Around 2.8 million Americans suffer from treatment-resistant depression, and though research has shown that IV ketamine can significantly improve their quality of life, these ketamine treatments are expensive, and access to them is limited. Early in the covid-19 pandemic, the Drug Enforcement Agency loosened restrictions on remote prescribing for Schedule III medications like ketamine. In response, enterprising healthcare entrepreneurs founded at-home ketamine clinics that ship oral ketamine to clients after one telemedicine appointment. Proponents of at-home ketamine therapy argue that this method makes an effective treatment available to many more people in need, while critics argue that ketamine delivered this way, with inconsistent oversight, is dangerous.
The National Institute of Mental Health estimates that 14.8 million people had a major depressive episode with severe impairment in 2020. The FDA hasn’t approved ketamine for use in depression or other mental health disorders, which can include PTSD, bipolar disorder, OCD, and generalized anxiety. But it can be prescribed off-label, and 20 years of research has shown it to be highly effective in reducing symptoms for those who have tried SSRI antidepressants and mood stabilizers without lasting effects. Ketamine used for mental health disorders is given in small doses, as compared to the higher doses used in anesthesia and pain management.
Ketamine that is provided at home has not been well studied; those currently providing that data are also benefiting from positive results. According to Nue Life (formerly My Ketamine Home), 66% of its patients reported significant improvement of their symptoms after their first treatment, while Mindbloom, the most well-known at-home provider, reported that as high as 89% of patients showed improvement after the first dose.
Brad is a 46-year-old healthcare professional who was diagnosed with bipolar disorder at age 25 and has had success with IV ketamine provided at a clinic for his symptoms of depression. He sought ketamine treatment as a last-ditch effort to avoid electroconvulsive therapy (ECT) after years of limited success with antidepressants and mood stabilizers. After his fourth IV treatment, he noticed a remarkable improvement in his depression. At one point during his monthly maintenance treatments, Brad’s doctor closed the clinic for several weeks due to a family emergency, which left Brad without the ketamine to help his depression. Brad decided to turn to an at-home provider.
Brad certainly benefited from one of the more compelling arguments for at-home ketamine, which is accessibility. He was fortunate to have found an IV clinic near his house, but there are still plenty of mental health sufferers without access to an in-person clinic. Since a common symptom of mental illness is dysfunction serious enough to prevent someone from leaving the house, at-home ketamine can provide a more realistic option. I interviewed Sam Zand, co-founder and chief medical officer of Better U, who lauded to the improved access of at-home ketamine: “We look to really enhance the safety, allowing people not only to access [ketamine] in a more convenient place, in their homes, rather than having to go to the office, which can be uncomfortable for them.”
Proponents of at-home ketamine, which is given in oral form, also argue that part of its accessibility is its affordability, especially compared to IV treatments, which can be prohibitively expensive. The average IV ketamine treatment can cost between $400 and $800 per session, with most doctors recommending an initial six sessions over two to three weeks. While the actual medication is inexpensive, patients are paying for a doctor on site, vitals monitoring, and other costs associated with a brick-and-mortar practice. It is tricky to compare the cost of at-home ketamine providers, since each offers varying doses per month and then different additional therapeutic options, such as group therapy or one-on-one sessions with their integration guides.
Integration is a term often used in ketamine therapy, and it refers to how patients can process the hallucinations or feelings they experience during their treatments. Nue Life is the most expensive, at $1,400 per month, but also includes more ketamine treatments and group therapy. Better U and Tripsitter are $600 a month, but each offer fewer ketamine treatments and varying levels of integration sessions. Brad said he found at-home ketamine to be less expensive initially, but more one-on-one therapy with an integration guide would cost extra: “If I wanted any further integration sessions after each treatment, the cost could add up to what I would spend on maintenance treatments with my IV clinic.”
One of the most significant criticisms of ketamine at-home is its potential for addiction.
