Sections in this document
Please find below frequently asked questions about our service.
Accessing the service
Is ketamine treatment available on the NHS?
The service described here is a ‘self-pay’ or ‘private’ service which is provided by Oxford Health NHS Foundation Trust (OHFT). All potential patients must establish their own funding arrangements.
Patients who live in Oxfordshire or Buckinghamshire and who are formally referred to the service by a consultant psychiatrist who is employed by Oxford Health NHS Foundation Trust may be considered for treatment funded by OHFT, ie ‘on the NHS’. The processes for this group are similar to those described in this website except that direct referral by a GP is not possible. The referral for OHFT-funded treatment must come from an OHFT consultant psychiatrist. If you then have ketamine treatment, you will remain under the joint care of the OHFT psychiatrist.
Unfortunately, we are no longer able to accept any new patients from outside Oxfordshire and Buckinghamshire. As of 19 February 2024, we are no longer able to accept those whose treatment is funded through an ‘Individual Funding Request’ to the Integrated Care Board. This is because we are a small team and we are unable to manage the variable processes required to secure funding for ongoing treatment, and to recoup payment.
Is ketamine a licensed treatment?
Drugs receive a licence if the MHRA approves them as safe and effective for a particular condition. Ketamine is not a licensed treatment for depression. It is used in depression as an ‘off-label’ treatment. However, ketamine is licensed as an anaesthetic and for analgesia because it is safe and effective for short term use for those conditions. A version of ketamine, Spravato esketamine nasal spray, has a licence for use in Treatment Resistant Depression alongside an SSRI or SNRI. It has not been approved by NICE (National Institute for Health and Care Excellence) and is therefore not available on the NHS. It is expensive. We are happy to provide this for those who would prefer it. Some details about this are provided in the FAQs.
How long is the waiting list?
Waiting times can vary throughout the year, on average once we have received a referral for you the appointment for an initial consultation will be booked for within 3 months.
Waiting times for treatment after an initial consultation can range from 1 – 8 weeks depending on the availability of appointments.
What if I can’t get a referral?
We will not be able to see you without a referral from your GP or psychiatrist. Sometimes people have found it helpful to take the information leaflet about the service to their doctor.
Do you accept referrals from psychotherapists or psychologists?
No. If you are seeing a psychotherapist or psychologist it would be extremely helpful to receive a letter describing the sort of work that you have done together. However, because we need a full medical background, the referral letter must come from a medically qualified doctor who has been responsible for your clinical care.
What are the reasons you decide not to offer a patient an assessment following referral?
We cannot give an exhaustive list as we review each case on the basis of how likely it is that the patient will benefit. A global assessment is made of this.
Some of the reasons include:
- Urgent need for intervention to save life. Such patients should contact their local team immediately
- Currently taking psychedelics from other legal or underground clinics
- Alcohol Use Disorder
- Lack of persistent alteration in mood. Some people have abrupt severe fluctuations in mood but do not experience low mood most of the day nearly every day. An exception to this is the frequent occurrence of suicidal ideas and behaviour.
- Recent mania
- Unstable social circumstances that would interfere with ability to persist with treatment.
- Patient does not allow us to communicate with any professionals involved in their care
Do you do treatment on weekends, in the evenings and on Bank Holidays?
Why is ketamine not routinely available on the NHS?
Ketamine is not licensed in the UK by the Medicines and Healthcare products Regulatory Agency for the treatment of depression. This is because, so far, no company has made an application for such a licence. This is because the cost of generic ketamine is low, the cost of gathering the data required by the MHRA is very high, and there is no possibility of patent protection for the currently available formulations. It is possible that companies may apply for the licencing of new formulations in the future.
Because the MHRA has not approved ketamine for the treatment of depression, the safety of ketamine has not been confirmed using the high quality of evidence required. Therefore, as with other unlicensed treatments, NICE will not consider whether it should be routinely available in the NHS. Because NICE has not given an opinion on its cost-effectiveness, the health commissioning bodies (formerly CCG, now ICB) cannot routinely fund it.
Versions of depression
I have anorexia with depression. Can ketamine help?
