New patient guide for ketamine, part 2

⬅️ Back to the Wiki

Quick Summary

  • Most ketamine treatment for TRD is in private clinics operated by a psychiatrist, anesthesiologist, or nurse practitioner.
  • Generally ketamine clinics are cash-pay only though an increasing number of insurance policies offer reimbursement.
  • Not all care is equal and can vary according to the experience and skill of providers. Look for experience, careful monitoring, intake processes, coordination with mental health providers, and truthful and transparent claims.
  • ⚠️ Be wary of clinics that don't measure how patients are doing (ie. don't use depression scales), make false or overly strong claims (e.g. "ketamine cures PTSD") not backed by current clinical trials, and clinics that don't provide intake assessments (as in, willing to provide treatment to just about anyone).

Discuss with us! Click on the orange bubble

How to choose a provider

Ketamine treatment for TRD is often provided in private practice clinics in the community. Most large health systems including academic medical centers do not provide ketamine treatment, although there are some that do (and this number is increasing). Ketamine clinics that provide ketamine infusions are often operated by a psychiatrist, anesthesiologist, or nurse practitioner. By law, therapists and psychologists cannot prescribe ketamine and a medical doctor (such as an anesthesiologist or psychiatrist) must write the prescription. Depending on state laws, nurse practitioners may be able to as well. Ketamine clinics offering KAP tend to be operated by psychiatrists, often in conjunction with therapists and psychologists. There are also clinics (either infusion or KAP) operated by other types of physicians, including internal medicine doctors, primary care physicians, and in rare cases even surgeons.

close up photography of yellow, green, red, and brown plastic game pieces connected by lines

Ketamine clinics are not regulated: ketamine use for the treatment of depression is off-label and there is no organization that oversees and regulates ketamine treatments. There is no oversight for ketamine clinics and no group that reviews the claims of each ketamine clinic to evaluate if they are evidence-based or not. This places additional burden on patients to find trustworthy providers and attempt to determine if they are receiving evidence-based treatments. Sadly, some clinics make claims that cannot be substantiated. Unfortunately, there may also be clinicians that push patients to do too many ketamine treatment sessions given the clinician can be incentivized to perform as many treatments as possible. Patients are advised to seek out providers who received their medical training (especially residency) at an accredited institution. Psychotherapists should have received their training at an accredited institution as well. Luckily, most providers in the ketamine treatment space care deeply about patients and do everything they can to help patients feel better. At Osmind, it has been inspiring to see that all of the providers we have met put patient health and wellness as their foremost priority.

One key factor for patients to decide is whether they want to do ketamine infusions or KAP. Considering cost can be important as well: clinics can vary widely in how much they charge for each treatment. However, patients should also recognize that not all treatments are equal (and cost is not everything): for example, a three hour KAP session with a highly experienced psychiatrist may be very different than a three hour KAP session with one who is inexperienced. KAP is quite different from traditional psychotherapy so KAP practitioners should have received training specifically in KAP. In this case, the highly experienced psychiatrist may charge more money for a single treatment. Patients must weigh both perceived quality and cost when making a decision.

Ketamine treatments are generally cash-pay only. Patients are usually expected to pay out-of-pocket for their treatment. Some clinics provide the patient a “superbill,” an itemized form that details services provided to a patient. Patients can use the superbill to create a healthcare claim and submit to their insurance or employer for reimbursement. Creating, submitting, and appealing insurance claims is widely known to be an extremely onerous process, fraught with convoluted submission protocols and constant rejections. Even worse, insurance plans generally do not cover ketamine treatment because ketamine is used for TRD as an off-label indication. Patients have had some success submitting reimbursement claims not for ketamine treatment, but for generic medical services. How much money a patient can get back for these claims varies widely among insurance plans and how the patient submitted their claim.

therapist taking notes

It is important to evaluate that providers are following best practices. There are certain things to watch out for:

  • It is highly recommended for patients to choose clinics that offer measurement-based care. This includes tracking quantitatively (using depression scales) how patients do over time, in order to optimally time the treatments and provide care when it is needed most. Patients should choose clinics who collect and use patient data to improve outcomes, instead of clinics that do not use any sort of measurement-based care and instead rely purely on subjective assessment. Without outcomes tracking, it can be difficult to know if the treatments are actually working, and the clinician would be unable to know whether to change any treatment approaches/parameters. For example, many infusion clinics schedule patients to maintenance sessions based on seeing how patients respond, but that requires some way to compare patient moods over time and detect when the moods become low enough to warrant a maintenance infusion.
  • What does the clinic claim to treat? The evidence to treat depression using ketamine is strong, but there is no strong evidence that ketamine can or should be used to treat other psychiatric conditions. If a clinic makes strong claims about being able to treat conditions such as OCD or PTSD using ketamine, you may want to be careful. The use of ketamine for these conditions is very much in the experimental and individualized stage, and should not be characterized as a standard or evidence-based treatment. It is reasonable for the clinic to provide ketamine treatment for these indications if the clinician makes a clinical decision this is the best option, the patient cannot find other treatments that help, and if the patient is clearly informed that such ketamine use is experimental. There is no problem with those clinics if they are transparent. However, be wary of clinics that make false claims or overly strong statements (e.g. “ketamine cures PTSD”) that cannot be backed by clinical trials. For example, for PTSD there have only been one small proof-of-concept placebo controlled trial and a case report that have been published. It is certainly possible that ketamine treatment can help with PTSD, but further research is needed before this becomes a standard approach.
    • At present, multiple ongoing trials are still exploring the effects of ketamine treatment for other psychiatric disorders such as autism spectrum disorders, social anxiety, and alcohol use disorder. These are very much experimental: there is still not enough data to conduct an analysis and clearly determine whether ketamine treatment is effective for these purposes. Be careful of clinics that make overly strong statements about the amount of clinical evidence.
  • If the clinic claims to create “proprietary ketamine blends” or use genetic testing / whole genome sequencing etc. to provide treatment for depression, you may want to find a different provider. There are no proprietary ketamine blends that can be personalized to patients. There is absolutely no evidence for the safety or efficacy of any sort of ketamine blend. It is currently not possible to personalize depression treatment based on genetic testing. Pharmacogenomics can be used to predict patient metabolism of certain antidepressants in a limited scope, but that is different than using genetics and does not have strong evidence indicating clinical utility [Harvard Health Blog].
  • Does the clinic have an intake process, or do they take every patient they meet? Before administering ketamine treatment to any patient, clinicians should conduct an intake session that assesses the patient’s past medical history, medication use, recreational drug use, behavior, and more. It is recommended that clinics also evaluate the patient’s psychiatric wellbeing and history of depression. If a clinic is willing to give ketamine without at least a basic intake process, you should be careful. It is not wise to provide ketamine without asking for detailed past medical history. It is recommended that most clinics should collect contact information of your primary care physician, though some reputable and high-quality clinics do not coordinate care in that manner.
  • It is recommended that IV infusion clinics have basic monitoring devices including blood pressure and oxygen saturation (pulse oximeter). Though ketamine infusion is shown to be relatively safe, there is a small possibility of potentially concerning acute effects on cardiovascular function. While not all reputable infusion clinics may provide such monitoring, it is recommended to choose a clinic that does.
  • Do you have a mental health care professional? If you have TRD, it is a good idea for you to have a mental health care professional oversee your mental health care. If you go to a ketamine clinic, it is optimal that the clinic itself will have a psychiatrist or therapist that provides your care. If it is an infusion center run by another type of clinician (e.g. anesthesiologist), the clinic should coordinate care with your mental health care provider and make sure that your ketamine treatments fit into the larger treatment plan for your TRD.

⬅️ Back to the Wiki

Related articles

New patient guide for esketamine
Treatment options for treatment-resistant depression
What is treatment-resistant depression (TRD)?

References

Andrade C. Ketamine for Depression, 4: In What Dose, at What Rate, by What Route, for How Long, and at What Frequency? J Clin Psychiatry 2017; 78:e852.

Andrade C. Ketamine for Depression, 5: Potential Pharmacokinetic and Pharmacodynamic Drug Interactions. The Journal of clinical psychiatry. 2017 Jul;78(7):e858-61.

Caddy C, Amit BH, McCloud TL, et al. Ketamine and other glutamate receptor modulators for depression in adults. Cochrane Database Syst Rev 2015; :CD011612.

Chilukuri H, Reddy NP, Pathapati RM, Manu AN, Jollu S, Shaik AB. Acute antidepressant effects of intramuscular versus intravenous ketamine. Indian journal of psychological medicine. 2014 Jan;36(1):71.

Dore J, Turnipseed B, Dwyer S, Turnipseed A, Andries J, Ascani G, Monnette C, Huidekoper A, Strauss N, Wolfson P. Ketamine assisted psychotherapy (KAP): Patient demographics, clinical data and outcomes in three large practices administering ketamine with psychotherapy. Journal of psychoactive drugs. 2019 Mar 15;51(2):189-98.

