Ketamine for Mental Health Treatment: From In-Clinic to At-Home Treatment

Written by Jodi Green

Often misunderstood as a party drug, the proliferation of ketamine therapy in recent years has been driven largely by the surging mental health crisis. One in five people suffer from mental illness, and in the wake of the COVID-19 pandemic, the World Health Organization reported a 25% increase in the prevalence of anxiety and depression worldwide.

While at-home ketamine has become as ubiquitous as in-clinic treatment, the end of the COVID-19 Public Health Emergency on May 11, 2023 may impact the availability of telemedicine services.  

How Is Ketamine Used for Mental Health Treatment?

In simple terms, ketamine impacts neurotransmitters in the brain, leading to clinically-proven reductions in anxiety, depression, and PTSD. In the words of some researchers, ketamine promotes neural plasticity, or “rewires” the brain. 

Notably, ketamine is not a “classic” psychedelic that acts on serotonin receptors (such as psilocybin (magic mushrooms), ayahuasca, or LSD), which are all Schedule I substances under the federal Controlled Substances Act and federally illegal to possess or prescribe outside of clinical trials or research. This makes ketamine the most accessible drug in the psychedelic family due to its status as a Schedule III controlled substance that can be prescribed by a licensed physician in the United States.

Ketamine comes in several forms. The most common and widely used is IV ketamine. Ketamine is also available in an intramuscular injection, an intranasal spray, and as a sublingual tablet, or troche. The first three are prescribed “off label” (as the FDA has approved them for use as an anesthetic and not for mental health) and typically administered in a clinic or doctor’s office. One type of ketamine, Spravato (esketamine), recently won FDA approval for treatment resistant depression and major depressive disorder, but some studies question its efficacy. Patients seeking ketamine should undergo a thorough health screening to avoid any contraindications, including a discussion of other prescriptions, prior substance abuse, history of psychosis, and cardiovascular disease, among other things. 

According to the National Institute of Health, nearly a thousand research papers have been published regarding the effects of ketamine on mental health, with over 400 in the last few years.

Can Ketamine Be Taken At Home via Telehealth for Mental Health Treatment? 

During the pandemic, ketamine and other controlled substances became available by prescription through audio-visual telehealth without an in-person appointment. 

Absent the Public Health Emergency carve-out for telehealth, the Ryan Haight Online Pharmacy Consumer Protection Act prevents the sale of controlled substances unless the practitioner has conducted at least one in-person medical examination of a patient, in remembrance of an 18-year-old who overdosed on opioids that were prescribed arguably without an adequate medical evaluation via telehealth. 

Specifically, as a result of the COVID-19 Public Health Emergency Declaration, in January 2020 the Drug Enforcement Agency (DEA) rolled back requirements for in-person examinations to obtain prescriptions for controlled substances under the federal According to a DEA bulletin, prescribing practitioners must be licensed, must issue prescriptions for a legitimate medical purpose, and the telemedicine communication must be conducted via an “audio-visual, real-time, two-way interactive communication system.” In addition, practitioners must otherwise be in compliance with any other applicable state laws governing prescribing and telehealth, which vary by state. 

The exemption to the limitations on telehealth opened the door to a new, still-growing swath of at-home ketamine therapy companies with that provide consultations virtually, with clever and evocative names like: Mindbloom, Field Trip, Nue Life, KetaMD, Better U, and Wondermed, among others.

Is At-Home Ketamine Beneficial, Safe, and Effective? 

A primary benefit of at-home ketamine is cost: it is significantly less costly than in-clinic treatments. Ketamine is generally not covered by insurance, although the cost of psychotherapy in conjunction with the treatment may be covered (in whole or part) depending on an individual’s health insurance plan. One study noted that the cost can range from $193 to $250 per treatment dose, which is 28% to 83% of the reported cost of a single in-clinic ketamine infusion. Depending on the locality, the cost of IV ketamine at some clinics can reach, or even exceed, $1000 per treatment. Patient access and comfort is also key: the time and distance to reach clinical providers can be time and cost-prohibitive. 

Unlike the numerous studies regarding other types of ketamine (which generally involve in-clinic treatment), limited research has surfaced regarding the safety and efficacy of at-home ketamine. As one 2022 study published in Frontiers in Psychiatry proclaimed, however, at-home ketamine “offers a safe and effective tool in the treatment of anxiety and depression.” In the study, nearly 50% of patients with treatment resistant anxiety or depression saw a 50% improvement in symptoms after using three at-home sublingual ketamine treatments. These scores increased even more after six treatments, with caveats that the study relied on self-reporting and no control group. The study also noted the need for further research to delineate the most effective dosing regimen.

That being said, a Vice story from 2021 outlined a variety of complaints by patients that received at-home ketamine, including one company’s failure to provide access to integration guides (which was apparently part of the package a patient purchased) and administration of the wrong dosage of prescription. 

For these and other reasons, some physicians and researchers are concerned with the risks (such as blood pressure fluctuations) and the potential for oversight (like prescribing the wrong dosage) associated with home treatment. These issues create opportunities for technological innovation, including remote monitoring, and may allow companies with robust risk-management and safety protocols to thrive. 

At its core, whether ketamine is administered in-clinic or at-home, one factor consistently arises: the impact of therapy and integration. Some studies have shown that psychotherapy following ketamine use makes ketamine therapy more effective and can prolong the therapeutic effects of the drug, but that further research is needed to fully explore the impact. 

As an alternative, integration services offered by non-clinically-licensed coaches or practitioners that have undergone psychedelic integration training may offer new, lower-cost option for patients seeking a means to understand and explore their experience. Although clinical data regarding the efficacy of sessions in the absence of a trained therapist has not yet been adduced, reports indicate that integration as a concept has been employed effectively for many years outside of the clinical model, including by indigenous peoples.

How Will the End of the COVID-19 Public Health Emergency Affect Ketamine Telehealth? 

On January 30, 2023, President Biden announced the end of the Public Health Emergency as of May 11, 2023. While proponents of telehealth continue to advocate for new legislation that would allow their services to continue, at this time, it appears that prescribing of controlled substances will revert to the in-person status quo on May 11th. Absent additional action by the DEA or Congress, this means that the exception that allowed for the proliferation of ketamine therapy via telemedicine will also disappear. For all practical purposes, this change may not impact the majority of patients currently undergoing at-home ketamine treatment. New patients would have to attend one in-person consultation with a physician, but could still self-administer a ketamine prescription at home. The elimination of telehealth options will likely affect the populations that need it the most, increasing costs and decreasing availability and access to services. Whether this change will have substantial implications on the viability of at-home ketamine industry remains to be seen.