Yes, we find that ketamine can help the depression and can make a big difference. It has helped some patients to be discharged from hospital. It is less helpful in combatting the disordered ideas about shape, weight and eating. We are grateful to a patient who was involved in this earlier study who called us to tell us how her life had been changed by it: this emboldened us to try ketamine in patients with anorexia. (If you are that patient, we managed to lose your contact details – do get in touch again!). The information about Treatment Resistant Depression all applies, and should be read carefully. Treatment needs to be long term.
I have bipolar disorder. Can ketamine help?
Patients with treatment resistant depression in bipolar disorder respond at about the same rate as those with unipolar depression. There is a risk of manic relapse, particularly perhaps in those where mania has previously been drug induced. Depending on the exact circumstances and history, we recommend taking a mood stabiliser before starting ketamine.
In the small number of patients we have treated (~5), we have not found ketamine to be useful in rapid-cycling bipolar disorder. Not only is it hard to time the doses, but it also does not appear to affect the cycling.
Does ketamine work for postpartum depression?
Yes. We and others have had very positive experience of its use for postpartum depression with rapid and permanent resolution after a short course of treatments. Research suggests that the level of ketamine and metabolites in breast milk is safe, though we still recommend caution and a ‘pump and dump’ strategy for three days after ketamine treatments.
There is also RCT evidence that IV ketamine, given at the time of caesarean, reduces the incidence of post-partum depression.
What the effects of ketamine on unborn foetus?
The effects of ketamine on the unborn foetus are unknown. Women of child-bearing potential should use effective contraception. It is essential that ketamine treatment is stopped during pregnancy and that a thorough review of risks and benefits is conducted before restarting. If you are trying to conceive it may be reasonable to restrict ketamine treatment to days when you are menstruating as a way of reducing risk – but this is not a perfect marker that you are not pregnant.
I am peri- or post-menopausal. Should I take ketamine?
If you have not had a review from a specialist in this area, we recommend that you do so as HRT can sometimes be very effective in alleviating depression and prevent the need for ketamine treatment. Sometimes a combination of both can be effective. We suggest you review https://www.balance-menopause.com/ in detail.
I am under 18. Can I have ketamine?
Possibly. We will need to work with you, your parents and your current doctors to work out if this is the right option for you. The adolescent brain may be more susceptible to being overactivated by ketamine and to developing brain lesions of uncertain significance (Olney lesions). However, adolescents with resistant depression can sometimes benefit.
I have emotionally unstable personality disorder / borderline personality disorder / PTSD / complex PTSD. Can I have ketamine?
The depression associated with these conditions does respond to ketamine. This can help with managing day to day life. However, entrenched patterns of thinking and relating can take a long time to change even when the depression is better. Ketamine may help with the avoidance that maintains these problems. Ketamine is particularly helpful for suicidal ideas in the context of depression.
Concurrent psychotherapy and engagement with another team are essential in these conditions, but often difficult to maintain.
Effects and side effects
Is ketamine safe?
Please look at the Side Effects section
Ketamine is not licensed by the MHRA as being safe for the treatment of depression. However, it has been licensed as safe for use as an anaesthetic and as an analgesic. This means that, although side effects are well known, it is considered safe for short term use as an anaesthetic or analgesic.
The important question of whether ketamine is safe if used regularly over a long period has not been formally answered and there are no published studies of its long-term use.
Our experience so far is that, at the frequency and doses we use, we have not observed important safety signals. This is consistent with the wide experience in the US.
Is ketamine addictive?
When people use ketamine illegally – either recreationally or for self-treatment – it is not uncommon for the dose and frequency of use to escalate. Drug abusers can become addicted to it.
Sometimes people find that if they stop ketamine their depression relapses. This is not the same as addiction. This is reliance. The same phenomenon has been noticed with other psychedelics such as psilocybin.
There are a handful of reports of patients who have been prescribed ketamine for the treatment of depression and who has become addicted. In all cases, the doses used are very much higher and more frequent than we use.
People who try to treat their depression with ketamine without medical support use higher doses, more frequently and are more likely to want to reduce the dose they are using than those who use it recreationally. We strongly advise against treatment outside a conventional medical setting.
For comparison, in our opinion, when used in a medical setting, ketamine is much less addictive and dangerous than strong opiates (eg fentanyl, methadone) or nicotine, is probably less addictive than benzodiazepines, and is probably about as addictive as whiskey.
