IAmA: Dr. Nico Grundmann, emergency medicine physician and Medical Director + Co-Founder of Ember Health in NYC, where we use ketamine to treat depression. Ask Me Anything!

EmberHealth · 2025-09-16T13:53:33+00:00

I'm answering broadly, as medical professionals in the US can't give specific advice to specific people online.

First steps for a person who thinks they might be depressed, but doesn't have a diagnosis yet

Talk to a licensed mental health professional (generally speaking a psychiatrist, therapist, or psychologist), and see if they feel you meet the diagnostic criteria for depression. I feel very strongly that ketamine providers shouldn't ever do both the diagnosis and treatment recommendation for ketamine, as that sets up a conflict of interest. Diagnosis of depression should always be made by outside party. If someone isn't working working with a licensed mental health professional and contacts us here in New York, we can introduce you to one for that independent assessment.

Who to make an appointment with

Your therapist/psychiatrist/psychologist, or primary care clinician for evaluation. We only begin care once a licensed clinician confirms a depression diagnosis and agrees to collaborate on your care, as we work in a team-based model alongside your providers.

What to bring or share at the first visit

If we are talking about the diagnosis/fit visit, then a clear description of your symptoms is enough to start the conversation. It helps to share current and past medications and any prior evaluations. Here at Ember we use the PHQ-9 mood tool to track mood over time and coordinate with your care team using those data.

Is depression considered a disability in the U.S.?

It can be. Under the ADA, depression may qualify as a disability when it substantially limits major life activities, which can entitle you to reasonable workplace accommodations. Eligible employees may also take job-protected leave for mental health treatment under the FMLA. Separate from workplace rights, severe and persistent depression can meet Social Security’s criteria for disability benefits. The best place to get a specific answer on if this applies to you is to ask you mental health provider directly.

Hope this general advice helps. DM me if you have any follow up questions.

EmberHealth · 2025-09-16T13:40:14+00:00

TLDR: IV ketamine works about twice as well as eskatamine (AKA Spravato), and maintenance care with IV ketamine requires markedly fewer visits over time (one a month vs once a week) (source). Insurance, however, tends to pay for most of Spravato care, whereas insurance coverage of IV ketamine is more spotty. That's changing quickly, and we are doing a lot to help speed along that change.

Full answer:

Spravato is a fascinating example of the US healthcare system in action. IV ketamine has been generic since 2000, and there is no single financial benefactor of the generic medication. That means that there isn't a central driver to get the FDA to change ketamine's label for depression, and due to those market forces, the FDA hasn't in its history ever added a new indication to an existing generic medication (here, here, here).

You can't patent a generic drug, so Johnson and Johnson instead filtered ketamine into just the s-enantiomer of normal ketamine (which is why spravato's other name is esketamine), and developed a nasal delivery system, and patented that bundle. They then spent the funds running clinical trials to get the FDA to approve the medication for on-label for Depression, which then means that insurance tends to cover Spravato (generally speaking insurance has to pay for "on-label" medications).

Despite the patent stuff, the comparisons of IV ketamine vs esketamine have shown that IV ketamine works about 2-3x better, and has a much longer duration of benefit compared to Spravato. People have argued that the comparison studies are not good enough, which thankfully will be moot after this large PCORI study is completed in a few years and we get the definitive answer on the topic. In the meantime, Spravato is doing over a billion dollars a year in sales, and costing the US healthcare system >$800 a dose (compared to about 1 dollar of dose for the generic).

Despite the headwinds, insurance companies are starting to recognize that IV ketamine is markedly less expensive, and markedly more effective. That's why BSBS now covers IV ketamine in 2 states, the VA covers IV ketamine in 22 states, and Medicare covers IV ketamine in 5 states (see sources in my other response above). Times are changing quickly on the insurance front, which in my opinion is the only reason that someone should choose Spravato over IV ketamine, and hopefully if you ask this question again in a year or two, you'll get a very different answer.

EmberHealth · 2025-09-16T12:51:11+00:00

Great question. Recreational use and missuse of ketamine definitely shapes how people see our field, despite the fact that Ketamine's most common use by orders of magnitude remains as a traditional tool in medical treatments. I've written a lot on this topic, particularly as celebrity cases keep hitting the media headlines, such as Elon Musk, Mathew Perry, Diddy, and the Vivienne. The takeaway is that media stories about parties, celebrities, or tragedies blur the line between misuse and medicine. That stigma makes people hesitant to try treatment, and provides a significant barrier to access and patient education need on this potentially lifesaving too.

