Psychiatric Consultation Protocols for Ketamine

The consultation visit is where a ketamine program earns (or loses) its clinical credibility. A fast intake with perfunctory screening can clear a patient for treatment in fifteen minutes; a proper psychiatric consultation for a candidate takes closer to ninety, and much of what that time produces never appears on the claim. You're assessing diagnostic accuracy, prior-trial adequacy, suicide risk, family psychiatric patterns, and the subtler question of whether this person has the psychological scaffolding to use what ketamine is about to open up. The patients who do best with ketamine are usually the ones whose clinicians asked the right questions before the first dose, not the ones who were most eager to start.

Initial Psychiatric Assessment Framework

Most ketamine candidates arrive with a depression diagnosis, a history of several medication trials, and a story about what hasn't worked. The consultation's job is to translate that narrative into the specific clinical details that shape treatment: which diagnoses are actually in play, which prior trials were adequate versus nominal, what the trajectory of the illness looks like, and which treatment approach (within the ketamine toolkit) is likeliest to help.

Comprehensive Diagnostic Evaluation

Clinical Interview Structure:

• Chief complaint and history of present illness
• Detailed psychiatric history including previous treatments
• Substance use history and current status assessment
• Family psychiatric history and genetic risk factors
• Psychosocial stressors and support system evaluation

Validated Assessment Instruments:

• PHQ-9 for depression severity and monitoring
• GAD-7 for anxiety symptom assessment
• MADRS for detailed depression evaluation in clinical settings
• C-SSRS for comprehensive suicidal ideation assessment

Treatment History Documentation

The phrase "treatment-resistant depression" is easy to write and harder to document. For ketamine to be the right clinical choice, and for the insurance conversation that may follow, the prior-trial history needs to be specific: which SSRIs at what doses for how long, why each was discontinued, whether adequate augmentation was attempted. A patient who tried three SSRIs for four weeks each has a materially different treatment history than one who completed four full trials with clear failure criteria.

Medication Trial Assessment:

• Specific antidepressants tried with doses and durations
• Treatment response and side effects experienced
• Reasons for discontinuation or treatment failure
• Augmentation strategies and combination therapies attempted

Psychotherapy History:

• Types of therapy received and duration of treatment
• Therapist qualifications and treatment modalities
• Response to psychotherapy interventions
• Integration plans with ketamine therapy

Risk Assessment and Contraindication Screening

The contraindication list is where screening decisions are made, but the real clinical work is noticing the patient who technically meets no exclusion criterion and yet still isn't a good candidate: the subclinical mania the patient didn't recognize as mania, the dissociative tendency they've always just called "zoning out," the ketamine curiosity that's actually a substance-use pattern hiding behind therapeutic language. Screening instruments catch the obvious cases; clinical judgment catches the ones that matter.

Psychiatric Contraindications

Absolute Contraindications:

• Active psychosis or history of schizophrenia
• Severe personality disorders affecting treatment compliance
• Active substance use disorder with ketamine or dissociatives
• Acute manic episode in bipolar disorder

Relative Contraindications:

• History of ketamine abuse or problematic use
• Severe dissociative disorders
• Active suicidal plan requiring immediate intervention
• Cognitive impairment affecting informed consent capacity

Suicide Risk Assessment

Ketamine has a specific anti-suicidal effect that can be lifesaving for high-risk patients, and the same population is the one for whom careful safety planning matters most. The consultation is not just assessing current risk; it's calibrating how the plan changes if ketamine begins to help, what happens if a session produces an unexpected emotional surge, and what the safety net looks like in the hours after the patient leaves the clinic.

Comprehensive Risk Evaluation:

• Current suicidal ideation intensity and specificity
• Previous suicide attempts and methods used
• Protective factors and reasons for living assessment
• Safety planning and crisis intervention protocols

Risk Stratification:

• Low risk: Passive ideation, strong protective factors
• Moderate risk: Active ideation, some protective factors
• High risk: Plan/intent, limited protective factors, requires enhanced safety measures

Treatment Planning and Goal Setting

By the end of the consultation, there should be a concrete treatment plan the patient can repeat back to you: what we're treating, what success looks like, how we'll measure it, what happens if it doesn't work, and what happens if it does. Vague goals (such as "feel better" or "have more energy") predict poor adherence and weak clinical data. Specific, measurable ones give both patient and provider something to orient around across a course of 10 or more sessions over 4-8 weeks.