Fond G, Loundou A, Rabu C, et al. Ketamine administration in depressive disorders: a systematic review and meta-analysis. Psychopharmacology (Berl) 2014; 231:3663.

Ghasemi M, Kazemi MH, Yoosefi A, et al. Rapid antidepressant effects of repeated doses of ketamine compared with electroconvulsive therapy in hospitalized patients with major depressive disorder. Psychiatry Res 2014; 215:355.

Harvard Health Blog - Gene testing to guide antidepressant treatment: Has its time arrived?

Kishimoto T, Chawla JM, Hagi K, et al. Single-dose infusion ketamine and non-ketamine N-methyl-d-aspartate receptor antagonists for unipolar and bipolar depression: a meta-analysis of efficacy, safety and time trajectories. Psychol Med 2016; 46:1459.

Loo C. Can we confidently use ketamine as a clinical treatment for depression?. The lancet. Psychiatry. 2018 Jan;5(1):11.

Malhi GS, Byrow Y, Cassidy F, et al. Ketamine: stimulating antidepressant treatment? BJPsych Open 2016; 2:e5.

Mathew SJ, Shah A, Lapidus K, Clark C, Jarun N, Ostermeyer B, Murrough JW. Ketamine for treatment-resistant unipolar depression. CNS drugs. 2012 Mar 1;26(3):189-204.

McGirr A, Berlim MT, Bond DJ, et al. A systematic review and meta-analysis of randomized, double-blind, placebo-controlled trials of ketamine in the rapid treatment of major depressive episodes. Psychol Med 2015; 45:693.

Murrough JW, Perez AM, Pillemer S, Stern J, Parides MK, aan het Rot M, Collins KA, Mathew SJ, Charney DS, Iosifescu DV. Rapid and longer-term antidepressant effects of repeated ketamine infusions in treatment-resistant major depression. Biological psychiatry. 2013 Aug 15;74(4):250-6.

Naughton M, Clarke G, Olivia FO, Cryan JF, Dinan TG. A review of ketamine in affective disorders: current evidence of clinical efficacy, limitations of use and pre-clinical evidence on proposed mechanisms of action. Journal of affective disorders. 2014 Mar 1;156:24-35.

Nemeroff, Charles B. “Ketamine: quo vadis?.” Am J Psychiatry. (2018): 297-299.

Newport DJ, Carpenter LL, McDonald WM, et al. Ketamine and Other NMDA Antagonists: Early Clinical Trials and Possible Mechanisms in Depression. Am J Psychiatry 2015; 172:950.

Sanacora et al. JAMA Psychiatry. 2017;74(4):399-405. doi:10.1001/jamapsychiatry.2017.0080

Short B, Fong J, Galvez V, Shelker W, Loo CK. Side-effects associated with ketamine use in depression: a systematic review. The Lancet Psychiatry. 2018 Jan 1;5(1):65-78.

Singh JB, Fedgchin M, Daly EJ, De Boer P, Cooper K, Lim P, Pinter C, Murrough JW, Sanacora G, Shelton RC, Kurian B. A double-blind, randomized, placebo-controlled, dose-frequency study of intravenous ketamine in patients with treatment-resistant depression. American Journal of Psychiatry. 2016 Aug 1;173(8):816-26.

Su TP, Chen MH, Li CT, et al. Dose-Related Effects of Adjunctive Ketamine in Taiwanese Patients with Treatment-Resistant Depression. Neuropsychopharmacology 2017; 42:2482.

Thomas RK, Baker G, Lind J, Dursun S. Rapid effectiveness of intravenous ketamine for ultraresistant depression in a clinical setting and evidence for baseline anhedonia and bipolarity as clinical predictors of effectiveness. J Psychopharmacol 2018; 32:1110.

Vande Voort JL, Morgan RJ, Kung S, et al. Continuation phase intravenous ketamine in adults with treatment-resistant depression. J Affect Disord 2016; 206:300.

Wan LB, Levitch CF, Perez AM, et al. Ketamine safety and tolerability in clinical trials for treatment-resistant depression. J Clin Psychiatry 2015; 76:247.

Wilkinson ST, Katz RB, Toprak M, et al. Acute and Longer-Term Outcomes Using Ketamine as a Clinical Treatment at the Yale Psychiatric Hospital. J Clin Psychiatry 2018; 79.

Xu Y, Hackett M, Carter G, et al. Effects of Low-Dose and Very Low-Dose Ketamine among Patients with Major Depression: a Systematic Review and Meta-Analysis. Int J Neuropsychopharmacol 2016; 19.