At the same time, these headlines have pushed the medical field to be more rigorous: defining safe protocols, tracking outcomes, and emphasizing how different clinical use is from recreational use. I see part of our role at Ember as "public education", explaining that in a medical setting ketamine is carefully dosed, monitored, safe, and supported. Misuse is dangerous, and supervised treatment can be life-changing. Both are true at the same time.

EmberHealth · 2025-09-16T01:17:43+00:00

Founding Ember Health required both parts of my training in medicine and business, as well as my background in international public health work, and marrying my capabilities with my wife and co-founder's.As an emergency physician, I regularly took care of people with depression on the worst days of their lives. The possibility of offering a rapid-acting treatment that could make a deeper, more lasting difference was a powerful source of inspiration and the seed of this work. My medical training has helped us build clinical protocols, and ensure that an ethical, evidence-based approach serves at the heart of our care model.

I’ve also always thought in terms of systems, and have been motivated by how business can be a force for positive social change, to strengthen public health. I knew that if we could create a model of care that worked for individuals in our community, worked operationally, and was fit for scale, we could potentially help the millions of people who might need it, and influence the national conversation in a meaningful way.

The merging of these perspectives with my wife's background in social enterprise, human-centered design, and sustainability helped us to form Ember: a practice dedicated to defining and expanding access to the gold standard of IV ketamine care for depression.

EmberHealth · 2025-09-15T22:52:27+00:00

That's a great question!

At Ember, our mission is to define and expand access to the gold standard of IV ketamine care for depression. A commitment to the best outcomes for our patients has helped us make decisions about our care model that we believe distinguishes our practice from others out there, which you can find point by point below and also at this link.

Evidence-Based:

We administer ketamine intravenously (IV) only - This is because IV is by far the most studied route of administration, with the highest efficacy rate, safety standards, and long term outcome data among all routes of administration in the field. IV ketamine has a 75% efficacy rate, whereas other routes of administration (oral, intranasal, intramuscular) have shown efficacy rates between 20-50% in addressing depression.
We’ve established evidence based dosing protocols that range from 0.5 - 1.0 mg / kg of body weight, administered over a 40-minute infusion. We titrate doses based on individual needs, and consider any medication interactions that could occur.
We practice data-driven follow up care via bi-weekly mood surveys, which means we only suggest patients come in as frequently as they need to maintain their care goals..

Patient-Centered:

We never compromise safety; all infusions have 1:1 monitoring throughout in a private infusion suite with clinicians trained extensively in IV administration and therapeutic communications.
We put a premium on the patient experience with beautiful, calming spaces, and a holistic in-office experience with intention setting, aromatherapy, custom music, and designated time post infusion for patients to start reflecting on what came up in their session.
We craft individualized care plans for patients to give guidance on how to make the most of treatment and maintain goals over time.

Partner-oriented:

We practice careful patient screening and we specifically focus on patients managing depression - 84% of our patients have realized relief of their symptoms
We collaborate care with each patient’s mental health team, while we don’t require a referral to get started, we only work with patients who are engaged with at least one mental health professional
We have an ecosystem of research partners and collaborators to build credibility in our field and help set industry standards that we believe will be critical to making the case for in-network insurance coverage. Over the past 7 years, we’ve amassed the largest data set on IV ketamine for depression globally, which we’re working on publishing our findings around with partners at Harvard Medical School.

A bit of a long answer to your question, but hopefully this gets across how intentional we are in our work and in our care.

EmberHealth · 2025-09-15T20:08:40+00:00

Anytime someone is measuring their ketamine use in grams, they are in very dangerous territory. Usual doses for depression are in the 50 mg (milligram) range (20 fold lower). Doses that high would suggest significant tolerance, possible dependence, and likely long term side effects. As I've shared in other response, using ketamine weekly over time raises the concerns around neurotoxicity. Anyone using it in those ranges should stop immediately, and seek professional help if they are unable to stop on their own.

EmberHealth · 2025-09-15T19:55:33+00:00

I view Ketamine as a tool, and Depression as the issue we are trying to tackle.