Could I become tolerant to ketamine?
Yes. Sometimes patients taking it for depression find that their depression is no longer controlled despite continuing to have treatment with ketamine. There can be several possible reasons, one of which is that they have developed tolerance to ketamine. In our clinic, we use a variety of strategies to minimise this.
We are currently formally evaluating the frequency of this but estimate that this becomes a problem for about 15% of people who take ketamine long term.
A treatment break or increase in the interval between treatments may be needed.
We sometimes add another off-label medication that has an antidepressant effect (eg pramipexole).
How well and how quickly does ketamine work?
For some people, ketamine can work within a few hours. For other people it may take a few treatments before their depression improves. It is not possible to tell who will respond, or how quickly to ketamine.
If you do not respond to 6 treatments of ketamine then you are unlikely to see a benefit from any further treatment.
What dose of ketamine is usually prescribed?
The dose of ketamine you are prescribed is decided by the ketamine clinic treatment team. Intravenous doses are calculated on your weight at 0.5mg/kg and will be reviewed before each treatment. For some people this dose will not change; however, doses may be increased or decreased during your treatment period.
Is there any way of knowing who will benefit?
Patients over 65 years old are less likely to respond or to respond more slowly. Therefore, a longer trial (eg up to 10 infusions) may be needed before it is clear that there will be no response.
People who have been extremely unwell with depression for a very long time (ie to the point of immobility and prolonged hospitalisation) may be less likely to respond.
Patients whose depression has not responded to ECT or to many antidepressants at high doses may be slightly likely to respond than those with less severe illness. However, they do sometimes respond dramatically.
These predictors have not been confirmed and patients who have been chronically or severely depressed, or who have had poor response to conventional antidepressants, have also benefitted.
There is a possibility that a genetic mutation predicts whether patients develop an initial response. However, we do not assess whether you have this mutation. There are no known predictors of a longer duration of response.
How does ketamine compare to ECT?
A single, large, well conducted randomised controlled trial has shown that ECT is slightly more effective than ketamine (Ekstrand 2022). Overall, ECT caused more cognitive side effects than ketamine, but ketamine caused more acute dissociative effects. Ketamine was slightly more effective in younger patients and ECT was slightly more effective in older patients. When the treatments were stopped, patients relapsed at the same rate. In practice, however, maintenance ECT is less commonly used than maintenance ketamine.
How does ketamine compare to psilocybin?
Psilocybin is not a licensed treatment for any condition and experience with its use in conventional medical settings is limited. There has been no research which compares the effectiveness of ketamine and psilocybin. It is possible that the effect of psilocybin last longer, though some patients report needing to take it repeatedly to maintain benefit. In current research, psilocybin is given 2 or 3 times to induce remission, compared to up to 6 with ketamine. Psilocybin treatment typically involves more preparation and integration sessions than we offer. Each treatment session lasts a day. There is preliminary evidence that long ketamine infusions lasting 4 days may result in longer duration of benefit than the 40-minute infusions we use. Psilocybin may be less likely to induce tolerance than ketamine and it is not associated with addiction.
I live a long way away. Can I stay overnight in Oxford?
Yes. Patients often do this. There are a variety of B&Bs, AirBNB, hotels etc available.
Can I drive or ride a bicycle if I am having ketamine?
Yes, but not until the morning after you have had ketamine treatment.
However, when you first start taking ketamine or when your dose is increased you may feel drowsy the next day. You should use common sense and not drive if you feel drowsy. It is your responsibility to decide whether you are fit to drive on each occasion.
Can the person bringing me for treatment sit with me?
No. The person accompanying you will normally be shown to a room where they can have a drink and wait with others. During times of covid-19 restrictions, the person accompanying you will not be allowed into the department but is welcome to make use of our cafe and hospital grounds.
There are two main reasons for this. Clinic bays are small, and staff need room to access the infusion pump during treatment. Also, there will be other patients having their treatments at the same time and we try to create a quiet and calm environment.
Additionally, staff are trained and experienced to be able to look after you during your treatment and through any of the side effects associated with ketamine. Friends or family members may find observing this distressing and alarming.
Taking other medicines with ketamine
Can I take other medicines if I am having ketamine?
