Ketamine Therapy Referral Guidelines for Primary Care Physicians

Most of the ketamine referrals I receive from primary care start with a familiar pattern: a patient the referring physician has known for years, a depression that has outlasted three or four antidepressant trials, and a provider who knows his toolkit has been exhausted but isn't quite sure what to do about it. The referral note, when it arrives, is usually short: "failed multiple SSRIs, considering ketamine, please evaluate." I appreciate those referrals (they're almost always appropriate), but they're also leaving information on the table that would help both of us, and particularly the patient. What follows is a practical guide to what a good ketamine referral looks like from the receiving physician's perspective: who's genuinely a candidate, what to include in the referral note, and how to frame the conversation with the patient so they arrive ready to engage.

When to Refer: Clinical Indications

Treatment-Resistant Depression

This is the largest and most clear-cut category. The conventional definition of TRD is failure of two or more adequate antidepressant trials, but in practice I see patients referred who have failed three or four. The clinical signals worth acting on:

• Failure of 2+ adequate antidepressant trials (6-8 weeks each at therapeutic doses)
• PHQ-9 scores ≥15 despite optimal medical management
• Functional impairment affecting work, relationships, or daily activities
• Patient preference for an alternative to continued medication trials

Earlier referral is reasonable when the patient's clinical trajectory is deteriorating despite compliant treatment, or when waiting another 8-week trial means another two months of unaddressed suffering.

Major Depressive Disorder with Passive Suicidal Ideation

For patients with passive suicidal ideation in the context of depression that hasn't responded to standard treatment, ketamine's rapid-onset profile is one of its strongest indications. A few important distinctions:

• Active suicidal ideation with plan or intent belongs in the emergency department or inpatient setting first; not Tovani Health
• Recent suicide attempts with ongoing depression can be referred once stabilized
• Inpatient discharge planning that needs intensive outpatient bridging is a strong fit
• Patients in the ED for crisis stabilization can be referred for follow-up after acute disposition

The point is to use ketamine's speed of action where speed matters, while keeping appropriate safety boundaries around acute risk.

Anxiety Disorders

Ketamine's anxiolytic profile is most evidence-supported for:

• Generalized anxiety disorder unresponsive to first-line treatments
• Panic disorder with agoraphobia limiting function
• Social anxiety disorder affecting professional/personal life
• PTSD with inadequate response to trauma-focused therapies

Response rates are somewhat lower than for depression alone, but for patients with comorbid depression and anxiety (the more common pattern), ketamine often addresses both.

Chronic Pain Syndromes

For pain conditions involving central sensitization, ketamine's NMDA-receptor mechanism is mechanistically aligned with the pathology:

• Fibromyalgia with comorbid depression
• Complex regional pain syndrome (CRPS)
• Neuropathic pain syndromes
• Chronic pain with central sensitization features

Pain referrals should clearly note the prior treatment trail (gabapentinoids, SNRIs, topical agents, opioid history) and the specific question for the consultant.

Who NOT to Refer

A clear "no" referral is more useful than an ambiguous one. Absolute contraindications:

• Active psychosis
• Untreated bipolar mania
• Current pregnancy or active breastfeeding
• Severe untreated cardiovascular disease (recent MI, severe heart failure, uncontrolled arrhythmias)
• Active substance use disorder involving stimulants or opioids
• Inability to provide informed consent
• No sober adult support person available for at-home sessions

Relative contraindications worth discussing rather than blocking:

• Stable schizophrenia spectrum disorder (case-by-case)
• Borderline personality disorder (treatable but requires careful integration support)
• Severe untreated PTSD with active dissociative episodes (may need stabilization first)
• Uncontrolled hypertension (often correctable before treatment)

If the patient sits in the relative-contraindication zone, a phone call to the consultant is faster than going back and forth in writing.

What to Include in Your Referral Note

The most useful referral notes are short but specific. The elements that actually move the consult forward:

1. Confirmed psychiatric diagnosis with DSM-5 criteria where applicable
2. Severity measures (PHQ-9, GAD-7, PCL-5) ideally trended over time
3. Complete antidepressant trial history with specific medications, doses, durations, and reasons for discontinuation
4. Current medications including all psychotropics and other relevant agents
5. Current vital signs, especially blood pressure
6. Relevant medical comorbidities (cardiovascular, hepatic, renal)
7. Psychotherapy history and current therapeutic relationship if any
8. Substance use history including alcohol and cannabis
9. The specific clinical question (e.g., "consider for ketamine vs. continued augmentation")

A two-paragraph referral with these elements often saves a 30-minute back-and-forth during the patient's evaluation.

