New guidelines urge caution with ketamine use for mental health treatment

The anesthetic ketamine is being hailed as a breakthrough therapy for people with post-traumatic stress disorder (PTSD), treatment-resistant depression and other mood disorders. But the drug does have side effects – some potentially life-threatening – and should only be prescribed and administered by trained health care professionals to ensure the patient's safety, according to new guidance released by the American Society of Anesthesiologists (ASA).

Long valued for its role in sedation and anesthesia during medical procedures, ketamine also has been shown to provide relief from depression symptoms in minutes or hours, while traditional anti-depression medications can take weeks to show benefits. Although ketamine is not currently approved by the Food and Drug Administration (FDA) for non-anesthetic uses, it is increasingly prescribed off-label, fueling the rapid growth of in-person and virtual ketamine clinics across the country. Ketamine is typically delivered by infusion or injection and some clinics provide it by mail, directing patients to treat themselves at home. 

Patients who receive ketamine at home or at nonaccredited outpatient clinics may not have access to the monitoring, rescue personnel or emergency resuscitation equipment necessary when anesthetic agents are being used, according to ASA's Guidance on the Safe Use of Ketamine Outside of Acute Pain Management and Procedural Sedation. Ketamine can cause a variety of side effects, including high blood pressure and slowed breathing, and administering it inappropriately can lead to life-threatening consequences such as respiratory failure, cardiac issues and seizures.

Following the untimely death of actor Matthew Perry due to the acute effects of ketamine, there has been a growing number of false or misleading statements and opinions in the press on its use. Ketamine was originally introduced and has its greatest use as an anesthetic. As anesthesiologists, we felt it was important to increase awareness of how to use it appropriately. People who have struggled with mental health issues and are understandably excited about a new treatment may not realize that they are risking their lives by receiving treatment without medical supervision in unaccredited clinics or offices without established safety standards."

Donald E. Arnold, M.D., FACHE, FASA, president of the ASA

The guidance, which is intended for all non-anesthetic uses of ketamine, recommends that the administration of ketamine for non-anesthesia purposes adhere to the same standards as other anesthetics and follow the same prescribing principles as other sedating medications. Patients should only be prescribed the drug for a medical indication as part of a comprehensive treatment plan, by an appropriately trained and licensed medical professional who monitors the patient with periodic face-to-face visits. Intravenous and intramuscular ketamine should only be administered in a monitored setting under the care of a licensed health professional where appropriate rescue equipment is immediately available, the guidance says. 

The guidance also notes:

• Ketamine treatment should have a therapeutic endpoint and a defined treatment course. 
• Medical professionals should take steps to ensure that ketamine therapy is being used as prescribed.
• Medical professionals should be vigilant for diversion to non-medical purposes. 
• Ketamine should be prescribed at the minimum dose necessary to achieve a desired clinical effect.
• Patients should be educated about the possible adverse effects of ketamine use.
• Ketamine should not be administered in doses that produce excessive sedation, unconsciousness or unresponsiveness, except when it is being used as a procedural anesthetic administered by a licensed health care professional in an appropriately equipped setting.

"Anesthesiologists are working with psychiatrists via joint research, training programs and other initiatives to advance mental health treatment using these drugs," said Dr. Arnold. "People who believe ketamine might be helpful in addressing their mental health issues should talk with their primary care physician or mental health professional."