Benzodiazepines such as Diazepam, Lorazepam and Clonazepam probably reduce the effect of ketamine, so we advise that these are not taken the night before or the day you have ketamine. If you are on long term benzodiazepines we will discuss how far and how fast you should reduce these before having ketamine. The Ashton method of reduction is a slow careful method which we recommend: https://www.benzoinfo.com/.
If you take venlafaxine or duloxetine, this may increase the risk of tinnitus following ketamine, but you should not stop it before starting ketamine.
Other than those listed above, ketamine should not affect your other medicines. Other painkillers including opioids (e.g. codeine), non-steroidal anti-inflammatory drugs such as ibuprofen, or paracetamol can be taken at the same time as ketamine.
When you start ketamine, you will be asked to complete paperwork asking about your current medications.
Before you take or buy any new medicines always tell your doctor or pharmacist that you are having ketamine.
Can I have oral ketamine straight after my infusions?
No. There will be a period of 3-4 weeks after your 3-6 ketamine infusions before you might start any oral ketamine. This is to see how long any benefit lasts.
Not everyone is suitable for oral ketamine treatment, this will be assessed during your telephone follow-up appointment.
We do not provide an ‘oral ketamine only’ service
Can I drink alcohol if I am having ketamine?
You should not drink alcohol on the night before and day you take ketamine and for 24 hours afterwards.
If possible, you should avoid drinking alcohol completely while you are taking ketamine. This is because alcohol may reduce the benefit and increase some of the side-effects of ketamine.
What other treatments do you prescribe?
Do you provide nasal esketamine?
Yes. Nasal spray esketamine (Spravato), in conjunction with an oral antidepressant, is licensed as safe and effective for the treatment of Treatment Resistant Depression. Ketamine does not have such a license and we use it ‘off-label’. The data supporting the use of esketamine nasal spray are of a much higher quality and of a longer duration than those supporting the use of ketamine.
Esketamine nasal spray was developed because the effect of ketamine was recognised to be novel and an important advance. There are randomised trials suggesting that ketamine is not inferior to esketamine.
We are happy to make esketamine nasal spray available and are registered with the Janssen for pharmacy and the Risk Mitigation Scheme.
Nasal spray esketamine (Spravato) is not available on the NHS because it has not been approved for routine use by NICE. The cost of the drug for self-pay patients is £326 or £489 per dose. Patients must come to the clinic for every dose and stay for an hour after administration. It cannot be administered at home. On top of this drug cost, we must therefore charge the same clinic fee (£225) to cover our staffing and clinic overheads as for ketamine (which costs about £1 per dose). The frequency of maintenance esketamine nasal spray dosing is initially twice weekly for four weeks, then weekly or every 2 weeks thereafter.
Do you offer psilocybin, MDMA, LSD, 5Me-OT or other psychedelic treatments?
No. Unlike ketamine, none of these drugs are licensed for medical use. Long term data on their safety and effectiveness is not available. It is not known how often they need to be given. We do not know if they will be more effective than ketamine. Given the very low cost of ketamine, and the high cost of developing new drugs to the point of licensure, it is rather unlikely that licensed forms of these other drugs will be more cost-effective than ketamine.
Will you prescribe other medications?
Should you experience acute sickness during your infusion we will prescribe an anti-sickness medication to be given in clinic.
Your referring doctor will remain responsible for your overall care and the prescribing of all other medications including any other antidepressants.
Will you take over as my psychiatrist?
No. The service is set up only to provide and manage ketamine treatment. Any other psychiatric care will remain with your current team. We are unable to take on the overall care of patients and will correspond with your referring team about your ketamine treatment.
I am under the care of an NHS team. What are the arrangements with them?
We do not have the option of admitting you to hospital and cannot follow you up as closely during crises as your local team can. The management of all your other psychiatric medication apart from ketamine will remain the responsibility of your current team. However, we recognise that, for a period, you may see more of us than them. Therefore, we keep in touch with your GP and current team and may advise about adjusting other medication (typically, reducing it).
This is why we need the names and contact details of your GP, psychiatrist and care coordinator. Many patients find that their contact with their local team reduces considerably once they start treatment with us. However, we ask that you remain ‘on the books’ of the local team so that, if there are acute crises, they are able to help you without requiring a re-referral from your GP. Your team is very welcome to contact us on 01865 902522 or at email@example.com.
