Over several decades, research has shown that ketamine has antidepressive properties. Ketamine is approved by the U.S. Food and Drug Administration (FDA) for the induction and maintenance of anesthesia, although it is also being used for the management of psychiatric disorders and chronic pain. Ketamine has been incorporated into the treatment of psychiatric disorders, such as major depressive disorder (MDD), bipolar disorder, and post-traumatic stress disorder (PTSD), as well as post-operative and chronic pain management. Intravenous (IV) ketamine therapy is not a first-line therapy for psychiatric disorders or chronic pain management and may be considered by the patient’s interdisciplinary team after failure of standard treatment.1 Please note that esketamine nasal spray, a derivative of ketamine, has been separately approved by the FDA for treatment-resistant depression.
Ketamine infusion therapy involves the administration of a series of infusions for the management of psychiatric disorders (e.g., major depressive disorder, post-traumatic stress disorder, acute suicidality). Ketamine is a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist that has traditionally been used for the induction and maintenance of anesthesia. In ketamine infusion clinics, psychiatric-mental health advanced practice nurses (APRNs) and psychiatric-mental health RNs are collaborating with other psychiatric and health care providers (including certified nurse anesthetists) to provide ketamine therapy services for individuals with chronic and medication resistant mental health disorders.1
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Ketamine Treatment Considerations Checklist
This checklist provides considerations for prescribing/administering ketamine infusion therapy and is not intended to be all inclusive.
State Scope of Practice
- Review applicable state nursing, medical, drug and facility statutes and regulations to identify existing and anticipated practice barriers.
- Verify whether the state board of nursing or other relevant board has issued a related opinion applicable to RNs and/or APRNs.1
- If in doubt consult the Scope of Nursing Practice Decision-Making Framework.
Treatment Recommendations
- Adults with moderate to severe depression
- Adults experiencing acute suicidality
- Individuals diagnosed with bipolar disorder (with managed mood stabilization)
- Individuals diagnosed with personality disorders (provided individual can manage infusions and engage in therapy)2
Considerations for Candidate Eligibility
Currently, there are limited empirically established recommendations for the use of ketamine treatment in psychiatric disorders. Therefore, the selection of appropriate candidates for ketamine treatment requires careful consideration regarding the risks and benefits of the treatment in the context of the individual’s severity of depression and/or suicidality, duration of current episode, previous treatment history, and urgency for treatment.4
- Intravenous (IV) ketamine therapy should not be considered for the initial treatment of psychiatric disorders or chronic pain management.
- Ketamine therapy should only be considered after failure of standard treatment:
- No sustained change following adequate antidepressant trials (some individuals will have tried several different anti-depressants), different medication combinations, and/or ECT/TMS.
- No sustained change in response to adjunctive group CBT or individual therapy.
- Evaluation of the contraindications to ketamine.1
Ketamine Therapy Exclusion
- Active substance abuse (Alcohol, cannabis, non-prescribed medications, etc.)
- Negative urine toxicology screening prior to the initiation of treatment and during IV ketamine treatment course may be warranted
- History of psychosis
- History of increased intracranial pressure
- Pregnancy (current)
- Uncontrolled hypertension
- Acute or unstable cardiovascular disease
- Previous negative response to ketamine2
Obtain Medical and Substance Use History
- Comprehensive diagnostic assessment to rule out diagnosis of current and past substance use and psychotic disorders:
- A baseline urine toxicology screen is recommended to ensure the accuracy of the reported substance use and medication record.
- Detailed and thorough history of previous antidepressant treatment to confirm adequate trial.
- Thorough review of past medical and psychiatric records and/or confirmation of the past depressive disorder history by family members are strongly encouraged. All current medications and allergies should be reviewed, including histories of opiate and benzodiazepine use.
- Obtain baseline symptom severity to later assess clinical change with treatment.1
Process for Referrals
- Individual should verify insurance coverage (e.g., private, Medicare, Medicaid)
- Obtain credentialing for ketamine infusion or collaborate with credentialed provider
Clinic Location and Equipment
- Accessibility to patients
- Comfortable infusion rooms
- Recovery area
- Required equipment:
- Standard IV infusion equipment
- Monitoring equipment (sphygmomanometer, oxygen saturation, etc.)
- Emergency equipment readily available (including emergency medications)
Documentation
- Electronic or paper record
- Procedure-specific forms
- Self-assessment tools (PHQ9, QIDs, anxiety rating scales, etc.)
