So many of the blogs we’ve had a chance to write over the past few years have been focused on helping those who are considering ketamine understand how their symptoms might resolve with treatment. In this blog we are going to answer: who is not a good candidate for ketamine?
As ketamine therapy for treatment-resistant depression, PTSD, and chronic pain continues to gain popularity and demonstrates its efficacy and safety, there is a growing sense of hope — rightfully so — among patients and clinicians alike. But alongside this promise comes an equally important clinical responsibility: discerning who is — and who is not — a good candidate for ketamine and Spravato (esketamine; the insurance-covered derivative of ketamine) therapy.
This is not simply about excluding people from care. It’s about ensuring that the treatment is safe, appropriate, and aligned with each person’s needs, vulnerabilities, and capacity to engage. Ketamine treatment can be powerful, and like all powerful tools, it deserves discernment.
Understanding the Clinical Landscape for Ketamine Treatment
Ketamine acts rapidly and works through mechanisms distinct from traditional antidepressants, making it uniquely suited for some patients. But that same uniqueness also introduces specific risks to ketamine treatment. Not everyone will benefit from ketamine therapy, and in some cases, its use may cause harm or destabilization. So much of the work of understanding how to chart a course forward regarding treatment must involve the input from the person seeking recovery. Clinicians should be used to describe options and even make recommendations, but at the end of the day, it is not the recommendation that helps a person feel better, it is the choice made by the patient to attempt a solution. All recovery begins with the decision made on the part of the patient to engage recovery. As we’ll discuss, below, the information is intended to help those considering next steps to be informed and to explore options with open eyes.
At Lumin Health, we begin every engagement with a thorough mental health screening — not just as a checkbox, but as a conversation — we also affirm that it is always the person with whom we’re speaking who is the agent of his/her/their recovery. Through our process of screening and evaluation, we uncover not only diagnoses and history, but also a person’s medical status, readiness and support systems that are so critical for safe engagement with ketamine and esketamine treatment.
Medical and Psychiatric Contraindications to Ketamine Therapy
The first category of concern that we look at involves contraindications for ketamine and esketamine therapy — conditions where treatment use poses safety concerns. Below are just some of the most common examples brought to us by patients that the Lumin Health team explores during the ketamine treatment intake process.
1. Active Psychosis
Ketamine treatment and Spravato (esketamine) is known to produce dissociative and perceptual effects. In individuals experiencing psychosis — such as occurs with schizophrenia — ketamine therapy may exacerbate hallucinations, delusions, or disorganized thinking. For these individuals, ketamine can be destabilizing rather than therapeutic — which requires specialized caution and extensive background checks before being admitted to the program.
2. Uncontrolled Hypertension or Cardiovascular Disease
Ketamine can transiently raise blood pressure and heart rate. For patients with severe or uncontrolled cardiovascular conditions, the physical risks of ketamine therapy may outweigh the potential benefits. We screen all patients for cardiovascular history and collaborate with primary care providers when needed.
3. Substance Use Disorders
While ketamine treatment shows promise in addressing some forms of addiction, individuals with active, unmanaged substance use disorders may be at higher risk for misuse or poor outcomes, even in a medically-monitored clinical setting. This does not mean a history of substance use is disqualifying; it means timing, stability, and readiness must be carefully assessed before starting ketamine treatment for mental health conditions.
4. Pregnancy
Ketamine has been shown to cross the placenta readily. The risks of regular exposure (such as would occur in treatment) is unknown to a developing fetus and should not be provided to people who are pregnant. Those who are planning to become pregnant should speak with a Lumin Health clinician to monitor the timing of treatment and how to stay safe.
5. Bipolar Disorder
Studying the use of ketamine to treat bipolar depression is underway and, while initial studies show promise, there remains concern that ketamine could potentially elicit a manic or hypomanic episode. It is important to speak with your clinician about mood stabilizing agents and appropriate monitoring to be sure that the first signs of mania are recognized to be appropriately managed.
6. Other
There are a host of other conditions to consider: diabetes (especially as people need to avoid eating 2 hours prior to treatment), recent stroke, seizure disorders, severe liver or kidney disease, porphyria, thyroid disease, dementias, and so on, that must be evaluated prior to initiating treatment. This is why it is so important to discuss not just the symptoms at hand, but also the broader picture of your medical health to be able to safely consider ketamine and esketamine treatment.
Psychological and Social Considerations before Starting Ketamine
Beyond medical criteria, there are more nuanced factors that may make a ketamine or esketamine treatment more challenging for a person. These are not steadfast exclusions, but rather clinical flags that call for caution and collaborative planning, which is a compulsory component of the Lumin Health onboarding process for ketamine treatment.
1. Difficulty with Emotional Regulation
Ketamine experiences can uncover vulnerabilities and deep emotional material — grief, trauma, fear — that can surface during treatments. For individuals who struggle to manage strong affective states, these experiences can be overwhelming. In such cases, the Lumin Health staff members are on site to help with difficult moments during ketamine and esketamine therapy, and work in collaboration with outpatient providers to ensure stability and thorough support systems are in place during the ketamine treatment program.
2. Limited Support Systems
The integration process after a ketamine treatment for mental health can be just as important as the session itself. Individuals without emotional or therapeutic support may find it hard to make meaning of their experience. Part of our role at Lumin Health is to assess whether adequate scaffolding is in place — or help build it before proceeding.
3. Unrealistic Expectations
While ketamine and esketamine for depression can bring rapid relief for some, for many it may result in partial relief, and for others, it may not be effective, at all. Ketamine and esketamine can take time to reach its full therapeutic benefit and is delivered as part of a broader “package” of things that a person works on in order to best achieve benefit. Alignment of goals and education is key and setting pathways to reach them is critical. At Lumin Health, will help you, with the knowledge we have regarding practices that can help support recovery, develop a tailor-made plan to be sure that both your expectations are realistic and your participation in your recovery answers your particular circumstance.
Who Might Not Be A Fit For Ketamine Therapy: A Summary
To recap, who might not be a good fit for ketamine therapy includes those with:
- Current psychotic disorders
- Certain cardiovascular conditions
- Active substance abuse without a support or stabilization plan.
- Pregnancy
- Other general medical conditions that could pose risk.
- Unreadiness to manage the treatment experiences and the thoughts and feelings the experience may cause
- Absence of therapeutic, familial, or community support
- Expectations inconsistent with ketamine’s clinical use
Moving Toward Safety and Fit for Ketamine Treatment
One of the most respectful things we can do in this work is say “not yet.” At Lumin Health, our job isn’t to get people into ketamine therapy — it’s to get people the right care at the right time. Sometimes that means preparing someone for ketamine treatment by strengthening supports or addressing other untreated conditions. Other times, it means recommending a different treatment pathway altogether.
Either way, it’s not about exclusion. It’s about timing, care, and trust.
The Role of Comprehensive Evaluation in Ketamine/Esketamine Therapy at Lumin Health
This is why a quick online screening can’t take the place of a thoughtful evaluation. Ketamine and esketamine safety depends on understanding not just diagnoses, but stories. Who is this person? What is their history with trauma? What do they hope for? What do they fear? What medical illnesses are they managing? These are not ancillary questions — they are central.
In a field where excitement can outpace caution, we return again and again to the ethics of care. Not everyone will be a good candidate for ketamine treatment right now, but everyone deserves to be seen clearly, heard fully, and guided wisely.
To learn more about our comprehensive screening process or to ask questions about your specific case for ketamine and esketamine therapy, don’t hesitate to get in touch with our team. We’d be grateful for the opportunity to explore options with you. Simply give us a call or book an appointment below.
