Ketamine and esketamine

Domain IX · Biomedical, neuro & digital

What it is

This is a prescriber-delivered medicine, not a psychotherapy. This guide is written for the psychotherapist working alongside the prescriber and treatment team. It contains no doses, schedules, combinations or preparation details; those belong to the prescriber and the official labelling.…

Format

• The psychotherapist does not set the medical course. Course length, session frequency and continuation are set by the prescriber according to labelling and are deliberately not given here. The phases below describe the psychotherapist's work around each stage.
• Before referral (exploration). Goal: recognise when a medical review of depression treatment is warranted, give balanced information, and route to the prescriber. Format: within ordinary therapy sessions. Move on when the client has a psychiatric assessment arranged.

Who practises it, and how they are trained or regulated

• United States. Esketamine: dispensed and administered only in REMS-certified healthcare settings; pharmacies must be certified and may dispense only to certified settings; outpatient offices must be enrolled. The patient self-administers the nasal spray under direct observation of a healthcare provider. The REMS remains in force; a June 2026 FDA letter approved only website workflow changes, with no change to…
• United Kingdom. Esketamine is licensed for treatment-resistant depression. NICE does not recommend it, within its marketing authorisation, for treatment-resistant depression in adults (TA854); people who started it on the NHS before the guidance can continue until they and their clinician decide to stop. In June 2024 NICE decided not to review TA854. A news report of the Royal College of Psychiatrists' 2025 position…
• Treatment course (in-clinic sessions). Each treatment session takes place in the certified clinic: blood pressure assessed before and after dosing, observation for at least 2 hours in the US label (until clinically stable in the EU), discharge only once clinically stable, no driving or machinery until the next day after restful sleep. Psychotherapist goal: continue regular psychotherapy, monitor mood, suicidality…

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Is it a group, retreat or community? How do they respond if someone wants to leave or raises a concern?
• How do you and the practitioner understand what is happening, in spiritual or cultural terms? Is that a source of comfort, worry, or both?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• clients not disclosing. Working: the prescriber has the information.
• plans to drive or go back to work; no support at home. Working: plan written and used.
• the client or service treating psychotherapy as optional. Working: sustained functional gains.
• no named responsible clinician (more common in off-label settings). Working: timely two-way contact.
• seeking extra supplies, online purchase, use with alcohol, bladder symptoms. Working: honest disclosure.

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.