Ethical ketamine: 5 Questions for ketamine specialist Raquel Bennett

Bennett discusses how ketamine is used to treat mental health issues, ethical best practices, and the future of the field.

Throughout her twenties, Raquel Bennett experienced debilitating depression. She tried talk therapy, somatic therapy, and medication, but nothing helped. Around her thirtieth birthday, a psychiatrist friend suggested she try psychedelic treatment in the underground. Bennett worked with a guide but did not have good experiences with MDMA and psilocybin. LSD was helpful, but it was hard to get. Trying ketamine was Bennett’s last ditch attempt to find something – anything – to ease the pervasive depression. She immediately felt better.

That was in 2002, a time when ketamine was known for its anesthetic or psychedelic effects, but few had explored its potential as an antidepressant. After her positive experience, Bennett thought to herself, Someone ought to study this. Eventually, she realized she needed to study ketamine. She enrolled in a clinical psychology PhD program at Argosy University, and when she began writing a dissertation about ketamine, the institution initially objected to her using the words psychedelic, hallucinogenic, or even entheogenic. Others told her she was committing professional suicide by studying such things. 

But Bennett stayed the course and continued studying the use of ketamine-assisted therapy for mental health issues. She has directly worked with clients, advised medical professionals interested in using ketamine, and founded the KRIYA Institute, an organization dedicated to the use of ketamine in psychiatry and psychotherapy. The Microdose spoke with Bennett about the legality of using ketamine to treat mental health issues, ethical best practices, and the future of the field.

So, ketamine is a schedule III drug, indicated for use as an anesthetic, but it’s now being used quite widely to treat depression. Is that legal?

There are five agencies that have a say in what is considered legal. Three are visible, and two are more hidden. First, there’s the Drug Enforcement Administration, which is mostly concerned with the distribution of illicit substances. Then there’s the Food and Drug Administration, which assesses the safety of substances, and determines what the medical applications are. Then there are state boards for medicine, psychology, and behavioral health, which supervise people working in those professions. 

One of the hidden forces here is malpractice insurance coverage. If there isn't a company that will cover the treatment you’re administering, it’s too much risk for the clinicians to offer it and generally they won’t. So insurance has a say in what you can and can’t do as a clinician, though people don’t always recognize that. The other hidden variable is the body of research literature. As a clinician, if you ever get in trouble you’re asked to show in the research literature how what you’ve done is in keeping with what is scientifically validated. If it’s not in the literature, you can’t do it. 

Confusion occurs because clinicians mistakenly think that because ketamine is in the DEA’s Schedule III, they’re allowed to prescribe it however they want. But that’s not true. It’s actually pretty tricky: as a prescriber, you are allowed to make use of a medication in DEA Schedule III according to your best clinical judgment. But if, say, the state board doesn't agree with your decision making process, they have the ability to suspend or revoke your license. And in general, state boards are holding very conservative views on the use of controlled substances for an off-label application. Of course, things change over time — applications that would have been unheard of in 2015 are now routine — but at this moment, state boards run a few years behind the field in terms of what they consider appropriate clinical use.

In a 2020 document, you lay out ethical guidelines for clinicians using ketamine. What do you think people should know about ketamine treatment for mental health issues? 

During ketamine treatment, there are three roles: someone who pays attention to medical or physical safety, someone who pays attention to psychological and spiritual well being, and then, of course, the patient, whose role is to participate as much as they can, and communicate honestly. It’s important that we acknowledge that there's two dimensions to safety: medical safety — your body being harmed — but also psychological or psycho-spiritual safety. 

When we talk about ketamine, folks tend to overemphasize medical safety; ketamine is relatively safe. But people are having difficult psychological or psychiatric adverse events, so if you’re not including a mental health professional experienced in these realms, that's going to be a problem. I have received over 1,100 unsolicited complaints from people saying they have been harmed by ketamine therapy and the vast majority are about psychological or psychiatric difficulties. Many of these are when patients are getting ketamine by themselves, or in a medicalized context without a lot of attention being paid to their psychological or subjective experience.  

The federal government’s COVID public health emergency declaration relaxed some requirements for drug prescription and has allowed the mail-order ketamine business to thrive. Now that the Biden Administration is ending that declaration, those businesses may need to adapt their policies. Given the ethical guidelines you’ve laid out, what do you make of the mail-order ketamine industry?

I do think there’s a place in the spectrum of ketamine services for at-home treatment when certain clinical criteria are met, and I outlined what I think those are at the beginning of COVID.  

For COVID safety and economic reasons, to do this, the clinician and client should know each other well, the patient needs to have undergone a proper in-take process and been thoroughly evaluated, and the patient needs to be closely monitored and given small doses. I’m concerned about things like accidents, addiction, and tolerance. 

I’m not saying you should never take lozenges home, but it needs to be done carefully and it needs to be integrated into ongoing treatment. What’s happening now is dangerous and insane — it's freaking nuts. Some ketamine telehealth platforms appear to be doing a very brief intake process, as short as five minutes. That’s completely unethical; it’s not safe. There is little or no psychological preparation, very little or no help during the patient’s experience, and little or no follow up care integration. It’s incredibly dangerous — I’ve recently gotten complaints about patients having adverse effects from mail order lozenges. 

And yes, in-person services are too expensive. We need to find other ways to reduce cost to increase accessibility. There’s no doubt that there’s a shortage of mental health services in this country, and that the ones that do exist are often inaccessible to many. But sending people drugs in the mail in massive doses without screening them correctly and without providing psychological support is not the answer. It’s a way for these companies to make money; it’s good for their wallets. But it’s not good for the patients because of the substantial risk for psychological harm. 

How long does ketamine treatment last, and how do clinicians know if it’s working? Or not working? 

In my clinical experience: ketamine works some of the time, but not all the time. There’s tremendous variability in what follow-up care looks like for people: some respond well and appear to get what they need out of a couple of sessions. Other folks want or need to come back on an annual basis, roughly once a year. Other patients feel they need a booster on a quarterly basis, and a very small number of clients need ketamine administration treatment on a monthly basis. 

We only make that available if they’re fully compliant with the rest of their treatment plan, and ketamine is never more than 10% of a patient’s treatment plan. We never use it by itself; we are also trying to incorporate behavioral strategies. If you’re not helping clients learn new skills and practice new skills in addition to the ketamine treatment, you’re creating addiction, plain and simple. And on that note, I should also say that there is no evidence whatsoever that daily ketamine is an appropriate or necessary way to use this tool.

Public opinion, scientific evidence, and availability of ketamine have all changed drastically over the last decade. Where do you see ketamine when you look to the future?

There’s a paradox in what’s happening in the field right now: there’s expansion and contraction. 

I’m thinking about breath — that continuous ebb and flow of contraction and expansion — and how the whole universe is expanding and contracting at every moment. 

In ketamine, the expansion is the need to increase access to care and services to people who need them. The contraction is agreeing on some guidelines for clinicians to keep people safe. How do we do those things simultaneously?

We also need FDA approval for generic racemic ketamine for a mental health indication. That’s a key that will unlock the door for broader medical insurance coverage for this treatment. Right now, insurance companies are able to deny claims for this service because it's not FDA approved, but once it is, that could set the stage for the VA and community clinics to use this tool. 

This interview has been edited and condensed for clarity and length.