Ketamine Providers Debate Standards of Care

The continuing expansion of clinics and clinicians offering ketamine for mental health treatment is raising questions about standards of care and the qualifications of providers offering these services. Rigorous debates are taking place among ketamine providers about ethical guidelines, the inclusion of mental health specialists on treatment teams, and what kind of collaboration best serves patients. 

A recent commentary on Ethical Guidelines for Ketamine Clinicians published in the Journal of Psychedelic Psychiatry by psychiatrist and psychotherapist Dr. Wesley Ryan, asserts that while a growing number of studies have established a clear benefit for the use of ketamine for depression, many clinicians providing therapeutic ketamine have little, if any, training to provide psychological or psychiatric care. 

In support of this statement Ryan cites the directory of the American Society of Ketamine Physicians, Psychotherapists, and Practitioners (ASKP3), a nonprofit professional association of therapeutic ketamine providers. 

As covered in a story by Lucid News, Ryan writes in his commentary that “the majority of ketamine providers draw from limited, if any, formal psychiatric or psychological training or experience, and provide in-office ketamine without psychiatric treatment planning or psychotherapy.” 

This statement sparked a sharp rebuke from Dr. Steven L. Mandel, an anesthesiologist who is President and Founder of Ketamine Clinics of Los Angeles. Mandel, who is the founding president of ASKP3, says that the organization was designed to be inclusive and welcomes physicians, psychotherapists and advanced practitioners from a range of disciplines. 

“You can’t separate the bad apples from the good apples by looking at their specialities,” says Mandel. “Most of our members, and there are well over 300 of them, are engaged at least half time in providing ketamine for mood disorders. Nearly all of them work with mental health practitioners.”

Ryan says he disagrees with this view and points to what he says is a larger trend among ketamine clinics that administer the drug without trained mental health specialists on the treatment team. “My understanding is most ketamine clinics provide ketamine independent of any psychotherapy, be that the doctor or psychotherapist employed by the clinic,” says Ryan who provides ketamine assisted psychotherapy. 

Ryan argues that if the focus is on the patient’s needs, inclusivity is not necessarily congruent with the best care and outcomes. “A ketamine clinic that suggests people go see a therapist after their session isn’t the same as one that provides psychotherapy as part of the treatment,” says Ryan. 

Dr. Robert M. Grant, a pulmonologist and member of the ASKP3 board of directors, says he also disagrees with Ryan’s assertion that most ketamine providers have limited training in psychiatric or psychological care. “Ketamine is typically provided by mental health professionals, or in collaboration with mental health professionals who refer clients, provide consulting services, or work on staff in the clinic,” says Grant who is a professor of Medicine at the University of California San Francisco and co-Founder of Healing Realms Psychotherapy.

Grant also disputes that the guidelines, which were compiled by KRIYA Institute, reflect a range of opinions from clinicians providing ketamine-assisted therapy. KRIYA Institute trains health care professionals offering therapeutic ketamine and provides clinical services to patients receiving this treatment. The KRIYA guidelines describe areas of responsibility for patients, psychotherapists and medical prescribers.  

“They were not vetted or discussed with others in the community of providers and clients who receive ketamine,” says Grant. “Guidelines are helpful if they build on consensus.” Grant adds that the KRIYA website did not indicate that the guidelines were open for comment.

According to Grant, the guidelines reflect only the personal opinions of Ryan and KRIYA Institute founder Raquel Bennett PsyD. and did not disclose that KRIYA Institute is wholly owned and operated by Bennett. “Although she calls it a foundation, KRIYA is not registered as a non profit organization and has no board of directors,” says Grant.  

Both the KRIYA guidelines and the commentary were originally credited to Ryan and Bennett. An updated version of the article includes content that is unchanged, but cites Ryan as the author of the commentary and gives Bennett credit for the guidelines. Dr. Tyler Kjorvestad, Editor-In-Chief of The Journal of Psychedelic Psychiatry, says this change was made to correct an editing error in the original version of the article which gave joint credit to both authors. 

Bennett says that she never stated or implied that KRIYA Institute is a foundation or a non-profit organization. According to Bennett, the KRIYA community has more than 3,000 members including medical and mental health professionals, researchers and ketamine patients. Bennet says she began documenting guidelines endorsed by this community in 2017 before ASKP3 was created. 

The guidelines document was discussed at KRIYA Conference run by the institute in 2018 and 2019 attended by members of ASKP3, says Bennett. Draft guidelines were posted in October 2020 and after a 10-week open comment period, she says feedback was incorporated into the version published in December 2020. 

