Ketamine has a long safety record as an anesthetic since the 1980s, and it has also been successfully used “off-label” for over a decade to treat conditions such as anxiety, depression, OCD, and PTSD, among others. Because ketamine promotes neuroplasticity, or in other words helps “rewire” the brain,” research shows that it can help stop the repetitive negative thoughts and behaviors that are at the core of many mental health conditions. While costs to access ketamine therapy can be high in some locations, and like any drug ketamine is not a cure-all, some patients and their doctors have been reporting life-changing results when no other treatment provided relief.
Ketamine is used off-label to treat a host of psychiatric conditions, including depression (including major depressive disorder and treatment resistant depression), bipolar disorder, social and generalized anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders, addiction and substance use disorders, and eating disorders. In addition, one form of intranasal ketamine (Spravato) has been approved by the FDA to use “on-label” for treatment-resistant depression.
Ketamine legality, past and present
In the United States, ketamine is a Schedule III controlled substance, which means that it has a low to moderate potential for abuse or addiction. Schedule III substances are subject to certain controls not applicable to all other prescription drugs, including the requirement that a medical professional with a specific license issued by the Drug Enforcement Agency (DEA) must conduct an in-person examination before prescribing it. This means that in the US, ketamine can be prescribed by a licensed physician, psychiatrist, or in some instances, a nurse practitioner.
Other mental health professionals, including psychotherapists, marriage and family therapists, and clinical social workers, cannot prescribe ketamine. However because studies show that ketamine treatment is most effective when used in conjunction with talk therapy (often packaged as KAP or “ketamine-assisted psychotherapy”), therapists often work hand-in-hand with ketamine prescribers to treat patients. Therapists typically are present either during a lower dose ketamine administration session or during a post-ketamine integration session. 1
Integration refers to coaching or therapy sessions carried out after a ketamine session to help the patient understand and “integrate” the often deep and complex thoughts and feelings they experience into their daily life. To that end, many certificate programs now exist to help therapists become better-equipped to help their patients process their experiences, some of the most well-known being those offered by: The Integrative Psychiatry Institute; Polaris; and Fluence. Patients may want to seek assistance from a certified professional prior to embarking on treatment.
Although ketamine was originally offered only as an in-clinic treatment, virtual clinics such as Nue Life developed as telehealth offerings using oral ketamine compounded by specialty pharmacies expanded to accommodate patient access during the pandemic. Although US President Joe Biden officially ended the public health emergency (PHE) that allowed for these treatments, on May 10, 2023 the DEA extended a temporary exemption allowing doctors to continue to remotely prescribe controlled substances without an in-person examination. According to the published rule, “for any practitioner-patient telemedicine relationships that have been or will be established up to November 11, 2023, the full set of telemedicine flexibilities regarding prescription of controlled medications established during the COVID-19 PHE will be extended for one-year—through November 11, 2024.” New permanent rules regarding ketamine telehealth have been proposed but not yet adopted.
What is treatment like at an in-person ketamine clinic?
Ketamine clinics can be found in most larger cities throughout the US. Traditionally, ketamine was offered as a mental health treatment only as an IV infusion, but in-clinic treatments have expanded to include a variety of other options such as intramuscular injections (IM ketamine), Spravato nasal spray, and oral or sublingual tablets.
Because ketamine is offered off-label, there is no approved dosage or treatment protocol and each clinic likely has its own policies and procedures (other than for Spravato, which is FDA approved for treatment resistant depression). Despite the absence of required protocols, ketamine therapy sessions are typically offered in a series of six injections over two to three weeks, based on procedures developed by medical professionals for efficacy over the years, but some clinics do still offer single sessions.
Many in-clinic ketamine sessions are scheduled to last around 40 minutes, but the length of the effects of ketamine can vary by individual tolerance and the type of treatment. Regardless of the type of ketamine used, patients are not permitted to drive after the treatment and will need to arrange a ride ahead of time.
In most clinics, patients receive ketamine treatment in a private room with a comfortable reclining chair, listening to music through headphones. In some instances, a medical provider or psychotherapist (or both) is present in the treatment room. In other instances, the patient may be left alone while being monitored by video, with access to a call button in case they need assistance.
Because ketamine is a dissociative drug, many patients feel as though they are floating outside of their body in a dreamlike state and are unable to see, speak clearly, or move around safely during the treatment. Unlike other psychedelics like MDMA, psychotherapy is generally not carried out while the individual is undergoing ketamine treatment unless it is delivered in a very low dose, because the drug tends to impact speech.
What is treatment like through an at-home ketamine program?
At-home ketamine treatment programs vary. Typically, after an initial consultation, the patient will receive a compounded dose or doses of oral ketamine via a mail-order pharmacy. The patient will then self-administer the drug at home after receiving instructions either over a video call with a medical professional or via written instructions. Some programs also provide a comprehensive host of resources on a website or app. These resources may include: additional preparation sessions, or consultations, with a coach or therapist to help the patient prepare for treatment and develop a healing mindset; messaging support with a coach or specialist; specially-curated music playlists; and individual or group integration sessions.