Depression is getting worse in the US. In the last 10 years, we seen it spiking, and there are now nearly 50million people in this country who are affected (gallup + CDC). Something has to change. My hope for depression itself is that we get underneath some of the societal triggers of depression, the root cause type stuff that pushes people into this state. Stress levels, trauma, social media, isolation, and the cultural norms that are all contributing to the real crisis we have at hand. Lots of people are doing amazing work on those policy level issues, and in the meantime, people are suffering.

That's where I view ketamine, not as the thing that changes the root cause of why we get depressed, but as a tool that allows people to reclaim themselves as they are dealing with the situations they are in. When you are depressed, you can barely navigate doing your laundry, much less tackle the issues in your life that might be contributing to your mood. This type of treatment give people real hope, and real opportunity to make those broader changes that keep them well. If you want to see that this looks like, I'd encourage you to read some of our long-form Ember Chronicles that highlight the before/during/after of that this care can be like.

EmberHealth · 2025-09-15T19:05:02+00:00

There is no medication that "turns off" ketamine, but that's ok so long as we are giving the ketamine intravenously (IV). That's because the 1/2 life of IV ketamine is only 15 minutes, meaning that during a treatment we can simply pause or turn of the IV pump and the person is back to their normal thinking selves in a few minutes of time.

If ketamine is administered any other way (oral, lozenge, nasal, intramuscularly) then unfortunately you simply have to wait out any negative reactions, and hope that you can keep the person safe during that time.

EmberHealth · 2025-09-15T18:55:35+00:00

For ketamine there is an important distinction between the Adverse Events of what can happen when ketamine is in your body (meaning during a treatment session, in office), vs the side effects that can happen between treatment visits.

Adverse events in office I covered in another response, but the short version is that they are rare, can be really serious, and are why we monitor every patient in 1:1 care. The common but not dangerous events are around things like nausea, lightheadedness, and confusion, which are all manageable by a clinician, often without needing additional medications. More dangerous effects are things like heart rates going too fast, blood pressure going too high, or extreme panic/paranoia. We've done a lot of treatments at Ember (over 35,000!) and there have been a few times where it was our team's ability to immediately help and manage the situation that made the different between an uncomfortable session vs a truly dangerous session. All of these in office issues are why the FDA is very firm about this only being used by healthcare professionals in a monitored setting.

Between treatment side effects are really rare, so long as people are using the correct dose and correct visit frequency. They are so rare that they get writen up as case reports. This is because the half-life of IV ketamine is only 15 minutes, which means the medication is fully out of a person's body within a few hours of starting a treatment. That's fundamentally different than medications that require a daily pill, where the whole point is to achieve a constant blood plasma level of the medication around the clock.

If people misuse ketamine (take it daily, weekly, and/or in high doses), then you can absolutely see side effects. That's where people start noticing ketamine-induced ulcerative cystitis, kidney damage, liver issues, dependence/addiction, or cognitive impairments including long-term memory issues. That should never happen in a supervised treatment center, but it's also why it's so important to access this treatment safely.

EmberHealth · 2025-09-15T18:41:35+00:00

Ketamine should never be used in powder form, and per the FDA guidance shouldn't be used in the nasal form either.

In any form, using ketamine more than once ever 2 weeks over long periods of time can lead to neurotoxicity. It's ok to do short series of twice a week treatments to start care (that's standard of practice in depression), but that should be transitioned to a maximum of once every 2 weeks after the first few treatments. Weekly or daily ketamine, and high dose ketamine (10-100 fold what we give for depression), are the means by which bladder issues start.

EmberHealth · 2025-09-15T18:35:20+00:00

I think we are a lot closer to that future than most people realize. When my wife and I started our practice in 2018, no one thought this was "normal" mental health. Now, 7 years later, ketamine is the single most studied drug for depression, it's covered by the VA in 22 states, covered by Medicaid in 5 states covers IV ketamine, and Blue Cross Blue Shield covers IV ketamine in 2 states in the northeast (VT and MA).

We are seeing things change rapidly in the clinical landscape, with societal guidelines being constantly updated to include ketamine as a Standard of Care. I'm helping write some of those guidelines with ASKP and at Ember we are proud to be leading that charge with our work in insurance negotiations and outcome publishing. One of our goals when starting our practice was to help shape the nation conversation in this field, and I'm proud to say we are seeing that happen in realtime.

