Written by Dr. Ladan Eshkevari
In this post:
- Key Indicators for Ketamine Suitability
- Ketamine Contraindications and Red Flags
- Collaborative Evaluation and Referral Process
Identifying ideal candidates for ketamine therapy is crucial for therapists aiming to responsibly refer patients to this innovative treatment. Initially used as an anesthetic, ketamine has gained attention for its rapid-acting antidepressant effects, particularly in treatment-resistant depression. However, not everyone is an ideal candidate for treatment. Mental health professionals must carefully consider whether patients can benefit from ketamine therapy based on their diagnosis, overall health, and current medications.
This article offers insights for therapists on how to identify ideal candidates for ketamine therapy and vet them for contraindications.
Key Indicators for Ketamine Suitability
IV ketamine therapy is a powerful intervention for mental and physical health. However, not everyone is a good candidate for ketamine therapy. Therapists can identify ideal candidates for ketamine therapy by focusing on patients with treatment-resistant depression, PTSD, OCD, severe anxiety disorder, or acute suicidal ideation who have no contraindications such as severe physical health issues, ensuring they undergo a thorough psychiatric evaluation and possess a willingness to engage in a comprehensive treatment plan. This careful selection process aims to maximize therapeutic benefits while minimizing potential harm.
Important considerations
Generally, ketamine treatment is for people with severe mental illness who have tried other medications with little or no relief. Typically, this patient will have also attempted alternative therapies to no avail, such as TMS (transcranial magnetic stimulation), group therapy, or individual CBT (cognitive behavioral therapy).
However, ideal ketamine patients don’t always fall under a traditional “treatment-resistant”’ category. Some ideal candidates have not tried typical antidepressants and choose not to because of SSRIs’ potential inefficacy and side effects. Still, they are suffering from significant mental health issues and are well-informed about ketamine’s clinically proven, rapid benefits.
Practitioners should weigh these factors when determining ideal candidates for ketamine therapy.
- The severity of symptoms: Ketamine is often successful for those dealing with significant depression and suicidal ideation. Therapists whose patients are suffering from extreme, hard-to-treat symptoms should consider educating them about ketamine.
- Duration of the current episode: A person dealing with depression for an extended time may be an ideal candidate for ketamine due to its ability to rapidly reduce depressive symptoms and suicidal thoughts by enhancing synaptic plasticity and promoting the growth of new neural connections.
- The urgency of treatment: Patients experiencing suicidal thoughts need immediate relief. Ketamine is extraordinarily effective in these cases, reducing suicidality within one day of a single IV dose and lasting at least one week. The benefits are even more enduring for six infusion protocols combined with psychotherapy.
- Availability of social support: Therapists must also consider whether the patient has friends or family to support them while undergoing treatment. Ketamine can alter how people think and feel, which can make them more sensitive to distress. Social support can buffer potential adverse effects, while lack of support could exacerbate them.
- Potential contraindications to ketamine: Therapists must rule out ketamine contraindications by carefully examining each patient’s mental history and ensure referring patients to appropriate ketamine providers that can manage medical history, such as heart conditions and interactions with other medications. The sections below provide more information about potential contraindications.
Ideal clinical profiles for ketamine therapy
Substantial clinical data shows that patients experiencing treatment-resistant depression, suicidality, and severe PTSD find incredible relief from ketamine therapy.
- Depression: Ketamine is most widely studied in people with treatment-resistant depression. The compound works by stimulating the release of glutamate, a major excitatory neurotransmitter. Glutamate promotes neuroplasticity, which can help “rewire” the brain to form new pathways that disrupt problematic thought patterns and make way for more productive perceptions and actions. Ketamine also works fast and has fewer side effects than SSRIs.
- Suicidal thoughts: Ketamine is also well-proven for assuaging acute suicidality. A Columbia University study revealed that one ketamine dose rapidly reduced the severity of depression in people with suicide ideation. It improved their thinking and reasoning within 24 hours, making them feel safer and less likely to harm themselves.
- Severe PTSD: Numerous clinical studies support ketamine as an effective modality for PTSD, a disorder where current treatment options show little efficacy. Ketamine’s glutamate stimulation can help some of the most debilitating symptoms, such as intrusive thoughts, flashbacks, nightmares, and other forms of sensory overload.
Contact Avesta, located in Washington DC, McLean, Virginia, and Bethesda, Maryland, to determine whether your patient is an ideal candidate for ketamine therapy.
Other patients that may benefit from ketamine
Research indicates ketamine can also help patients with various mood and emotional disorders like bipolar depression, generalized anxiety disorder, obsessive-compulsive disorder, and social anxiety disorder.
