I Think We're Using Ketamine Wrong
That's a strong statement and I want to be careful with it. I prescribe ketamine. I believe in it as a clinical tool. But the way I see it being used in a lot of settings concerns me, and I think it's worth saying out loud.
I often walk people through what I call “The Landscape”. It’s a “Wild West” out there of evolving treatments, and it’s a helpful metaphor to think of it as “getting a lay of the land”: with more medicalized treatment on one side, and more psychotherapy focused treatment on the other.
Ketamine is not just one thing. It is not just one treatment.
It is a versatile tool that shape shifts depending on how it’s used and in what context.
Here's the version of ketamine therapy that I think misses the point: a subscription model, too many lozenges shipped to your hose, instructions to microdose daily, encouraging journies by yourself, check back in a few months. In that setup, ketamine is basically just another antidepressant or as a reckless self led journey tool primed for unleashing trauma, leaving people feel lost and alone, or ready for an addiction to form. The daily small or “micro” dose versions basically position is as another antidepressant. A novel one, sure. But it's being used the same way: here's your medication, take it on schedule, hope it works (but now with addictive potential that could possibly damage your kidneys and bladder).
Except it's an antidepressant with addictive potential. And we don't have long-term data on daily microdosing. That's just not me being blindly conservative. That's just what's true right now. We don't know. We could learn in 30 years it was a great idea (it probably isn’t). But we’re just not there yet to ethically recommend it.
What I think ketamine actually does well
On the “spectrum”, I land close to the middle, on the psychotherapy side. In this position, I acknowledge the physiological benefits that occur (a whole topic for another day is the research on whether subjective effects are necessary for psychedelics to work, but then arguably they’re no longer “psyche-delic” in the original sense of the word!). But these benefits are often short lived: 2 days to 2 weeks depending on the person. But then what? We’re still learning. Many clinic models will continue offering treatment (infusions or spray most often) at about the interval it takes the benefit to wear off, at some ongoing interval (kind of like ECT and TMS) until eventually, we hope it sticks. And you know what? It does work sometimes! Do some people just get ongoing infusions forever every 2-6 months? Maybe? Is that okay? Maybe. How long on average does it take for these protocols to go to no infusions needed? We’re learning. Unclear.
So while we figure all that out in terms of a more medication, physiology focused protocol. Us on the therapy side are noticing how, akin to the psychedelic and shamanic world (and all of life really), noticing the content that comes up, the subjective experience, and its integration is key to lasting changes.
As the saying goes: “if nothing changes, nothing changes.”
When I prescribe ketamine, I personally think about it as a psychotherapy enhancer. A deepener, an accelerator. A magnifying glass and a flashlight. Not a standalone treatment. Not a chemical that fixes your brain chemistry. Something closer to a window: a window into your mind and soul during a session, and a temporary neuroplastic state where the therapeutic work can go deeper than it usually does.
I've seen it do something that's hard to replicate with medication alone or talk therapy alone. Not every time. Not magically. Not even always quickly. But in the right context of a strong therapeutic relationship, a clear rationale, a patient who's been doing the work and is stuck in a specific way, it can create space for something to shift that wasn't shifting before. And that’s how many therapists and facilitators have discussed it - something to help flow what was stuck before. Someone once joked it can be “like an emotional spiritual laxative”.
It’s a very active process that requires your active participation.
That's a very different claim than "ketamine will transform your depression" or “ketamine will make you feel better.” I don't make that claim. I don't think anyone should. Like all “psyche-delics”, ketamine doesn’t necessarily help you feel better. It can help you feel. And sometimes, feeling “worse” before we feel better (as stuff comes up and we have to work through it) is part of the process. Feeling better is on the other side. You were just given the first step, the entry point. This is “your mission, should you accept it”. The journey is not the end, it’s an opening, or an invitation rather, to a beginning.
How I actually prescribe it
For my ongoing therapy clients, we might have a deepening session with what’s called a psycholytic very low dose about once every 3 months in a 2 hour session. Not as a separate event, but woven into the work we're already doing together.
For my small group of highly trusted and well trained therapists, I might prescribe small batches, enough to cover 3-6 in-person journey sessions at a time. We start around 100mg with lozenges and go up thoughtfully if the clinical picture supports it, maybe to 400 milligrams maximum. Then we stop and take stock. What moved? What didn't? Do we continue, change course, or call it? Is a period of integration what’s best now?
I don't prescribe huge amounts at a time. I don’t prescribe for anyone.
I don’t preside over multiple IVs at a time. I don’t leave people in a waiting room with Spravato, checking on the blood pressure occasionally.
This isn't scalable. And that's part of the point.
What's happening with ketamine that’s worrisome
Ketamine has become lucrative. Not exclusively, but often.
I understand the demand: they hear about it’s rapid antidepressant effects, they like the idea of not taking a daily med, or they’re interested in psychedelic therapies.
We’re seeing a pattern that gets repeated in healthcare: cutting corners of quality and relationship wherever possible. Sometimes, this is carefully balanced in the name of access. Another sometimes, it’s not. And as psychedelics are nonspecific amplifiers of our minds and hearts - they might also be non specific amplifiers of our systems.
I've had people come to me specifically because they tried that and it felt empty, or felt better and then symptoms returned quickly (because if nothing changes, nothing changes). Or irresponsible. Or they got a few months of lozenges from a company they'd never heard of and thought, is this really how this is supposed to work?
The therapeutic relationship isn't a nice-to-have. It's the container that makes the medicine meaningful. Ketamine in the context of a real clinical relationship, with someone who knows your history and is paying attention to how you're changing - that's a fundamentally different thing than ketamine as a product.
What I wish the field would be more honest about
We're early. The research on ketamine for depression is promising, but it's not the whole story. The research on optimal dosing, frequency, route of administration, long-term effects of repeated use - a lot of that is still being figured out. The psychedelic therapy field in general is changing so fast that what we think we know today might look different in five years.
I think the honest thing to do with that uncertainty is to name it. Not to withhold treatment (these are real tools that help real people) but to be straightforward about what we know and don't know, and to be careful with how we use them in the meantime.
For ketamine assisted psychotherapy, that means careful doses. Short courses. Ongoing clinical relationships. Pausing to assess. And the heaviest emphasis on integration. Being willing to say "this might not be the right tool for you" even when someone really wants it to be.
It's less exciting than the marketing. But I think it's better medicine.
Patricia Pop, MD is a board-certified psychiatrist providing integrative telepsychiatry and psychotherapy for adults throughout California. She combines evidence-based medication management with ongoing therapy, including ketamine-assisted psychotherapy, Brainspotting, and TEAM-CBT.