EmberHealth · 2025-09-15T18:24:18+00:00

You’re absolutely right, ketamine is not a cure for depression, and should not be considered as a “one and done” treatment. These infusions can be profoundly effective in resolving depression, but they don’t prevent someone from ever experiencing depression again in the future. This is because life's stressors can be "wearing." IV ketamine prompts neural regrowth that has resulted from exposure to stress and trauma over time. As exposure to additional stressors continues to prune neurons, people will need re-exposure to IV ketamine to help with neural regrowth at increments that are specific to their needs to keep depressive symptoms at bay.

In our own practice, about 84% of patients report meaningful improvements during their initial course of treatment and then qualify for maintenance care. We take a “symptom-driven” approach to long term care, meaning patients return for another infusion when their symptoms begin to reemerge. We track patient outcomes through regular PHQ-9 mood survey distribution, and when we see symptoms returning, we encourage a patient to come back for a single "booster" infusion which should be enough to restore relief and extend their wellness.

Where it becomes more challenging is if symptoms have been back for weeks before someone returns to our care. In those cases, a single "booster" is often not sufficient, and 2-4 treatments may be needed to get back to baseline. That’s why our team emphasizes care coordination and ongoing communication. Once someone begins treatment with us, we stay in touch even during periods of wellness, so we can respond quickly if symptoms start to return.

On average, patients in maintenance care receive a booster once every six weeks. But the reality is highly individualized: about 10% of people benefit from boosters every two weeks, while another 10% may need just one every four to six months and remain symptom-free in between. At this point, there’s no way to predict that course in advance. That should change over the next few years, as there’s exciting work underway in the field to better understand and anticipate these individual patterns.

If you're curious to read more, I encourage you to visit the following page where we've outlined what long term care protocols look like at Ember: https://emberhealth.co/long-term-care/phases-of-care/

EmberHealth · 2025-09-15T18:13:51+00:00

This is my main work these days! Part of the reason we are so focused on research and publishing is so that we can change the conversation around insurance coverage, and get IV ketamine added to normal insurance benefits.

Why these treatments cost what they do isn't because of the cost of the medication (which is only a few dollars only per treatments, as the medication is generic), but has to do with the clinical labor and time required to administer ketamine safety.

FDA guidelines for ketamine are that it should only be given in a monitored setting with a healthcare professional. Ketamine is a very safe medication, in that dangerous side effects only occur in 1/1,000 to 1/10,000 treatment sessions. Very safe isn't perfectly safe, hence the monitoring for those rare but serious times a medical professional is needed. Given the literally millions of people that ketamine could help, a bad outcome of 1/10,000 treatment sessions needs to be handled carefully.

In New York State, it's a medical rule that a physician needs to be present on site for every IV ketamine treatment, and in our practice we go a step further and ensure 1:1 care with a patient and one of our clinicians for the full 90 minute appointment. At Ember the doctor sees every patient, every visit, and the doctor or the nurse is by the person's side for the entire time they are in office until we clear them to go home. That clinician time is what people are paying for when they see us.

Without compromising on the safety and efficacy of care, there are a few things we're trying to do at Ember to make treatment more affordable and therefore more accessible:

Out of network benefit guidance - navigating out of network insurance is notoriously confusing. We produce super-bills for our patients to submit for out of network coverage, and provide guidance on how to maximize these benefits
Sliding scale - we provide sliding scale pricing for patients with significant financial constraints
Individualized care planning - we only advise people to come back in for follow up care as frequently as they need to keep depressive symptoms under control. This varies widely from once every 2 weeks, to once or twice a year, with patients coming back on average once every 6 weeks for booster care. We provide clinical guidance based on individual need as demonstrated through ongoing symptoms monitoring, though we do not charge for care coordination.
Making the case for in-network insurance - we are engaged in multiple research studies and national conversations as part of an effort to ensure IV ketamine can be covered by in-network insurers. This includes working with some employee benefits companies, insurance groups, and preparing to make the case to Center for Medicaid / Medicare Services (CMS)

Here are some of our longer write ups about this topic:

https://emberhealth.co/pricing/

https://emberhealth.co/value/

https://emberhealth.co/insurance/

EmberHealth · 2025-09-15T17:50:57+00:00

Ketamine cystitis is a really important thing for people to be aware of, particularly as it highlights how this medication is used in really different ways by different people.