I am seeing a psychotherapist privately. Will that influence my care?
We very much support the combination of ketamine and psychotherapy. This may help you to make the most of being well, using your newly well mind to explore issues that you were unable to address when depressed.
We provide psychotherapy groups (see elsewhere).
We are unable to recommend particular therapists but recommend that if you are considering starting therapy you chose either someone who is experienced in Acceptance Commitment Therapy (ACT), which is a NICE approved therapy for pain, or in psychedelic assisted psychotherapy:
We are always happy to speak with therapists who can contact us on firstname.lastname@example.org or 01865 902522.
Can I join therapy groups if I am already in therapy myself?
Yes. Anyone who is receiving ketamine treatment at the clinic can join the Preparation and Integration Groups irrespective of whether they are already in personal therapy or not. If you are already in group therapy, we will need to discuss whether it is appropriate to join the integration groups.
Patients who are in the maintenance phase of treatment and are not already in regular psychotherapy, but feel the need to be in therapy, have the option of joining a weekly psychodynamic psychotherapy group. Patients in this psychodynamic group do not join the integration group sessions.
What are the time commitments for the therapy groups?
The preparation and integration sessions are optional but recommended. They are designed to help you get the most out of the experiences you have with ketamine treatment.
You will be offered 2 preparation group sessions between your assessment and starting ketamine treatment. As the material covered in session 1 and session 2 is slightly different, it is important to attend both sessions. There will be a maximum of 4 patients in these groups, and the group members will remain the same across both sessions. Sessions run on 2 consecutive Tuesdays between 14:30 and 16:00.
You are encouraged to attend an integration group session each week that you have an IV ketamine infusion. The potential frequency of attendance will vary depending on which stage you are in treatment, and how often you receive IV ketamine treatment. These sessions run every Friday between 14:30 and 16:00.
Patients who are in the ketamine psychodynamic group should attend online sessions each week between 18:00 and 19:30 except for planned therapy breaks. The minimum amount of time for a patient to be a member of this group is 1 year, and the longest is 2 years. Patients who are considering joining this group should plan to join for approximately 18 months.
Clinical results and research
What research are you doing?
Our clinic is focussed on delivering treatment, is run under the auspices of the NHS and is not primarily a research clinic.
As with other NHS services, we routinely ask patients to provide information which helps us with making clinical decisions and in order to evaluate our service.
We are also now running a project evaluating the effect of long-term ketamine on changes in different frequencies of brain waves. You may be invited to participate in this or future research projects. Participation in research is always optional.
How do your results compare with those of other clinics?
We have not compared our results with others. There are many factors that may cause different clinics to have different results. For example, different clinics probably see slightly different sorts of patients. We aim to be transparent about our results and to keep expectations realistic. We would be surprised if, like-for-like, our results are better or worse than elsewhere.
Why should I come to Oxford rather than elsewhere?
We have more experience of long-term ketamine use than any other UK provider.
Our user satisfaction is high.
We are transparent about our results.
Our costs are competitive. We run within the NHS and are priced to cover costs, not to make a profit.
|The effectiveness of ketamine
|The overall side effects of ketamine (high score = good)
|The assessment interview you had before starting ketamine
|The follow-up reviews with a doctor which you had
|The support from nurses on, and between, treatment days
|The clinic’s administrative processes
|The forms your were asked to fill in
Outcome QIDS scores — long term
Summary: patients who received the ‘Oxford Protocol’ continued to benefit for 18 months.
*falling N is because some patients in this analysis have not yet had eg >12 months treatment.
Summary: In a population with TRD:
- 49% of those who start ketamine think it is sufficiently worthwhile that they continue with regular treatment
- 6% are discharged off treatment, well
When should I go to another provider rather than Oxford?
- Your local NHS service provides ketamine.
- You have a closer clinic. Ketamine treatment is not a one-off so the practicalities of getting to and from Oxford are important. It takes 60-90 minutes to get from London to Oxford by car or train.
- You want a friend/relative in the room with you.
- You want a private room for treatment. (We do not yet provide single rooms or allow friends/relatives into the treatment space with the patient).
- You are looking for help with addiction
- You are unable to use the electronic systems we use and do not have anyone who can help you do this.
