychiatry Research.
Singareddy is a Fellow of the American Psychiatric Association and the American Academy of Sleep Medicine and practices measurement-based care, tracking outcomes to guide every treatment decision. He shares updates on Instagram.