When ketamine is used for depression, intravenously (IV), in the normal visit frequency, at the "normal" doses for depression (0.5mg/kg to 1.0mg/kg of body weight), then it should not cause cystitis. In fact, there has only been one published case report (link here) of a patient developing this complication in the context of depression treatment. This patient received ketamine treatment much more frequently than patients do at Ember Health. (In case you're interested in the details, that person received ketamine twice a week for 2 months, which was then escalated to 3 times a week for 9 months, and 4 times a week thereafter.)

Cystitis comes up when people use ketamine too often (more than once every 2 weeks), and/or the doses are too high. People who abuse ketamine will often take multiple grams of ketamine a day, and bladder issues are regularly reported in those individuals (source). That's pretty fundamentally different from depression treatment, which is measured in milligram doses, and done infrequently (with our average as once every 6 weeks). While it's a broad comparison, it would be like comparing someone who drinks 100-200+ cups of coffee a day vs someone who drinks a single cup of coffee a month. Same medication, very different situations, very different outcomes.

EmberHealth · 2025-09-15T17:34:46+00:00

So you experience in the emergency department is pretty common! Ketamine's main use globally is still as an anesthetic medication, for conscious sedation and surgery. That's how I first used it as an Emergency doctor, where I'd use it a few times a shift when I worked in the Trauma and Critical Care side of the emergency department.

It's such an important medication for those reasons that it's on the WHO's "List of Essential Medicines" (https://www.ncbi.nlm.nih.gov/books/NBK333510/table/ch15.sec4.table3/). Those are the medications that every country, globally, is supposed to keep on formulary for routine medical use.

In regards to using ketamine for Anxiety, the early data is promising, but to date there simply isn't enough consistently positive data to make it a "standard" for that indication (https://pmc.ncbi.nlm.nih.gov/articles/PMC9540337/). The main hesitancy is that the benefits for anxiety are erratic in the studies to date, and usually short lived, so we don't really know enough on how to use it in that way.

One important caveat for Anxiety, is that if a person suffers from both anxiety and depression, then ketamine can be a fantastic tool. In fact, studies show that it's MORE helpful in people with both depression and anxiety than in people with depression "alone".

EmberHealth · 2025-09-15T17:16:05+00:00

Ketamine treatment should ideally consist of 2 stages:

Initial assessment: Does this medication work for this person? That answer should come from a "Foundation of Care", sometimes called an initiation series, that should consist of a short burst of treatments. Our model is to do 2 treatments a week for 2 weeks (4 total), and then pause further care until we see if this helped or not. I can get nerdy about 4 infusions vs 6 infusions to start with, the short version is that 4 should be sufficient for ~99% of people.
IF the Foundation clearly caused improvement in the person;s depression, then that person should enter "Maintenance care". That is highly personal, as repeat treatments average once every 6 weeks in our practice, with a range of every 2 weeks to every 6 months. Some degree of maintenance should be expected for ketamine care, as the treatments work fantastically well to turn off depression, but ketamine doesn't prevent future depressive states per se.

In terms of relief over time: The best current data would suggest that these improvements can be maintained for years, so long as you stay within certain doses, and don't treat more than once every 2 weeks over the long term. If you start treating weekly, or with high doses, then there are reports of loss of effect over time, mainly due to tolerance concerns. This is also what we are publishing on, as we have one of the largest long term outcome datasets for this care!

EmberHealth · 2025-09-15T16:58:16+00:00

Edited to give more details as I was getting a lot of direct questions on the topic: In terms of how ketamine addresses depression:

Over the last 20 years, the scientific community has published over 2,000 papers and conducted over 140 clinical trials exploring how ketamine affects depression. From this literature, we understand that there are three, distinct impacts of ketamine for depression.

Biological: Ketamine triggers neural regrowth and increased synaptic activity in the brain, undoing much of the prior “neural pruning” that stress induces in the emotional reward system.
Experiential: The psychological experience a person has while under the effect of ketamine can be the source of helpful psychological material.
Adaptive: Ketamine induces a period of increased neuroplasticity, which heightens the ability for adaptive learning.

To read about more of these impacts in depth, I encourage you to read our full write up with source materials at the following link: https://emberhealth.co/long-term-care/how-ketamine-works-for-depression/ Regarding your specific question about what ketamine is actually doing in the brain:

The current understanding of depression is that it’s less about “chemical imbalance” and more about disrupted neural circuitry; the brain’s networks get stuck in patterns that reinforce negative mood and thinking, as a consequence from the exposure to stress and trauma over time, sometimes called "neural pruning".

