Ketamine Injections & Spravato for Depression: Safety, Contraindications, and Effectiveness
If you’ve been battling severe depression, PTSD, or crippling anxiety, you may have heard about the breakthrough success of ketamine treatment. At Philadelphia Integrative Psychiatry, Dr. Danish and his team have seen ketamine’s profoundly positive impact on patients who haven’t found relief with other treatments. Ketamine (an anesthetic used off-label for mood disorders) can spark rapid improvements in mood – often within hours – offering hope when traditional antidepressants fail. Under careful medical supervision, ketamine therapy is extremely safe for the vast majority of patients (over 99% experience no serious issues) [1]. However, like any powerful treatment, there are crucial contraindications (reasons not to use it) that must be assessed to ensure each patient’s safety. In this post, we’ll explain the relative vs. absolute contraindications for ketamine injections and Spravato (esketamine nasal spray), covering mental health, substance use, and medical factors. Understanding these precautions will help you and your providers decide if ketamine therapy is the right path toward healing.
Ketamine’s Remarkable Impact on Depression, PTSD, and Anxiety
Ketamine has been a game-changer for treatment-resistant depression, PTSD, and other tough-to-treat conditions. Unlike standard antidepressants that can take weeks to work (if they work at all), ketamine’s effects are rapid and often dramatic. Many patients report relief from depressive symptoms, PTSD flashbacks, suicidal thoughts, or anxiety within a day of their first session. A meta-analysis of clinical trials found “rapid and robust antidepressant effects” after a single low-dose ketamine infusion in patients with stubborn depression [2]. With repeat dosing, those benefits can be sustained for weeks [2]. Spravato (esketamine nasal spray), a form of ketamine’s active ingredient, has also proven effective when combined with an oral antidepressant, though its efficacy is slightly lower compared to IM or IV ketamine [3]. Clinical trials showed that 16.7% of patients achieved full remission after 4 weeks of Spravato (versus only 2.9% on placebo), and about 65% had a significant response by 74 days [3].
Equally important, ketamine is highly safe under medical oversight. The most common side effects (like a temporary rise in blood pressure or mild dissociation) are closely monitored by professionals during treatment. That said, ketamine isn’t for everyone. Next, we’ll clarify how absolute and relative contraindications come into play – and what specific mental health, substance use, and medical conditions might make ketamine or Spravato unsuitable.
Understanding Relative vs. Absolute Contraindications
Before diving into the specific contraindications, it’s helpful to know the difference between absolute and relative contraindications. An absolute contraindication means a condition or factor that completely rules out a treatment – the risks overwhelmingly outweigh any potential benefit. In such cases, ketamine therapy should not be given under any circumstance. A relative contraindication, on the other hand, means caution is warranted: the treatment might still be used if the potential benefits outweigh the risks and if extra safety measures are in place. In other words, relative contraindications are not automatic “no’s,” but they do require careful consideration and often additional monitoring or adjustments.
For ketamine (whether IV/IM injections or Spravato nasal spray), absolute contraindications tend to be serious health conditions that could be worsened by ketamine’s side effects (like its tendency to briefly raise blood pressure) or conditions that make the psychedelic/dissociative experience unsafe. Relative contraindications might include less severe versions of those issues or situations where the risk can be mitigated. Below, we break down the contraindications into three categories – psychiatric, substance use-related, and medical – noting which are absolute versus relative. By identifying these factors ahead of time through Dr. Danish’s thorough intake process, our team ensures that ketamine is only administered when it’s safe to do so.
Medications to Avoid on Ketamine Treatment Days
Certain medications can interfere with ketamine’s effects or increase the risk of side effects. To optimize your treatment experience and ensure safety, we recommend avoiding the following medications on the day of your ketamine session:
Benzodiazepines (BDZs): Medications like Xanax, Klonopin, Ativan, and Valium can blunt ketamine’s antidepressant effects and reduce the depth of the therapeutic experience. If you are on a long-term BDZ regimen, discuss with your provider whether adjustments are needed.
Stimulants for ADHD (Adderall, Ritalin, Vyvanse, etc.): Stimulants can increase blood pressure and heart rate, which may compound ketamine’s transient cardiovascular effects. To minimize risks, we recommend avoiding stimulants on ketamine treatment days and resuming them afterward, if needed.
Lamotrigine (? Debate Over Impact on Ketamine Response): Some research suggests that lamotrigine, a commonly used mood stabilizer, may reduce ketamine’s antidepressant effects. However, the evidence is mixed, and further studies are needed. If you take lamotrigine, discuss with your provider whether any adjustments should be considered to optimize your ketamine response.
Mental Health, Substance Use, and Medical Contraindications
Psychiatric Contraindications
Active Psychosis or Schizophrenia (Absolute Contraindication): If a patient is experiencing hallucinations, delusions, or has a chronic psychotic disorder like schizophrenia or schizoaffective disorder, ketamine is generally not recommended. The dissociative, mind-altering effects of ketamine could worsen psychosis or cause severe disorientation [4].
Uncontrolled Bipolar Mania (Absolute Contraindication): Ketamine is effective for bipolar depression, but if someone is currently in a manic or hypomanic state, ketamine could potentially aggravate mania. Active mania is an absolute reason to postpone ketamine [4].
History of Psychosis (Relative Contraindication): Even if you’re not currently psychotic, a history of psychotic episodes (for example, past postpartum psychosis) warrants extreme caution [4].
Substance Use Considerations
Any and all drugs of abuse should be completely avoided. Ketamine is not currently used to treat active substance use disorders at our clinic.
Cannabis (Marijuana): Avoid marijuana on ketamine treatment days, as it can intensify dissociation and sedation [7].
Alcohol and Opiates: Alcohol and opioid pain medications should also be avoided on ketamine days due to their depressant effects [7].
Conclusion
Getting in Touch with Dr. Danish and His Team: Dr. Danish and his experienced staff at Philadelphia Integrative Psychiatry are here to answer your questions and guide you every step of the way. Contact our office today to take the next step toward hope and healing.
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Disclaimer: This guide is for informational purposes only and not a substitute for medical advice. Any treatment—whether a supplement, medication, procedure, injection, therapy, or device—carries potential risks, especially when used in excess or by individuals with certain medical conditions or genetic predispositions. Always consult a qualified healthcare provider before starting any treatment.
