The short answer
Yes — both TMS and Spravato can be used without a daily antidepressant.
No — that does not mean a person stops medicines they are already on in order to start. The usual plan is: keep medicines steady at the start, judge the new treatment on its own, and only later — if the person is well and stays well — talk with the prescriber about a slow taper of one medicine at a time.
TMS and medicines
TMS is magnetic pulses to a depression circuit, delivered in clinic. No medicine goes through the body. You are awake, and can drive and work the same day. Usually about 5 visits a week for about 6 weeks.
Can it be used alone?
- Yes. TMS is FDA-cleared for major depressive disorder in adults who did not improve enough on an antidepressant in the current episode. The clearance does not require a daily antidepressant to be taken at the same time.
- In practice, many people start TMS while continuing their current medicine and therapy. That is deliberate — change one thing at a time, so the team can tell what helped.
If you are already on medicines
- Continue them at the start unless the prescriber changes the plan for a safety reason (for example, a medicine or condition that affects seizure threshold is always reviewed at screening).
- Reassess mid-course and at the end of the course on symptom scores (for example PHQ-9), not on feeling alone.
- If response is strong and holds, the prescriber may later consider tapering an antidepressant — slowly, one medicine at a time, with a follow-up plan.
Spravato and medicines
Spravato is a glutamate-system nasal spray given only in a certified clinic under the REMS program, with at least 2 hours of monitoring after each dose, blood pressure checks, and no driving until the next day. Induction is usually twice a week for weeks 1–4, then weekly, then weekly or every 2 weeks.
Can it be used alone?
- Yes, for treatment-resistant depression (TRD) — since January 2025, Spravato is FDA-approved as a standalone treatment (monotherapy) for TRD in adults. TRD means major depression that did not respond adequately to at least 2 oral antidepressants.
- In the trial behind that approval, about 22.5% reached remission at week 4 on Spravato alone, versus about 7.6% on placebo spray.
- Different rule for the other use: for depressive symptoms in major depressive disorder with acute suicidal thoughts or behavior, Spravato is approved together with an oral antidepressant. It has not been shown to prevent suicide and does not replace hospital care when hospital care is needed.
If you are already on medicines
- Continue the oral antidepressant at the start in most cases. Starting Spravato is not a reason to stop it.
- Benefit is judged at the end of induction (week 4). If there is no meaningful movement, the prescriber should say so plainly and re-plan.
- If you reach remission on Spravato alone under the TRD monotherapy label, or stay well on a combined plan, any later taper is prescriber-led and separate from the Spravato schedule.
What “weaning off” looks like when it is appropriate
- Wait for a real, sustained response — not one good week.
- Taper one medicine at a time, in small steps, over weeks to months depending on the medicine and dose.
- Go extra slowly with medicines known for discontinuation symptoms — paroxetine and venlafaxine are the hardest; fluoxetine is usually the easiest because it leaves the body slowly. Discontinuation can feel flu-like, with dizziness, electric-shock sensations in the head (“brain zaps”), nausea, irritability, and vivid dreams.
- Benzodiazepines are never stopped abruptly after regular use — withdrawal can include seizures. A slow, planned taper with the prescriber is the only safe route.
- Track sleep, mood, anxiety, and PHQ-9 during the taper. If symptoms return, pause or step back — that is information, not failure.
- Medicines for other conditions — anxiety, bipolar disorder, sleep, pain, blood pressure, and other medical problems — are not automatically replaced by TMS or Spravato. Each one keeps its own reason and its own review date.
This page is based on CAMHP's Meds & Weaning FAQ, prepared 2026-10-17 for Dr. Danielle Dronet, DSW, LISW-S, from the Complete Consult Guide (Mississippi) and the FDA record checked October 2026.