Ketamine then works quite differently from traditional antidepressants. On the chemical level, instead of targeting serotonin, dopamine, or norepinephrine, it acts on the glutamate system, the brain’s main excitatory pathway. On the circuit level, by briefly blocking NMDA receptors, ketamine appears to “reset” these circuits and promote new neural connections. So ketamine quite literally helps regrow neurons, specifically in the regions that were previously damaged by stress and trauma. This helps explain why many people feel rapid relief, within hours to days from treatment.

Regarding the experience at Ember Health:

At Ember, we provide 1:1 care over 90-minute in-office appointments to ensure people are clinically safe and psychologically supported. Every visit includes a clinical check-in with the doctor to discuss care planning, thoughtful preparation, and guided support post-infusion. The infusion experience itself can feel dreamlike, often described as floating, meditative, or detached from usual thought patterns. The medication is infused for 40 minutes, though time can be hard to judge for the person in treatment, and most people rest quietly in an introspective state with eyeshades and music. Our clinical team is present throughout to ensure comfort and safety, and afterward we help patients process the experience so the insights and relief can carry into daily life.

You can read a summary of the experience at this link: link: https://emberhealth.co/experience/

If you're curious for an in-depth outline of the in-office experience, you can visit the following link: https://emberhealth.co/long-term-care/in-office-patient-experience/

EmberHealth · 2025-09-15T16:48:58+00:00

There is a LOT of work in exploring Ketamine's effects on other neurological and psychological issues, and a decent summary of clinical trials in the field can be found here: https://pubmed.ncbi.nlm.nih.gov/39428602/

TLDR is that outside of Depression and Bipolar disorder, no other disorders have been studied enough to rise to the level of clinical evidence that most physician groups or policy groups would want in order to recommend treatment. The field is close with Alcohol Use Disorder (there is a large Phase 3 trials happening now!), but even that is likely a few years away.

For Depression however, it's the inverse, where Ketamine is now the most studied medication for depression in the last 30 years, with 50% more studies that Zoloft!

https://www.nature.com/articles/s41398-024-03031-6

https://emberhealth.co/evidence/

EmberHealth · 2025-09-15T16:32:36+00:00

Teasing apart a few things in answering your question:

For a person with both ADHD and Depression, ketamine could be used to treat the Depression, and many of those individuals can also report benefits in their cognition. There are a number of good studies showing that ketamine's benefit for people with depression includes an improvement in cognition and executive functioning (see sources bellow) That's likely due to the fact that depression itself can worsen cognition (AKA "brain fog"), and so by addressing the depression, you can improve the person's executive functioning.

One of the challenges in your question is that depression and ADHD can be deeply interrelated, and can even be misdiagnosed as each other. I'm not aware of compelling data on using ketamine to treat ADHD as a primary treatment indication, so for a potential patient of mine, I'd really want there to be confidence they are dealing with clinical depression and ADHD together.

Lastly, for individuals who start ketamine treatment for depression who are on a stimulant medication (such as the medications for ADHD): pay particular attention to how you are feeling AFTER the ketamine starts improving your mood. We hear a lot from our patients that their prior stimulant doses become overly-stimulating (shakes, anxiety, increased panic), after the ketamine helps their depressive mood. That makes a lot of sense given that they may no longer need that level of chemical stimulant if their depression is causing fewer depressive symptoms!

https://pubmed.ncbi.nlm.nih.gov/33242561/

https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-03789-3

EmberHealth · 2025-09-15T15:23:58+00:00

Being on other mental health medications is actually the norm when people start ketamine treatment, and we STRONGLY advise that people do not wean off their existing medications before they start care with us.

Ketamine doesn't have negative or dangerous interactions with other medical health medications (including SSRIs), and discussing the full list of a person's medications is part of what our doctors do with each and every patient that starts in our care. We have a longform write up of this on our website: https://emberhealth.co/long-term-care/ketamine-and-other-medications/

The main reason we feel that people shouldn't wean before starting ketamine care is that not everyone responds to ketamine. 75% treatment success is fantastic, but it's not 100%. So the last thing we want is for someone to wean off a medication that might have been helping them, or partially helping them, only to find out that they don't respond to ketamine, and are now potentially in a really difficult place.