- Clinician assessment tools (CSSR, MOCA, MMSE,CGI, etc.)
- Document pertinent information on the individual’s healthcare record in an accurate, complete, legible, and timely manner
- Informed consent:
- Include risks, benefits, and potential side effects, as well as alternative therapies and their risks, benefits, and potential side effects
Manage Treatment Expectations
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Consult ketamine package insert and current literature for drug-specific considerations, contraindications, dosages, side effects, etc.
Pre-Treatment Medical Consultation
- History and physical
- Patient receives medical clearance:
- General medical clearance
- Specialty medical clearance (e.g., cardiac, neurological, opthamologic, urologic) as necessary based on history
- Pre-procedure labs (e.g., liver function tests, creatinine)
- Establish process for infusion and medication orders
- Evaluate contraindications to ketamine
- Administer pre-medication, as appropriate, to mitigate adverse events
- Consider recommending trial infusions to assess for responsiveness, efficacy, and tolerability of side effects prior to prolonged treatment.
- Standard course of treatment is usually a “ketamine challenge” three-to-five treatment trial (IV infusion every other day or twice per week x 3-5) to assess responsiveness to ketamine treatment. Usual starting dose is 0.5mg/kg with increase up to 1.0mg/kg depending on the response4
Administration Protocol of Ketamine by an Appropriate Provider
- Dosage (dosage is weight-based with range 0.5-1.0mg/kg)
- Volume
- Infusion time (typically infused over 40 minutes)
- Frequency (typically twice per week for 4-5 weeks with taper)
- Monitoring individual receiving ketamine during infusion
- Vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation)
- Level of consciousness
- Signs/symptoms of ketamine toxicity
- Dissociative effects
- Patient and caregiver education
- Patient sent home with appropriate driver/caregiver1
- Establish an emergency response system
Recovery
- Recovery to pre-administration vital sign baseline levels
- Baseline sensorium
- Absence of dissociative effects
Follow-Up
- Psychiatric evaluation post-treatment to assess effects, suicidality, etc.
- Patients should be monitored closely using a rating instrument to assess clinical change to better reevaluate the risk to benefit ratio of continued treatment. Assessments of cognitive function, urinary discomfort, and substance use should be considered if repeated administrations are provided (eBox 4 in the Supplement).
- Considering the known potential for abuse of ketamine, clinicians should be vigilant about assessing the potential for patients to develop ketamine use disorder.
- The number and frequency of treatments should be limited to the minimum necessary to achieve clinical response.3
- Treatment regimen – # infusions administered over # days
- Maintenance infusion(s)
- Continuous Quality Improvement
- Tracking adverse events
- Patient satisfaction
Drug Disposal and Diversion Prevention
Implement proper drug waste and disposal measures consistent with federal, state, and local law to prevent drug diversion and misuse.
Access/Reimbursement Considerations
- Many insurers (private and public) may not cover
- Establish fee schedule
- Establish collection method for self-pay patients
- Know how clinic is billing for your services
- Educate billing staff
- Identify applicable billing codes treatment1
Approved by the APNA Board of Directors June 2019. Updated August 2023.
The APNA Board of Directors would like to thank the members who contributed to the development of this resource: Paula Bolton, MS, APRN-BC; Julie A Carbray, PhD, FPMHNP-BC, PMHCNS-BC, APN; Rise Mitchell, BSN, RN, DNP, PMHNP; Mary Ann Nihart, MA, APRN, PMHCNS-BC, PMHNP-BC
Resources
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1. “Ketamine Infusion Therapy Checklist.” Ketamine Infusion Therapy, AANA, July 2016, www.aana.com/docs/default-source/practice-my-aana-web-documents-(members-only)/ketamine-infusion-therapy-checklist.docx?sfvrsn=350b49b1_4.
2. Turner, Mason, and Loretta Wilson. “Very Special K: A Little Goes A Long Way: Changing the Conversation about Mental Health Treatment.” Kaiser Permanente, June 2017.
3. Sanacora, Gerard, et al. “A consensus statement on the use of ketamine in the treatment of mood disorders.” JAMA psychiatry 74.4 (2017): 399-405.
4. Parikh, Sagar v. et al. “Developing an IV ketamine clinic for treatment-resistant depression: a primer.” Psychopharmacology Bulletin (2021) Jun1; 51(3): 109-124.
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