- You want a less ‘medical’ experience. We are based in an NHS hospital rather than a private clinic.
What are your plans to improve the clinic?
We are constantly open to suggestions, but our facilities mean that there are limitations in what is practical. We are planning to open new space at the Warneford towards the end of 2022 but we do not have a budget to refurbish this space at present.
If you have suggestions for improvements, please let us know.
Cost effectiveness and financing
What is the evidence that the ketamine you provide is cost-effective?
The cost of each IV treatment is £225 and of oral ketamine is £60 per month.
There have been no long-term cost effectiveness studies of ketamine.
Ketamine is not a licensed treatment for depression. It has meta-analysis level evidence for a 7- day benefit. Guidelines for its use have been published in American Journal of Psychiatry. Nasal esketamine is licensed is not NICE approved, and costs approximately 400 times as much, per dose, as ketamine.
Short term racemic ketamine may be superior to and is at least non-inferior to esketamine. NICE has reviewed esketamine nasal spray several times. The last consultation document where a cost per QALY was given says (p34) that : ‘Using the committee’s preferred assumptions, the ERG’s ICER [for Spravato esketamine nasal spray] was in the range of £64,554 to £72,158 per QALY gained’. The current NHS list price for esketamine 84mg (which is the dose that would likely be administered weekly for the most severe cases) is £489 per dose. The current NHS list price for a vial of IV ketamine, from which it is usual to treat about 7 patients, is £7. Each oral, weekly, ketamine dose costs about £15. Drug costs for four week’s treatment with esketamine (ie not including service costs) are £1,956 (assuming no NHS discount). The total costs of drug, administration and follow-up with ketamine, are £225+60 = £285. It is highly likely that this cost differential means that the cost per QALY of ketamine is well under the conventional NICE threshold of £30k per QALY.
Cost per QALY nasal esketamine (NICE): £64,554 to £72,158
Drug cost per weekly dose nasal esketamine: £489
Total cost per week nasal esketamine including administration: £714
Drug cost per week ketamine (assuming monthly IV and weekly oral): £15
Total cost per week ketamine including administration (assuming monthly IV and weekly oral): £71
Inferred cost per QALY generic ketamine: £6,455-7,216
I will have trouble paying. Should I proceed?
You should carefully consider your budget and the following factors:
- Ketamine treatment is not a one-off. If you respond, you are very likely to need continued treatment. This usually continues for several years before people feel strong enough to stop. Some patients have been coming for up to 10 years.
- The costs of having ketamine at our clinic are not just those of the treatment. Travel and accommodation costs can be considerable. If someone is bringing you, will they continue to be available? Can you actually manage public transport? Taking time off work can be difficult.
- If you are working, will your employer be sympathetic to the amount of time you need to take off?
Can you reduce your costs if I help you with your work?
We are grateful for the many offers we receive, but cannot alter our processes or costs.
What education and training work do you do?
We run an international journal club for clinicians and researchers, twice a month, 5.30pm on 2nd and 4th Tuesdays. See www.ketamineconference.org.
We host the world’s only hybrid international academic conference for clinicians, academics and policy makers devoted to ketamine and related compounds for psychiatric disorders. The next one is September 11th-13th 2023 in Oxford. See www.ketamineconference.org.
We host regular peer-support / anonymous case review sessions for other clinicians working with ketamine in the UK: 3rd Wednesdays at 2-3pm
We host visiting clinicians from the UK and abroad who want to understand more about how to run a ketamine service. Such visits are usually for a day.
We train clinical fellows who spend a year with us full time learning about a broad range of Interventional Psychiatry treatments.
MSc and medical students have run service evaluations as dissertations for their courses.
Trainee psychiatrists can elect to be involved in the therapy groups, special interest sessions and as part of training in other Interventional Psychiatry Service modalities.
We introduce medical and nursing students to IPS.
If you would like to be involved in any of this, please send an email to email@example.com
I would like to train in psychedelic psychotherapy. Can you help?
We are developing the psychotherapy side of our work but do not run any psychedelic psychotherapy training programmes. These are available through other providers in the UK and US.
Science of ketamine treatment
How does ketamine work as an antidepressant?
Non-urgent advice: Downloadable information
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Page last reviewed: 20 February, 2024