From our survey

TMS versus esketamine on a commercial plan in St. Charles

When a second or third antidepressant stops pulling its weight, the next conversation usually opens up a menu. The trouble is that the menu is rarely explained side by side, and almost never in terms of what your employer insurance will ask of you. This piece lays the main options out in one place for commercially insured patients in St. Charles County.

First, some context from a survey we commissioned. We quizzed 443 grown-ups in ten states across the Midwest, Missouri included, about depression treatment, and its figures come from the final validated data. Two numbers frame this comparison. Of our respondents, 64 percent wanted the option of care without medication, while TMS itself was known to a mere 25 percent. Of the 173 respondents on commercial plans, 71 percent wanted a drug-free option, while 49 percent were open to ketamine therapy. So most people want something they cannot yet name.

Here is how five common paths compare. None of this is a recommendation. Suitability is a question for your clinician.

Option 1: Switching or adding a medication

• Involves medication: Yes.
• Regulatory status: Many antidepressants and add-on medications are FDA-approved for depression.
• Typical coverage path: Pharmacy benefit. Generics are usually on low tiers. Brand-name drugs may require step therapy, meaning you try cheaper ones first.
• Time commitment: Daily doses, with several weeks before you can judge the effect.
• Who drives: You do. No supervision needed.

This is the path most people have already walked. For someone who has tried it more than once, it may still be a reasonable next step, but it will not satisfy anyone set on avoiding medication.

Option 2: Structured psychotherapy

• Involves medication: No.
• Regulatory status: Not an FDA-regulated product. Evidence-based approaches such as cognitive behavioral therapy have long research records.
• Typical coverage path: Outpatient mental health benefit. Usually a copay or coinsurance per visit, and in-network therapists are key.
• Time commitment: Often weekly sessions over several months.
• Who drives: You. Telehealth sessions are common.

Therapy is the easiest drug-free route, though in-network therapists with openings in St. Charles County can take persistence to find.

Option 3: Transcranial magnetic stimulation (TMS)

• Involves medication: No.
• Regulatory status: A medical device the FDA has cleared for adults whose major depression antidepressants have not relieved.
• Typical coverage path: Medical benefit with prior authorization. Plans commonly require documented antidepressant trials and sometimes psychotherapy.
• Time commitment: Expect a session every weekday for roughly four to six weeks.
• Who drives: Usually you. There is no anesthesia, and most people return to normal activity right after.

TMS is the option that best fits the drug-free preference most people in our survey expressed, and the one fewest people have heard of. Its biggest practical demand is the daily schedule. A provider near home or work matters. For 43 percent of respondents, being close by was a top-two provider priority.

Option 4: Esketamine (Spravato)

• Involves medication: Yes. It is a nasal spray medication.
• Regulatory status: FDA approval for treatment-resistant depression; administered only in certified healthcare settings that follow a safety program.
• Typical coverage path: Prior authorization is standard. Depending on the plan, the drug may run through the medical benefit or a specialty pharmacy, and the observation visit is billed separately.
• Time commitment: Early treatment is typically twice a week, then tapers to weekly or less often. Plan on two-plus hours of observation at every visit.
• Who drives: Not you. Driving yourself is off the table until the day after, so line up a ride.

Esketamine is not drug-free, and it should not be confused with ketamine products sent home by telehealth firms, none of which carry FDA approval for depression. For people open to a medication, it is a supervised, approved option worth asking about. Brain Recovery Centers lays out what a Spravato course involves.

Option 5: Electroconvulsive therapy (ECT)

• Involves medication: No medication for depression itself, but it requires general anesthesia.
• Regulatory status: An established, regulated medical procedure.
• Typical coverage path: Medical benefit, often with prior authorization, usually through a hospital.
• Time commitment: Several sessions a week for a few weeks, with recovery time after each.
• Who drives: Not you, during the course.

ECT is generally reserved for severe depression or cases where other options have failed, and memory side effects deserve discussion with the treating team.

What the comparison means for your wallet

Across every option, the insurance question is going to come up, and our survey suggests you will care about it. When respondents picked their two biggest provider priorities, insurance coverage made the cut for 85 percent. Just over half would accept a covered option with more hoops over a simpler one they paid for themselves; 23 percent would go the other way, and 26 percent were unsure.

For commercially insured patients, three practical steps apply no matter which column you land in:

• Ask your insurer for the specific medical policy on the treatment you are considering, not just the benefits summary.
• Confirm the provider is in network for the service, not just the practice as a whole.
• Get a written estimate of your share for the full course, not a single visit.

A St. Charles note on logistics

Two options on this list, TMS and esketamine, depend on repeated in-person visits. For someone who works in St. Louis County and lives in St. Charles, O'Fallon, or Wentzville, that raises a real choice between a provider near home and one near the office. With esketamine, it also raises the question of who can drive you twice a week during the early phase.

Bring the list to your doctor

Nearly three in four people we surveyed, 74 percent, said they would follow their own doctor's lead on trying a new treatment. That doctor is who should help you choose among these columns. Show them this list, tell them whether drug-free matters to you, and ask which options your history and your plan make realistic.

Treat this comparison as background rather than medical advice; it cannot forecast your response to any treatment.

If you are thinking about suicide, please do not wait for a referral or an authorization. Text or phone 988 at any time; the Suicide and Crisis Lifeline connects you with a person right away.

Methodology

Pollfish ran the survey on its consumer panel, with a June 23, 2026 cutoff; the publisher commissioned and funded the work. The sample: 443 finished questionnaires, each from an adult 18 to 64 living in Oklahoma, Indiana, Missouri, Wisconsin, Iowa, Ohio, Kansas, Minnesota, Nebraska, and Illinois. Beyond the commercial plan group, percentages describe the whole sample, and all are final.