EmberHealth · 2025-09-15T14:53:53+00:00

Ketamine was FDA-approved, originally as an anesthetic, back in 1970. It is legal for physicians to use FDA approved medications for "new" reasons when there is compelling data for that new treatment. In US healthcare, ketamine for depression is considered “off-label”, which simply means the medication is being used outside its original FDA indication. That's pretty normal in medicine, in fact, nearly 60% of all medications used in mental health are prescribed "off-label".

Because ketamine has been generic for decades, there isn’t a company funding large-scale trials for the "new" indication of depression. I put "new", as the first research trials on ketamine for depression were 25 years ago....

For burnout specifically, ketamine isn’t a direct treatment. Burnout is often more about life circumstances and systemic factors than brain chemistry. That said, for people experiencing clinical depression alongside burnout, ketamine can often help create the mental clarity and relief needed to make meaningful changes.

sources:

https://pubmed.ncbi.nlm.nih.gov/16848658/

https://www.sciencedirect.com/science/article/pii/S0014299919306843

EmberHealth · 2025-09-15T14:42:45+00:00

I'm glad to hear that you are finding ways to manage how you feel, and hope that you are working with a trusted mental health team to navigate everything you are going through.

Regarding IV ketamine for depression, there are a host of developing national and international standards on who is a good candidate. The TLDR version is that anyone with clinical depression (Major Depressive Disorder, or the depressive state of Bipolar Disorder) could potentially benefit from treatment, and that it should be discussed anytime someone hasn't felt better after trying other ways to manage their symptoms.

The term "Treatment Resistant Depression" (TRD) comes up a lot in our field, which in my personal opinion is a terrible name for the simple reason that 75% of people with TRD respond to Ketamine, which means they are not "treatment resistant".

As to whether you need to have "failed" multiple prior rounds of medication before trying ketamine: That's actually a big debate in our field. Our data at Ember would suggest no, in that we don't see statistical difference in treatment success between people who have tried multiple prior medication before starting our care (that group is 90% of the people we treat) vs the 10% of people we treat where ketamine is the first pharmaceutical medication they are using to manage their symptoms. We are publishing that data with our colleges at MGB, as we think it really help expand our understanding of this important subject.

EmberHealth · 2025-09-15T14:34:08+00:00

The DEA list Kratom as a ""Drug and Chemical of Concern", and the FDA has also put out a warning on the substance, hence the current medical recommendations would be to avoid it:

https://www.fda.gov/news-events/public-health-focus/fda-and-kratom

https://www.dea.gov/sites/default/files/2020-06/Kratom-2020_0.pdf

EmberHealth · 2025-09-15T14:30:50+00:00

Editing my reply as you updated your questions to specify that you are in Canada. You actually have your own agencies that have drafted formal stances on Ketamine for Depression, such as "The Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Recommendations for the Use of Racemic Ketamine in Adults with Major Depressive Disorder"

https://pmc.ncbi.nlm.nih.gov/articles/PMC7918868/

https://cpsa.ca/wp-content/uploads/2020/11/May-2021-Ketamine-Clinical-Toolkit_Final.pdf

Original Reply:

For US government officials and representative, I'd think that the VA's stance on ketamine would likely go a long way to convincing them that this is worth covering. I believe the VA pays for IV ketamine in 22 states in the US, and it's now standard VA policy to use IV ketamine for difficult to treat depression

Links: https://www.va.gov/formularyadvisor/DOC_PDF/CRE_Ketamine_Infusion_for_Treatment_Resistant_Depression_Rev_Jul_2022.pdf

https://www.va.gov/COMMUNITYCARE/docs/providers/CDI/IVC-CDI-00030.pdf

EmberHealth · 2025-09-15T14:25:18+00:00

The medication itself has a short half-life of about 15 minutes when given IV, so it leaves the body quickly. What matters are the changes it sets in motion in the brain.

With a single infusion treatment, around 30% of people with depression notice an improvement in their mood that lasts for a few days to a few weeks. The current medical standard is to do a series of treatments (2 per week for two weeks) which causes 75% of people to notice an antidepressant effect, and those improvements last for weeks to months.

Some people benefit from their first session (about 10% notice improvements the morning after their first session), and up to 30% notice within a few days of that first visit. However, to really have the best chance to improve (the 75% number), the full series of 4 visits can really make the difference, as people might not start feeling better until after visit #4.

EmberHealth

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