The DEA categorizes ketamine as a Schedule III drug, giving it a moderate to low rating for addiction. According to Robert Gable, emeritus professor of psychology at Claremont Graduate University who has conducted research on drug toxicity and misuse potential, ketamine is less addictive than your daily cup of caffeinated coffee, as well as alcohol and nicotine. Even though the risk of addiction for ketamine is low, especially at the low doses for both at-home and IV ketamine, each CEO I interviewed had several different ways of mitigating the risk, including only sending out a certain amount of ketamine at a time. The most common form of ketamine shipped to a patient is a lozenge or a troche that a patient must hold in their mouths without swallowing or spitting for 7 to 10 minutes, which is uncomfortable.
The more concerning drawback of at-home ketamine is the difficulty of monitoring a patient’s vital signs. Ketamine can raise blood pressure and lower oxygen rates, which makes a doctor’s office the ideal setting for administering it. Almost all of the at-home providers send a blood pressure monitor for a patient to use before and after the treatment, but there is not much that can be done if blood pressure gets too high. Every at-home provider does insist and verify that the patient has someone home with them for safety, but immediate intervention would be limited. With each IV ketamine treatment, Brad has had a lowered oxygen saturation requiring supplemental oxygen, but his at-home ketamine provider had no way of monitoring this. At-home providers argue that they compensate for these risks with their initial medical screening. According to Kazi Hassan, chief medical officer for Nue Life: “The most important thing is, of course, with any medical indication is proper screening. Anytime we suspect uncontrolled hypertension, it is an issue.”
Most criticisms of at-home ketamine come purely from medical concerns, but like other psychedelic medications, ketamine cannot be examined in such one-dimensional terms.
Ketamine causes dissociation, which can make a person feel disconnected from reality. It can produce hallucinations or bring up traumatic memories, and without any processing of the affiliated emotions, the ketamine can be only minimally effective. In fact, each CEO I interviewed mentioned what they call “integration,” or this processing, which includes setting an intention before undergoing the treatment and examining the potential meaning behind what the patient experienced during the treatment.
Sam Ko is a board certified emergency physician and member of the American Society of Ketamine Physicians, Psychotherapists & Practitioners (ASKP3), as well as founder and medical director of the IV clinic Reset Ketamine in Palm Springs, California. Ko is an avid believer in integration: “Because ketamine is a psychedelic, it’s going to create these non-ordinary states of consciousness, and when someone’s not prepared for it, they don’t have an intention. They’re not going to integrate it. Then it may not be as effective.”
Every at-home ketamine provider I spoke to emphasized the value of integration and offers counselors, or integration “guides,” to help patients through each treatment session. Since at-home ketamine clinics are unregulated, though, the training of the guides differs. For most of the providers, integration guides did not need to have any formal education in psychology or therapy, and guide training is largely done in-house. Richard Ginzel is the CEO of ViveaMind, a company that combines psychedelic medication with intensive integration and other forms of therapy, based out of Costa Rica. Ginzel was an integration guide with one of the larger at-home ketamine providers for over a year. While overall his experience as a guide was positive, he felt that the training provided was inadequate: “So there was never any training on how to have their guides really help people. The training for their coaches was to ask a couple of questions, and, just say, thank you for sharing that with me.”
During his treatments at his IV clinic, Brad often had the feeling that he was dead and that he was watching his body from above. The experience was not scary for him, though, and after processing his vision with his doctor, he gained a different insight into any underlying emotions. The integration he had after his at-home treatments was less effective, but he also had more muted dissociations with the oral medication, he said.
As the evidence mounts for ketamine’s effectiveness in improving depression and certain other mental health disorders, ketamine therapy options will likely continue to expand, even without FDA approval. For Brad, he still prefers the results he gets at his IV provider, but he is glad for at-home ketamine as an option for maintenance of his depression, especially since it is more affordable and easier to access. Ketamine therapy, in all of its forms, can save someone suffering from serious mental illness. Even if at-home ketamine is not ideal, the option for some could be life-saving and offer a better quality of life patients couldn’t attain before.