Individualized Treatment Plans

Therapeutic Objectives:

• Specific, measurable treatment goals and timelines
• Functional improvement targets (work, relationships, self-care)
• Quality of life enhancement priorities
• Integration with ongoing mental health treatments

Treatment Protocol Selection:

• IV vs sublingual administration considerations
• Dosing frequency and maintenance planning
• Integration with psychotherapy and other interventions
• Monitoring and adjustment protocols

Informed Consent Process

The informed consent conversation for ketamine is not a signature you collect; it's a conversation you have. A patient who cannot articulate, in their own words, what ketamine will feel like during the session and how it differs from a standard medication is not yet consented, regardless of what the form says. Good consent in this context is measured by the patient's ability to describe the treatment back to you, not by the completeness of the paperwork.

Comprehensive Patient Education:

• Mechanism of action and expected effects explanation
• Potential benefits and realistic outcome expectations
• Side effects profile and management strategies
• Alternative treatment options and rationale for ketamine selection

Consent Documentation:

• Written informed consent with detailed risk discussion
• Patient understanding verification and documentation
• Ongoing consent process for treatment adjustments
• Right to discontinue treatment at any time

Frequently Asked Questions

What does a thorough psychiatric consultation for ketamine therapy include?

Core elements: confirmation of working diagnosis (DSM-5 criteria), screening for conditions that contraindicate ketamine (bipolar with manic features, active psychosis, dissociative disorders), detailed history of prior medication trials with specific doses and durations, suicide risk stratification, substance use history, family psychiatric history, current support structure, prior psychotherapy history, and assessment of psychological readiness for the dissociative experience. Time investment: typically 60-90 minutes for an adequate first consultation, much of it not visible on the claim form but essential to outcome quality.

How do you assess whether a patient's prior antidepressant trials were "adequate" for TRD eligibility?

Adequacy criteria: therapeutic dose (e.g., sertraline ≥100 mg, escitalopram ≥10-20 mg) for at least 6-8 weeks of consistent daily dosing, with the patient adherent to the regimen. Common reasons trials are deemed inadequate despite the patient reporting "I tried it": stopping at 25% of therapeutic dose due to early side effects, missing 30%+ of doses, taking it for 2-3 weeks before declaring failure, or never adjusting the medication when partial response was observed. Two adequately conducted trials at therapeutic dose for adequate duration is the threshold; less than that means optimization remains the appropriate next step.

How is suicide risk assessed during ketamine consultation?

Standard psychiatric suicide-risk stratification: assessment of current ideation (frequency, intensity, intent), specific plan or means, prior attempts and their lethality, recent stressors, current support structure, and access to lethal means. Important distinction for ketamine candidacy: passive suicidal ideation in the context of stable TRD is often appropriate for outpatient ketamine treatment. Active ideation with plan, means, and intent requires inpatient stabilization first; ketamine is not a crisis intervention. The consultation establishes which side of that line each patient is on, and structures appropriate safety planning either way.

What disqualifies a patient during psychiatric consultation?

Several presentations move a candidate out of at-home ketamine consideration. Active psychosis or untreated bipolar mania: ketamine's dissociative effects can destabilize. Severe dissociative disorder: risk of compounding existing dissociation. Active substance use disorder involving stimulants or opioids: safety and response concerns. Current pregnancy: contraindication. Severe untreated cardiovascular disease: risk of hypertensive response. Inability to provide informed consent: disqualifying. Active suicidal crisis with plan/means/intent: requires inpatient stabilization first, not at-home outpatient ketamine. Some of these are absolute; others can be revisited after underlying issues are addressed.

Conclusion

A well-conducted consultation does more than qualify a patient for a protocol; it establishes the therapeutic alliance that carries the clinical work through the hard moments a treatment course will inevitably produce. The patient who remembers being taken seriously during their intake is the patient who texts you when they're having a rough night in week three; the one who was processed through quickly is the one who silently drops out. The ninety minutes spent on a proper consultation return themselves many times over in treatment completion, outcome quality, and the clinical confidence of the program itself.

Considering ketamine therapy for a patient who hasn't responded to standard care?

Tovani Health is a physician-led at-home ketamine therapy practice serving Florida and New Jersey. We conduct full 60–90 minute psychiatric consultations on every candidate before any treatment begins, and we coordinate with referring providers throughout the course.

Refer a patient via /eligibility →

Want to discuss a case directly before referral? Call 561-468-6981.

Benjamin Soffer, DO — Tovani Health

---

Related professional reading: clinical protocols and patient selection, referral guidelines for primary care physicians, clinical supervision protocols, evidence-based outcomes review, SSRI vs ketamine pharmacological comparison.