Most ketamine programs require the patient to agree to have another person present (a “sitter”) to monitor them during the experience, although that person does not have to have medical training. Some programs may supply a blood-pressure cuff to check for high blood pressure, a common side effect of ketamine. As with in-clinic ketamine treatments, it is recommended that the patient find a comfortable and quiet place to undergo the treatment, often with an eye mask and headphones to avoid disruptions, and a journal handy to jot down any insights.
Research regarding the safety and efficacy of at-home ketamine is limited to self-reported findings, but one 2022 self-reported study found that nearly 50% of patients with treatment resistant anxiety or depression saw a 50% improvement in symptoms after using three at-home sublingual ketamine treatments. On the other hand, some physicians are concerned about the safety of at-home ketamine due to the potential for blood pressure fluctuations, abuse and oversights like prescribing the wrong dosage. 2
How much does ketamine therapy cost?
Ketamine costs can vary widely, from less than $200 per treatment for at-home ketamine to as much as $1,000 for some in clinic sessions. Patients should also bear in mind that many ketamine clinics only offer treatment in programs of six or more sessions for maximum efficacy. Additional maintenance doses of ketamine following an initial course of treatment may also be needed to maintain efficacy for certain types of mental health disorders, such as treatment resistant depression. 3
In general, the differences in costs arise from a number of factors including: the type of ketamine treatment (IM, IV, lozenge, etc.), the location of treatment, the number of treatment providers present during a session, the number of sessions purchased, and other treatment offerings provided in conjunction with the ketamine treatment, such as coaching, counseling, or group therapy. And although ketamine is generally not covered by insurance, psychotherapy in conjunction with the treatment may be covered (in whole or part). Patients should inquire about what is included and check with their insurance provider to help assess and compare costs.
At-home ketamine is usually less expensive because less overhead is required and the cost of the compounded drugs is minimal. Costs in one study were found to be between $193 to $250 per treatment dose, but sometimes more, which is 28% to 83% of the reported cost of a single in-clinic ketamine infusion. 4
Whether ketamine is administered in-clinic or at-home, one factor consistently arises in discussion: the impact of therapy and integration. Studies show that psychotherapy makes ketamine therapy more effective and can prolong its therapeutic effects. Integration services offered by coaches may be a lower-cost option for patients, as training programs for psychedelic integration for non-medical-professionals have launched over the past few years. Patients should ask for certifications and training in ketamine therapy to assess provider qualifications. 5
How to vet a ketamine clinic
When vetting a program, whether in-clinic or at-home, the provider should require a comprehensive set of assessments—psychological and physical—as well as assistance for preparation and integration. These services can range from extensive in-person counseling to simple online instructions depending on which ketamine services you choose. It is usually a good sign if a provider asks for prescriptions and medical records to confirm the accuracy of medical and psychological assessments, as this shows a commitment to patient safety. All providers, whether medical, psychological, or coaches, should have experience, training, and certifications specific to ketamine therapy.
- Drozdz, S. J., Goel, A., McGarr, M. W., Katz, J., Ritvo, P., Mattina, G. F., Bhat, V., Diep, C., & Ladha, K. S. (2022). Ketamine Assisted Psychotherapy: A Systematic Narrative Review of the Literature. Journal of pain research, 15, 1691–1706. https://doi.org/10.2147/JPR.S360733
- Hassan, K., Struthers, W. M., Sankarabhotla, A., & Davis, P. (2022). Safety, effectiveness and tolerability of sublingual ketamine in depression and anxiety: A retrospective study of off-label, at-home use. Frontiers in psychiatry, 13, 992624. https://doi.org/10.3389/fpsyt.2022.992624
- McMullen, E. P., Lee, Y., Lipsitz, O., Lui, L. M. W., Vinberg, M., Ho, R., Rodrigues, N. B., Rosenblat, J. D., Cao, B., Gill, H., Teopiz, K. M., Cha, D. S., & McIntyre, R. S. (2021). Strategies to Prolong Ketamine’s Efficacy in Adults with Treatment-Resistant Depression. Advances in therapy, 38(6), 2795–2820. https://doi.org/10.1007/s12325-021-01732-8
- Hull, T. D., Malgaroli, M., Gazzaley, A., Akiki, T. J., Madan, A., Vando, L., Arden, K., Swain, J., Klotz, M., & Paleos, C. (2022). At-home, sublingual ketamine telehealth is a safe and effective treatment for moderate to severe anxiety and depression: Findings from a large, prospective, open-label effectiveness trial. Journal of affective disorders, 314, 59–67. https://doi.org/10.1016/j.jad.2022.07.004
- Walsh, Z., Mollaahmetoglu, O. M., Rootman, J., Golsof, S., Keeler, J., Marsh, B., Nutt, D. J., & Morgan, C. J. A. (2021). Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review. BJPsych open, 8(1), e19. https://doi.org/10.1192/bjo.2021.1061
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