The Clinician’s Guide to Ketamine Therapy: Patient Selection and Protocols | Part 3
Synopsis: Part 3 of our Clinician’s Guide to Ketamine Therapy, we dive into patient selection, dosing strategies, treatment scheduling, side effects, and the nuanced conversation around ketamine addiction. You’ll walk away with a practical understanding of how to apply ketamine therapy safely and effectively, grounded in both real-world experience and current scientific literature.
Key takeaway: Safe, ethical, and effective ketamine therapy starts with the right patient selection, thoughtful dosing, and clinical oversight—empowering providers to deliver care that is both compassionate and science-based.
This blog is proudly sponsored by Clifton Insurance Agency, Inc., a trusted leader in the liability and high risk niche market insurance industry.
Mention “Ketamine StartUp” and receive FREE quotes & exclusive policy discounts. Learn more about how they support ketamine clinics here.
Discover clinical insights on patient selection, dosing, and treatment scheduling in Part 3 of our guide to ketamine therapy for mental health.
A Clinician’s Guide To Ketamine Therapy: A 3-Part Series
Welcome to Part 3 of our three-part blog series designed for clinicians seeking a deeper understanding of ketamine therapy.
Whether you're a budding ketamine therapy specialist, exploring treatment options for your patients, or simply need a refresher on the science and protocols, this series offers a clear and comprehensive foundation.
In Part 1, we’ll explore the current state of mental health, the historical journey of ketamine, and how this decades-old anesthetic has reemerged as a powerful mental health intervention.
Finally, here in Part 3 we will cover patient selection, dosing strategies, treatment scheduling, and side effect management.
Let’s begin by exploring patient selection!
Prefer listening over reading? Check out Episode 31 of our podcast: The Clinician’s Guide to Ketamine Therapy: History, Science & Real-World Protocols and jump to 23:22 to dive right in.
The episode is on Apple Podcasts, Spotify, Overcast, or on your favorite podcast platform. Watch the discussion on YouTube here.
Ideal Patient Selection
So you might be curious: Who’s the ideal patient? How do you select them? What’s the dose? What’s the schedule? Let’s explore that here.
We’ve already discussed the various indications for ketamine therapy in part 2. Now, let’s review the contraindications:
Schizophrenia or psychosis (personal or family history): This may be a contraindication, as ketamine can potentially exacerbate these conditions.
Active phase of bipolar disorder: Ketamine may worsen symptoms if the patient is currently manic or severely depressed.
Uncontrolled hypertension: Since ketamine can elevate heart rate and blood pressure, uncontrolled cases pose a risk of reaching dangerous levels.
Active substance abuse:
Some clinics treat patients actively using ketamine, cocaine, opioids, or alcohol.
At our clinic, we do not. However, there is emerging research in this area.
Unstable cardiovascular disease: Patients with coronary artery disease may require a stress test before treatment.
Glaucoma or elevated intraocular/intracranial pressure: There’s a theoretical risk that ketamine may increase these pressures, so uncontrolled cases should be carefully evaluated.
Pregnancy: Not enough research exists on ketamine’s embryonic effects, so pregnancy is considered a contraindication.
Estrogen receptor–sensitive breast cancer: Theoretical risk exists because ketamine and its metabolites may stimulate estrogen receptors.
Previous adverse reaction to ketamine: This would also be a clear contraindication.
Active suicidal ideation with a plan:
If a patient is actively suicidal and high risk, they would not be a candidate for outpatient ketamine treatment.
In such cases, immediate psychiatric intervention and possible hospitalization would be necessary.
Finding the right ketamine dose isn’t one-size-fits-all. Most patients fall between 0.5 to 1 mg/kg, with gradual titration guided by research and real-time response.
Ketamine Therapy Dosing
As far as dosing goes, the majority of the research used 0.5 mg per kg, slowly infused over 40 minutes for a total of 6 infusions. We’ve taken that research protocol and extrapolated it to treat conditions like generalized anxiety disorder, PTSD, bipolar disorder, and social anxiety disorder.
In general, we begin most patients with an initial dose of 0.5 mg/kg over 40 minutes. Research shows that the dissociative effect (some of those non-ordinary states of consciousness) is a strong predictor of symptom improvement.
