When We Decline Ketamine for a Patient

Why we publish a “when we say no” list

Most ketamine clinic marketing focuses on who ketamine helps. That is fair. The research on treatment-resistant depression, PTSD, chronic pain, and other conditions is real, and people deserve to know about it. But there is a quieter side to running a clinical practice that almost never gets written about: the patients we decline, the patients we ask to come back later, and the reasons we do that.

We publish this list because radical transparency helps both sides of the conversation. If you are reading this and one of the situations below matches your circumstances, you can save yourself a consultation that ends in a referral. And if none of these apply, you can read this list and feel a little more confident that the clinic asking you to fill out a long screening form is not just bureaucratic — it is doing the work.

Ketamine is FDA-approved as an anesthetic; its use for depression, anxiety, PTSD, and chronic pain is off-label. That regulatory status raises the bar on screening, not lowers it. Off-label use carries a professional duty to select patients carefully, document our reasoning, and decline when the risk-benefit picture does not look right.

The framework below draws from three primary sources. The 2017 consensus statement by Sanacora and colleagues from the American Psychiatric Association Council of Research Task Force, published in JAMA Psychiatry, remains the foundation. The U.S. Food and Drug Administration Spravato (esketamine) prescribing information from Janssen sets the regulatory boundary on a closely related compound. And the American Society of Ketamine Physicians, Psychotherapists & Practitioners (ASKP3) clinical practice guidelines describe how peer clinics screen patients in 2023 and beyond.

Active psychosis or untreated schizophrenia spectrum

Ketamine produces dose-dependent dissociation as part of how it works. In someone whose nervous system is already producing psychotic features — hallucinations, delusions, severe disorganization — adding a dissociative agent is not a clinical experiment we run on an outpatient basis. The 2017 APA consensus statement names active psychosis among the relative contraindications, and ASKP3 reinforces this position in its 2023 guidance.

This is not a comment on whether someone with a history of psychosis can ever be a candidate. People with stable, well-treated schizophrenia spectrum conditions sometimes pursue ketamine for co-occurring depression or pain in carefully coordinated settings. What we screen for at our clinic is active psychosis — current symptoms, recent decompensation, or a clinical picture that needs an inpatient or specialty setting rather than an outpatient infusion suite.

Unstable or unpredictable cardiovascular disease

Ketamine reliably raises blood pressure and heart rate during the infusion. In a healthy nervous system this is well tolerated. In someone with unstable angina, recent myocardial infarction, severe valvular disease, an aneurysm, or a known arteriovenous malformation, that transient cardiovascular load is not a small thing. The Spravato prescribing information lists aneurysmal vascular disease, arteriovenous malformation, and intracerebral hemorrhage among contraindications, and the same logic informs how we think about IV ketamine.

If you have unstable cardiac disease, our answer is to pause and ask your cardiologist whether your situation can be optimized to the point where an outpatient infusion is reasonable. Sometimes the answer is yes after a procedure or medication adjustment. Sometimes the answer is no, and we say so plainly.

Severe, untreated hypertension on the day of infusion

This one is more practical than philosophical. Every infusion at our clinic begins with a vitals check. If your blood pressure is uncontrolled at that moment, we reschedule. We are not going to add the cardiovascular load of a ketamine infusion on top of a baseline that is already unsafe.

We do not publish a single hard cutoff because the right number depends on your baseline and your medications. What we will say is that if you have hypertension, we want it managed by your primary care provider before you book a series with us. Showing up the day of with readings well outside your target range is a common reason for a same-day reschedule, and it is not something we apologize for.

Pregnancy and breastfeeding considerations

We do not provide elective ketamine infusions during pregnancy. The safety data in pregnant patients is limited, animal data raises concerns about neurodevelopmental effects of NMDA antagonism, and the 2017 APA consensus statement names pregnancy as a relative contraindication for elective ketamine in mood disorders. Severe perinatal depression that may warrant ketamine is a decision for a coordinated obstetric and psychiatric team, not an outpatient ketamine clinic.

For breastfeeding patients, we discuss timing, pumping, and what is known about ketamine’s pharmacokinetics in lactation. Our pregnancy and breastfeeding article walks through the reasoning in more detail, and we always recommend looping in your obstetrician.