“Members of ASKP were invited many times over the years to participate in those conversations. And there is some overlap between the two communities of providers,” says Bennett who says ethics have been discussed extensively in the KRIYA clinical community. Bennett notes that the founding members of ASKP3 met at a KRIYA Conference, Mandel and Grant have both attended, and members of the ASKP3 board have spoken at the event.  

“ASKP3 appears to be going to great lengths to try to discredit me or this document, which is already in the published literature. That is puzzling,” says Bennett who says she has been contacted by state and federal regulators who support the guidelines. “All kinds of medical and mental health professionals can participate in therapeutic ketamine, according to this document. I wish that we could focus on our common ground and find ways to work together.” 

Different Guidelines and Models of Collaboration 

The KRIYA guidelines advise medical professionals providing therapeutic ketamine to work collaboratively with clinicians who are trained to provide mental health treatments. “The ethical ketamine clinician practices within the scope of their professional license, and they recognize their limitations with respect to their professional training and experience,” reads the guidelines. “They actively seek consultation as needed, and they make referrals to other professionals as needed.” 

Grant says he agrees with this point, but says it begs the question about how best to provide training for providers of therapeutic ketamine. Grant says that psychiatry residents, psychologists, and other mental health professionals typically do not receive training in administering ketamine, but are trained in the diagnosis of mental health conditions and some aspects of psychotherapy. 

Anesthesiologists, critical care physicians and emergency physicians typically are trained to use ketamine, says Grant, but at higher doses than are used for depression. “A collaborative approach to advancing the science and craft of ketamine therapy is warranted,” says Grant. 

Ryan says anesthesiologists use ketamine at doses about ten fold higher to anesthetize people for surgery, and emergency medicine physicians also use higher dosages for procedural sedation. “This is fundamentally different from the use of ketamine to work through trauma, PTSD, or depression,” says Ryan, who adds that these physicians are not trained to interact with patients in respect to their mental health. 

Bennett notes that in ketamine treatment, attention needs to be paid to the patient’s psychological safety as well as their medical safety. “There is no doubt that people with anesthesia or ER training are very good at attending to the patient’s physical safety. But they tend to overlook or under-value the psychological care that these patients need before, during, and after ketamine treatment,” says Bennett. “That is the reason that collaborative care is essential.”

Mandel says no one could take issue with the benefits of a collaborative approach to provide therapeutic ketamine for mood disorders and that this treatment flourishes in a collaborative environment. But he notes that there are still questions when it comes to training and which medical specialities are qualified to provide therapeutic ketamine. 

According to Bennett, ASKP3 board members have not adopted or endorsed the KRIYA guidelines because more than fifty percent of ASKP3 members do not use a collaborative model. “More than half of the current membership at ASKP are anesthesiologists, ER docs, and anesthesia extenders (CRNAs) who do not require a visit with a mental health professional before providing ketamine treatment for a mental health disorder,” argues Bennett. “Those members want to be able to continue providing ketamine infusions without interference or accountability, even though the treatment of mood disorders is a non-anesthesia indication.”

Bennett says that in her nineteen years of working in the field, she has observed that patients with mood disorders who stay improved over time use multiple strategies, not just ketamine alone. “I think we should be wary of ketamine providers who don’t encourage integrative care, especially when those providers benefit financially from providing never-ending ketamine infusions to patients,” says Bennett. “This is a clear conflict of interest.” 

Mandel says it is arrogant for one person alone to appoint themselves an arbiter of ethical behavior, especially a person such as Bennett who he says is not licensed to provide ketamine. He emphasizes that there are different ways collaboration can occur. “Others may be well intentioned but uninformed. There are always going to be bad apples and we do everything we can to set the standards and hold them to account,” says Mandel.

According to Grant, ASKP3 developed their own draft guidelines and an ethical code early in 2020 and posted the drafts for member comment from approximately September 2020. “The ASKP3 guidelines are more nuanced, in that they highlight how skilled clinicians will also use insights from their clinical experience,” writes Grant. “We advise that such claims be highlighted as provisional and based on local experience rather than medical literature.”

Mandel says the ASKP3 statement on ethics is available to ASKP3 members and all of them subscribe to these standards as a condition of membership. He says he is not sure how widely accessible they are to the public. “Providers who are not in compliance with our standards and not working collaboratively with mental health professionals are not practicing ethically,” says Mandel. 