What Happens After Referral

The Tovani Health intake-to-treatment timeline is typically 5-10 days:

1. Eligibility screen (5 minutes online)
2. Video consultation (30 minutes with prescribing physician) within a few business days of screen
3. Prescription sent same day if approved, to the compounding pharmacy
4. Medication ships within 1-3 business days
5. First session scheduled as soon as patient has medication and a sober support person available

We'll send a brief evaluation summary back to the referring provider after the consult, with the treatment plan and any questions for the referring team. Ongoing communication during the loading phase (typically 10+ sessions over 4-8 weeks) is welcome, particularly around medication coordination if the patient is being weaned off other psychotropics.

Coordination Matters

Effective ketamine therapy referrals require thorough assessment, appropriate patient selection, and robust care coordination. By following evidence-based guidelines and maintaining collaborative relationships with ketamine providers, primary care physicians can significantly improve outcomes for patients with treatment-resistant mental health conditions. The ketamine consultation isn't meant to replace primary care; it's meant to add a tool when the existing toolkit has been honestly tried and found insufficient.

Frequently Asked Questions

When should a primary care physician refer a patient for ketamine therapy?

Strong indications: failure of two or more adequate antidepressant trials (each at therapeutic dose for 6-8 weeks), PHQ-9 score ≥15 despite optimal medical management, functional impairment significantly affecting work or relationships, comorbid anxiety or PTSD that hasn't responded to standard treatment, chronic pain conditions (fibromyalgia, CRPS, neuropathic pain) refractory to first-line treatment. Consider earlier referral when depression severity warrants faster response than 8-week SSRI trials can deliver, particularly with passive suicidal ideation that needs faster intervention.

What information should a referral letter include for ketamine consultation?

Useful referral elements: confirmed psychiatric diagnosis (DSM-5 criteria where applicable), severity measures (PHQ-9, GAD-7, PCL-5 as relevant) ideally trended over time, complete antidepressant trial history with specific medications, doses, durations, and reasons for discontinuation, current medications including all psychotropics and other relevant agents, current vital signs (especially blood pressure), relevant medical comorbidities (cardiovascular, hepatic, renal), psychotherapy history, substance use history, and the specific clinical question (e.g., "consider for ketamine vs. continued augmentation").

Which patients should NOT be referred for ketamine therapy?

Absolute contraindications: active psychosis, untreated bipolar mania, current pregnancy, severe untreated cardiovascular disease (recent MI, severe heart failure, uncontrolled arrhythmias), active substance use disorder involving stimulants or opioids, inability to provide informed consent, lack of sober support person for at-home sessions. Relative contraindications worth discussing rather than blocking: stable schizophrenia spectrum disorder (case-by-case), borderline personality disorder (treatable but requires careful integration support), severe untreated PTSD with active dissociative episodes (may need stabilization first).

How quickly can a referred patient typically begin ketamine treatment?

The Tovani Health intake-to-treatment timeline is typically 5-10 days. Patient completes a 5-minute online eligibility screen, schedules a 30-minute video consultation with the prescribing physician, and if approved, the prescription is sent to the compounding pharmacy that day. Medication ships within 1-3 business days. First session can be scheduled as soon as the patient has medication and a sober support person available. For straightforward TRD referrals without complicating factors, beginning treatment within a week of referral is realistic.

Refer a patient or get a curbside

If you have a patient who fits the referral criteria above, the simplest pathway is to point them at the eligibility screen below; we'll handle the rest and send you back a summary. For provider-to-provider questions about a specific case, the phone line is faster.

• Patient eligibility screen: tovanihealth.com/eligibility (5 minutes, FL and NJ residents)
• Provider line: 561-468-6981 (curbside questions about a specific case welcome)
• What you get back: an evaluation summary with the treatment plan and any questions for your team after the consultation.

Benjamin Soffer, DO — Tovani Health

Related professional reading: psychiatric consultation protocols, clinical protocols and patient selection, SSRI vs ketamine pharmacological comparison, evidence-based outcomes review.