Recent suicide attempt without a coordinated psych team

This is the situation where we have to be careful with language, because we treat depression that includes suicidal ideation. We are not declining people because they are struggling. We are declining people whose acute risk profile needs more than what an outpatient infusion can offer.

If you have made a suicide attempt in the recent past and you do not currently have an active treating psychiatrist or crisis team, our first job is helping connect you to that infrastructure. Outpatient ketamine is not crisis stabilization. It is not a substitute for a safety plan, a treating clinician who can adjust medications and monitor risk between sessions, and the structure that keeps a high-acuity patient alive long enough to benefit from any treatment. ASKP3’s 2023 guidance specifically calls for psychiatric coordination in cases of high-acuity suicidality, and that lines up with how we operate.

Once that scaffolding is in place, ketamine can be a meaningful part of the conversation. We have seen it help. But the order matters. Psychiatric team first, then ketamine.

Active substance use disorder targeting dissociatives

Cannabis use alone is rarely a hard stop. Many of the patients we treat use cannabis for sleep or pain, and we work with that. What is a hard stop, until it is addressed, is active misuse of dissociative agents — ketamine itself, PCP, or DXM — or active untreated substance use disorder more broadly.

The reasons are layered. Repeated recreational ketamine exposure changes how a clinical infusion lands. The setting we provide is built for therapeutic context; we are not interested in feeding a pattern that is harming someone. And ASKP3 specifically lists active dissociative misuse among the patient-selection exclusions in its 2023 guidance.

If you are in recovery and have a treatment plan, that is a different conversation. Ketamine has actually been studied as an adjunct in addiction treatment in coordinated programs. Honesty during screening matters here more than anywhere else. We would rather know up front and help you find the right sequence of care than discover the picture mid-protocol.

Untreated bipolar disorder with mania risk

Bipolar depression responds to ketamine in a meaningful subset of patients. We have written about that in our bipolar depression overview. What we screen carefully for is whether mood-stabilizer coverage is in place and whether a treating psychiatrist is involved. Active mania, mixed states, or psychotic features are reasons we pause. The risk of destabilizing a fragile mood baseline is real, and we are not equipped to manage that as a standalone outpatient practice.

Severe hepatic impairment and other medical edge cases

Ketamine is metabolized in the liver. Severe hepatic impairment is named in the 2017 APA consensus statement as a relative contraindication, and we screen for it as part of our intake. Other situations that prompt extra caution and sometimes deferral include uncontrolled hyperthyroidism, severe untreated obstructive sleep apnea, recent intracranial pathology, or active complex medication regimens with significant interaction risk. Our medication interactions article goes deeper on the drug-level screening we do.

What “not yet” looks like vs. “not at all”

Most of what we have described here is reversible. Not yet is the more common verdict than not at all. A blood pressure that is uncontrolled today can often be managed with a primary care visit. A bipolar diagnosis without psychiatric care can be paired with a treating psychiatrist. A recent crisis can be stabilized into a longer-term care plan. Substance use can be addressed in a treatment program, and the door reopens after.

When we decline, we try to be specific about what would change our mind. If we say no today, we will tell you what a yes would require. Sometimes that is six months and a different clinical picture. Sometimes it is a single appointment with your primary care provider. The point is that no is rarely the end of the conversation.

What we recommend instead

If we decline, we do not just send you away. Depending on the picture, we may recommend connecting with a primary care provider, a treating psychiatrist, a substance use program, an OB practice, or an inpatient or partial-hospitalization setting. If your primary care provider is the right next step, our piece on how to talk to your PCP about ketamine can help frame that conversation.

Research suggests ketamine may help across a range of conditions, but the evidence supports it in selected patients, in clinically appropriate settings, with the right safety scaffolding. Studies indicate that proper patient selection is one of the strongest predictors of both safety and outcome. Our safety overview describes the monitoring side of that equation. Marla Peterson, CRNA, oversees every infusion, and the screening discussed here happens before anyone is ever connected to an IV.

We say no because we want this to actually help — not to gatekeep. A safe yes for the right patient at the right moment is worth more than a fast yes for everyone who walks through the door. — Music City Ketamine

If you are not sure which side of these lines you fall on, the consultation is where we figure it out together. We are happy to spend the time. And if the answer today is not yet, we will tell you exactly what would move you to yes.