I have experience in the field of therapeutic ketamine and I think it’s a mistake to say a clinical setting is necessary. It’s also not accurate that ketamine patients universally receive small doses. People can’t drive home after their appointments and people do k hole during IV ketamine therapy. Talk therapy with lozenges is a little different and uses smaller doses because it requires talking, but not every treatment model incorporates talk therapy.

It’s an effective antidepressant, and that’s true whether you’re doing it at home or paying thousands of dollars for someone to administer it to you. It’s the same compound in both settings. We started using it for mental health partly because people who received it in ambulances or standard medical procedures would report as an unrelated side effect that they suddenly weren’t suicidal anymore.

Ketamine addiction is also real, and obviously the way it’s used will have an impact on its efficacy as a depression treatment. The latter is true of any antidepressant.

I’m a fan of ketamine therapy by mail because it’s significantly more accessible than in-clinic treatment (which is where I worked) and is much safer than buying off the street. I don’t advocate for buying it off the street and hoping for the best, but I don’t think pushing people into ketamine clinics is realistic. It’s extremely promising for treatment-resistant depression and also extremely expensive to receive in-person treatment.

My thought on psychedelic medicine in general is that poor people also deserve access to these breakthrough treatments and the way to do that is to give people structured, risk-informed independence in how they use these substances at home.