At our clinic, we use an escalating dosing protocol, as long as the patient can tolerate it and their vital signs remain stable. This means we gradually titrate the ketamine dose with each successive treatment. The goal is to avoid going too high or too low.
Think of it like the Goldilocks principle: not too hot, not too cold…but just right. And that “just right” dose is unique to each patient. Some are highly sensitive, while others are not.
So what’s the general range?
Doses are weight-based.
Most patients fall within the 0.5 mg/kg to 1.0 mg/kg range.
There are outliers as some need less, while some need more.
As for scheduling, the initial studies classically administered three sessions per week for two weeks (totaling six infusions). However, other research has shown that twice-weekly sessions for three weeks can be just as effective.
Treatment Scheduling
So those are some of the research protocols. At our clinic, what I’ve found effective is to still complete the six-infusion series, but to space them out more gradually:
Week 1: Two infusions
Week 2: Two infusions
Week 3: One infusion
Week 4: One infusion
This still totals six infusions, but allows for a tapering effect.
What I’ve noticed is that the initial sessions benefit from being grouped more closely together, while the later sessions can be spaced out more easily. This approach differs slightly from the strict research settings and better reflects real-world clinical application.
From research to real-world protocols: Discover how ketamine infusion schedules can be adapted to meet patient needs, balancing science with clinical experience
Pain Disorder Dosing and Protocols
Now, when we talk about pain, the term encompasses a wide spectrum—so it's not as straightforward. The research shows a large variation in both dose and infusion length.
Some studies have used:
Very low doses of 0.5 mg/kg per day
Up to 1 mg/kg per hour
In fact, in some of the meta-analyses we referenced, infusion protocols included:
30-minute infusions
4-hour infusions for 10 days
5-hour infusions for 7 days
24-hour monitored infusions for 4 days in ICU settings
These are long, intensive protocols, often for severe and refractory pain.
In general, however, what we’ve found in our clinical practice is that the higher the dose and the longer the infusion, the more durable the pain relief.
At our clinic, we offer:
80-minute, 2-hour, and 4-hour infusions
Specifically for Complex Regional Pain Syndrome (CRPS)/RSD, we typically administer 4-hour infusions daily for five days
For other conditions like fibromyalgia or trigeminal neuralgia, we may space sessions with a one-day break in between.
Again, we often extrapolate from depression and PTSD research - three infusions per week for two weeks can be a viable option.
As for dosing in chronic pain, it's typically higher:
Most patients fall between 0.5 mg/kg/hour to 1.25 mg/kg/hour
But again there are outliers. With some needing less, while others needing more.
While ketamine is generally well tolerated, understanding potential acute and long-term side effects is key to safe and informed clinical use
Acute and Potential Long-Term Side Effects of Ketamine Therapy
Now on to the topic of acute and potential long-term side effects of ketamine therapy.
Many patients feel anxious before their first session. For patients it can be like standing at the edge of a diving board. You’ve seen others dive off it safely, but you haven’t jumped yet. That hesitation is totally normal. Some patients even experience panic attacks, especially if they’re not mentally prepared for the experience. This can lead to what they describe as “scary” or “bad trips.”
Other acute effects we've observed include:
Hypoxia: While ketamine typically preserves respiratory function, we’ve seen cases where patients become hypopneic (shallow breathing) during infusions. That’s why we do continuous vital sign monitoring.
Seizure risk: Though rare, this is a possibility and highlights the need for monitoring.
Unexpected cardiac responses: For example, one patient experienced atrial fibrillation with rapid ventricular response (RVR) - a surprising but real event. This is why emergency protocols are essential in a clinical setting.
Post-Infusion Effects and Longer-Term Risks
Around 10–20% of patients report nausea post-infusion. For this, we keep IV Zofran (ondansetron) on hand.
Headaches are also common, so we offer IV Toradol as needed.
Some patients may feel fatigued for up to 24 hours after treatment.
There are also important theoretical long-term risks to keep in mind:
In patients with an undiagnosed or unreported history of schizophrenia or psychosis, ketamine could potentially trigger paranoia, psychotic episodes, or even full-blown schizophrenia.
Chronic, high-dose use has been associated with interstitial cystitis (bladder inflammation).