However, clinical data is not as straightforward for these conditions compared to ketamine’s benefits for depression, PTSD, and suicidality. For instance, ketamine’s mechanisms can sometimes induce manic episodes, which may exacerbate hypomanic bipolar disorder symptoms.
Therapists whose patients are suffering from these mood disorders must closely collaborate with the individual’s physicians and ketamine clinicians to determine an appropriate protocol.
Ketamine Contraindications and Red Flags
Patients may not be eligible for ketamine therapy if they:
- Are pregnant: Pregnant women are typically excluded from ketamine therapy due to the lack of research on the compound’s effects, posing potential developmental or maternal-fetal risks.
- Have uncontrolled hypertension or cardiovascular disease: Those with unmitigated hypertension or acute cardiovascular disease may not be ideal ketamine candidates due to the drug’s known effects on blood pressure and heart rate.
- Have psychosis: Patients with psychosis might experience worsening of their symptoms due to ketamine’s psychoactive properties.
Uncontrolled medical conditions such as thyroid conditions, mental health histories, seizures, and drug interactions may also factor into ketamine suitability.
Contact Avesta, located in Washington DC, McLean, Virginia, and Bethesda, Maryland, to determine whether your patient is an ideal candidate for ketamine therapy.
Is ketamine contraindicated in heart and thyroid conditions?
Ketamine can increase blood pressure, heart rate, and cardiac output, which can negatively affect those with a history of uncontrolled high blood pressure and other heart conditions. Usually, patients with thyroid diseases that are not well controlled already have an increased heart rate, which ketamine could exacerbate. Most doctors recommend getting blood pressure or thyroid issues under control with medication before embarking on ketamine treatments.
Is ketamine contraindicated in people with a history of psychosis or schizophrenia?
People with psychosis or a family history of the condition may not be ideal ketamine candidates, but the diagnosis doesn’t make them ineligible. Ketamine’s dissociative psychedelic effects mean a person can experience out-of-body experiences, which could worsen delusions and active hallucinations. People who have had adverse reactions to other dissociative anesthetics in the past could be at higher risk.
Still, ketamine for depression can be safe and effective in patients with a history of psychosis or current symptoms. These cases require that clinicians collaborate to determine the correct dosage and frequency of infusions, along with close patient monitoring.
Is ketamine contraindicated in seizures?
There are some conflicting data regarding the potential risk of seizures associated with ketamine. However, reports indicate a rise in ketamine seizures is related to illegal and recreational ketamine use, in which people may encounter a contaminated and potentially harmful version of the drug. Research shows that there is no contraindication in epileptic patients for using ketamine.
Is ketamine contraindicated with substance use histories?
Ketamine’s therapeutic indications include treating addiction. However, ketamine has a history as a party drug, which comes with abuse potential, especially for those with active issues. This risk is why therapists should never recommend at-home ketamine therapy.
Many clinics prescribe ketamine for remote use. However, a recent survey found that over half (55%) of respondents who tried this approach either accidentally or purposely used more than the recommended dose. The risk was even higher among the younger generations.
On the other hand, patients who receive monitored IV therapy may significantly benefit from ketamine.
Licensed clinical social worker Lisa Kays sometimes recommends ketamine for depressed patients with substance use issues, particularly those on SSRIs who have tried to quit but struggle with feeling terrible afterward, which often leads them back to the pattern. She suggests ketamine therapy as it can provide a sort of “boost” for these individuals, making it easier to quit by alleviating the negative feelings associated with cessation.
Does ketamine negatively interact with other drugs?
Ketamine can have poor interactions with other drugs and medications.
- Central nervous system (CNS) depressants, such as opioids, benzodiazepines, and barbituates, could exacerbate ketamine’s sedative effects.
- Sympathomimetics, such as cocaine, amphetamines, and LSD, mimic or stimulate the adrenergic nervous system and can raise blood pressure.
- Lamotrigine may reduce ketamine’s effects.
- Benzodiazepines tend to shorten the beneficial duration of ketamine on depression.
- Antipsychotic medications, like haloperidol, risperidone, and clozapine, might interact with ketamine, though the evidence’s quality is still in question.
Collaborative Evaluation and Referral Process
Assessing ideal candidates for ketamine therapy is often a collaborative process between the therapist, patient, prescribing physician, and ketamine clinicians.
Therapists who have any questions about whether ketamine is safe for their patients should contact established clinics, like Avesta, that offer in-house IV infusions or Spravato therapy.
Avesta’s practitioners regularly consult with social workers, therapists, psychiatrists, and physicians to determine whether patients can safely benefit from IV ketamine or Spravato. Avesta also communicates with therapists throughout the protocol to answer questions and follow up on treatment outcomes.
Contact Avesta, located in Washington DC, McLean, Virginia, and Bethesda, Maryland, to determine whether your patient is an ideal candidate for ketamine therapy.
