Depression is a common, severe, and potentially life-threatening syndrome. Several preclinical and clinical studies suggest that the glutamatergic system is involved in the mechanism of action of antidepressants. The non-competitive NMDA antagonist ketamine has been shown to have a rapid (hours) therapeutic effect in unipolar depression, treatment-resistant depression, and bipolar depression. Intravenous (IV), intramuscular, sublingual, or oral administration of subanesthetic doses of ketamine results in rapid, robust and relatively sustained antidepressant effects including the rapid resolution of suicide ideation. 

Pain categorization is important for determining diagnostic workup, guiding treatment decisions, and predicting outcomes. Among chronic pain patients, between 15% and 25% are estimated to have a predominantly neuropathic etiology.  For CRPS type I, which fails to meet the most recent International Association for the Study of Pain definition of neuropathic pain but is the most common indication for ketamine treatment, the estimated prevalence rates vary between 20 and 30 per 100,000 person years.  Yet, these statistics may belie the true burden of neuropathic pain, as studies have shown that neuropathic pain may be associated with a poorer quality of life than comparable degrees of non-neuropathic pain.  A recent review found the strongest evidence for IV ketamine to be for the treatment of neuropathic pain and CRPS, although the non-neuropathic pain condition they compared them to was fibromyalgia.  In addition to fibromyalgia being a particularly challenging condition to treat, the studies cited also utilized lower dosages. Anecdotal evidence also supports intermediate-term benefit for ketamine infusions for non-neuropathic pain conditions such as refractory headaches and back pain.

The following clinical algorithm was developed to implement and ensure the safe use of ketamine for the treatment of moderate to severe, treatment resistant depressive symptoms, moderate to severe obsessive compulsive disorder. This guideline is based on an extensive review of the literature as well as the combined collaborative experience of physicians using ketamine for the treatment of depression. Given the safety and high degree of flexibility in the administration route of subanesthetic doses of ketamine, this guideline provides a set of broad and flexible recommendations that can be implemented as recommended by the psychiatrist, pain medicine physician, or primary care physician working in consultation with anesthesia to best fit specific cases, with the goal of reducing patient symptoms of psychological disease and chronic pain.

Ketamine administration for depression and chronic pain will follow ASA guidelines for Moderate Sedation/Analgesia (Conscious Sedation). Under this guideline, Conscious Sedation is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually not impaired.

Ketamine has not been approved by the FDA to treat depression, bipolar disorder, PTSD, or chronic pain.


Ketamine has been associated with a decrease in pain, depression, bipolar, and PTSD symptoms with results lasting for days to weeks to months. There is no way to predict how any single person will respond to ketamine infusion therapy. These effects may not be long lasting and will most likely require further infusions.

What to expect: 

An intravenous line (IV) will be started in an extremity so you can receive ketamine. The risk of venipuncture (IV line insertion) may include temporary discomfort from the needle stick, bruising, infiltration or infection. Fainting may also occur. Your blood pressure, heart rate, and oxygen saturation will all be monitored throughout the infusion under the supervision of a physician.  Patient monitor will observe the patient for 30-60 minutes after ketamine administration. This monitoring will be conducted in the same place where the treatment was administered.

General Requirements:

The administration of ketamine for the treatment of depressive symptoms and chronic pain will be under the constant supervision of an anesthesia provider with a physician in office and with rapid access to resuscitation equipment.


1. Adult patients who are American Society of Anesthesiologists (ASA) PS 1 or 2 are usually considered appropriate candidates for moderate or deep sedation and they will be considered ideal candidates for ketamine administration. Patients with ASA PS 3 and 4 can be considered for ketamine administration but they will require additional precautions. ASA scores will be determined by the anesthesia provider. 

2. Adult patients reporting moderate to severe depressive symptoms who have failed to respond to at least 2 adequate treatment trials, those reporting suicidal thoughts with a history of depression (with an active, established relationship with a psychiatrist), patients with co-morbid depressive symptoms and pain who cannot receive standard oral antidepressant therapy due to medical problems affecting their PO intake, patients reporting severe obsessive compulsive disorder, patients with post traumatic stress disorder, postpartum depression, and patients diagnosed with depressive bipolar disorder.

3. Adult patients without contraindications for ketamine treatment including active psychotic symptoms or history of a primary psychotic disorder (e.g., schizophrenia or schizoaffective disorder), manic symptoms, hypersensitivity to the drug or its components, history of severe, ongoing alcohol or substance dependence (including ketamine), severe liver disease, pheochromocytoma, uncontrolled hyperthyroidism, and ASA PS 5 and 6.

4. Adult patients with chronic neuropathic pain issues including phantom limb pain, postherpetic neuralgia, complex regional pain syndromes, diabetic neuropathy, trigeminal neuropathic pain, pain related to Lyme Disease, chemotherapy-induced neuropathy, and pain related to stroke or spinal cord injuries referred by a pain management specialist or neurologist.  

5. Adult patients suffering from new onset daily headaches, fibromyalgia pain, pain related to Crohn’s disease, chronic sickle cell pain, chronic migraines, cancer pain, and breakthrough non-cancer pain referred by a pain management specialist, primary care physician, oncologist, or neurologist.

Risks/Side Effects:

Side effects normally depend on the dose and how quickly the injection is given. The dose being used is lower than anesthetic doses and will be given slowly over 40-60 minutes. These side effects often go away on their own.

Common side effects:

· hallucinations

· nausea and vomiting

· increased saliva production

· dizziness

· blurred vision

· increased heart rate and blood pressure during the infusion -out of body experience during the infusion

· change in motor skills

These symptoms dissipate when the infusion is stopped. If they are severe, another medication such as a sedative can be used to treat the symptoms. You should not drive the day of an infusion and can resume driving the following day.

Ketamine Insurance Coverage Information

Ketamine has not been approved by the FDA to treat depression, bipolar disorder, PTSD, or chronic pain.

New Tampa Interventional Pain and Sports Medicine
2321 Crestover Lane
Wesley Chapel, FL 33544
Phone: 813-257-9617
Fax: 813-333-0453
Office Hours

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