And finally, while uncommon in clinical settings, addiction is a potential risk, particularly with frequent or unsupervised use.
Though ketamine carries a low risk of dependence, responsible in-clinic use and patient screening are essential - especially as research explores its potential to treat addiction itself
On the Topic of Ketamine Addiction & as a Treatment for Addiction
Any medication or drug that can alter one’s perception has the risk for addiction. Therefore we cannot ignore ketamine addiction or abuse. We believe the risk of addiction is significantly lowered when ketamine is administered only in a clinical setting, under a doctor's supervision. We do not recommend prescribing home ketamine. especially for patients with a history of substance use disorder and we strongly advise against providing vials for intramuscular self-administration.
A Dual Role: Risk and Potential Treatment
Interestingly, while ketamine carries some addiction risk, it is also being investigated as a potential treatment for substance use disorders, including:
Alcohol use disorder
Cocaine use disorder
Opioid use disorder
A systematic review published in Frontiers in Psychiatry, highlighted promising early research on this topic. And in August 2024, Exeter College in the UK launched a new study exploring ketamine’s potential in treating alcohol addiction.
From Patient Selection to Addiction Treatment: Putting It All Together
Understanding who should and should not receive ketamine therapy is essential to delivering safe and effective care. Patient selection, along with dosing and scheduling protocols, form the foundation of successful treatment. While each patient and response is unique, the vast majority can benefit when guided by protocols supported by the scientific literature.
With thoughtful, science-backed, and ethical practice, clinicians can also minimize the risk of ketamine addiction. At the same time, we're encouraged by the growing research into ketamine as a potential treatment for substance use disorders, a promising new frontier in mental health care.
If you found Part 3 helpful and haven’t yet explored the earlier parts of this series, be sure to check them out:
In Part 1, we explore the current state of mental health, the historical journey of ketamine, and how this decades-old anesthetic has reemerged as a powerful mental health intervention.
In Part 2, you’ll take a closer look at how ketamine works, types of patient experiences, and key scientific studies across multiple indications.
Related Questions:
Who is not a good candidate for ketamine therapy?
Ketamine therapy may not be a good fit or appropriate for patients with a history of schizophrenia or psychosis, uncontrolled hypertension, active substance abuse, unstable cardiac conditions, pregnancy, or certain cancers like estrogen receptor-sensitive breast cancer. It’s also not suitable for individuals in an active manic phase of bipolar disorder or those who are acutely suicidal with a clear plan.
How does scheduling differ between clinical practice and research protocols?
While research often schedules ketamine infusions three times per week for two weeks, in real-world settings like ours, we space treatments out more. We typically do two infusions per week for the first two weeks, followed by one per week for the next two weeks, for a total of six. This allows flexibility without compromising effectiveness.
This blog is brought to you by Clifton Insurance Agency, Inc.. Learn more about their services at CliftonInsuranceAgency.com and how they support ketamine clinics.
🎉 Exclusive Perk: Mention “Ketamine StartUp” and get FREE Quotes & Policy Discounts! Click here to take advantage.
If you enjoyed this blog, check out these posts too:
13 Best Practices For Ketamine Therapy Clinics
Discover 13 best practices to help you start, grow, and refine your ketamine clinic. Learn how to improve patient care and build a thriving practice.
4 Ways To Help Your Patient Prepare For A Ketamine Infusion
Learn essential methods to optimally prepare your patients for ketamine therapy, aiming to enhance their treatment experience and outcomes. This blog details four critical techniques to ensure patients are both mentally and physically primed for their sessions, contributing to the success of your ketamine clinic.
Does Age Predict Your Patient’s Response To Ketamine Treatments?
There are plenty of factors that determine whether your patient responds to ketamine infusions or not. Is age one of these factors? Read this blog post to find out based on a study conducted on this matter.
Part 3 of our Clinician’s Guide to Ketamine Therapy, we dive into patient selection, dosing strategies, treatment scheduling, side effects, and the nuanced conversation around ketamine addiction. You’ll walk away with a practical understanding of how to apply ketamine therapy safely and effectively, grounded in both real-world experience and current scientific literature.
Discover clinical insights on patient selection, dosing, and treatment scheduling in Part 3 of our guide to ketamine therapy for mental health.