Ryan says that the KRIYA guidelines appear to be based on consensus while the ASKP3 statement represents the organization rather than the greater community of ketamine providers. Bennett argues that the points raised by Grant and Mandel about the KRIYA guidelines do not address their content or the central question about what is important in ketamine treatment for a psychiatric indication. She says that the publicly available version of the ASKP3 Standards of Practice in the Therapeutic Use of Subanesthetic Ketamine on the ASKP3 website appears to be a brief summary of the field rather than detailed guidelines. 

Bennett says she believes she is more than qualified to provide psychological care before, during, and after ketamine treatment. She says she has been studying the therapeutic properties of ketamine for nearly twenty years, is author of the first manuscript about using ketamine as a treatment for depression, and founder of the first public conference on the uses of ketamine in psychiatry and psychotherapy.

“I have trained thousands of physicians, residents, and psychotherapists all over the globe on different approaches to working with therapeutic ketamine,” says Bennett, who believes that it is disrespectful and inappropriate for Mandel to suggest that her contributions to the field do not have value. 

According to Bennett, she has received hundreds of unsolicited complaints over the years from patients who were distressed by the ketamine treatment that they received. “It is notable that a large number of these complaints are about anesthesiologists or other physicians who are not psychiatrists,” says Bennett. “This data tells us that something is going wrong when ketamine is administered without psychological care.” 

Training and the Role of Psychiatrists

From his perspective, Ryan believes that a multiple year post graduate psychiatry residency is the best physician qualification for those who work with patients receiving ketamine. “This concern over practitioner training and scope of practice is well founded,” writes Ryan in his commentary. “It is simply not possible to provide a truly informed consent, including risks if the provider does not have psychiatric training.” 

Mandel says he has a different view about the credentials and training required to provide ketamine. If someone receives a therapeutic ketamine treatment from an emergency room doctor who has studied the clinical research, discussed this treatment with colleagues, and received formal training in ketamine treatment, does this mean that doctor has mental health training? asks Mandel. 

“I would say they have some. Ryan would say they do not know enough about the alternatives to give informed consent. That is an absurdity,” says Mandel. “It simply isn’t true. Emergency docs are giving ketamine more often than other physicians are and keeping patients fully informed.”

According to Mandel, there are different ways that collaboration can occur between clinicians who are not trained in mental health treatments and those who are. He notes that some non-urban areas in the US have months-long waiting lists for patients to see a psychiatrist. “If a nurse practitioner calls a therapist and says, ‘I have a patient here, this is the situation, here is my take, what do you think?’ Is there something I’m missing? Is that working with a mental health provider?” asks Mandel. 

Ryan says that in such a scenario, the nurse practitioner may miss salient points that they don’t know to assess for. “This is not ideal care,” says Ryan, who adds that in his view, a better clinical model would involve a nurse practitioner calling a psychiatrist. 

Bennett notes that the widespread use of telehealth makes it possible for every ketamine patient to have access to a mental health professional online. According to Bennett, providers of therapeutic ketamine who are not mental health professionals are largely unable to do the differential diagnosis, psychological preparation, and integrative care, or manage psychiatric emergencies as skillfully as a trained mental health provider. 

The KRIYA guidelines do not specifically advise including a psychiatrist on a treatment team, but recommend that ketamine clinicians receive “special training and/or mentorship in working with therapeutic ketamine” including substantial education in medical, psychological and psychedelic domains. 

“The patient population is the most important aspect to consider–and without a doubt psychiatrists are the most qualified based on the amount of training in working with this population,” says Ryan. 

Mandel counters that “the vast majority of practitioners do not agree with limiting the provision of ketamine treatments to just psychiatrists.” According to Mandel, the majority of practitioners providing therapeutic ketamine feel strongly that the field should be inclusive and not exclude groups who demonstrate “the knowledge, experience, and ethics necessary to safely provide effective treatment, including a wide variety of physicians and some advanced practitioners.”

Grant believes that barriers to access to therapeutic ketamine mostly arise from the limited numbers of ketamine practitioners and the lack of information about ketamine among practicing psychiatrists. He argues that Ryan and Bennett’s perspective would limit supply of practitioners further. “Access could improve if mental health professionals and other clinicians learn about ketamine, which is not currently happening at scale,” says Grant. 

“The purpose of the Ethical Guidelines,” says Bennett, “was to create a path for more clinicians to participate in providing ketamine treatment in a safe way.”