How We Keep You Safe: A Look Inside Our Ketamine Protocols

When patients ask me about safety, what they usually want to know — though they don't always say it this way — is "should I trust this?" It's a fair question. Ketamine has been used in operating rooms for more than fifty years, but the at-home version is newer, and the headlines don't always make the distinction. So instead of giving you a checklist of acronyms, let me walk you through how I actually think about safety from the moment you fill out our questionnaire to the day after your last session.

Who I say no to (and why that matters for you)

The single most effective safety measure isn't equipment. It's deciding, before anyone takes a dose, whether ketamine is the right fit. That's the work of the eligibility questionnaire and the intake call.

Ketamine raises blood pressure for a few hours. For most healthy adults that's a non-event — a transient bump that resolves on its own. For someone with poorly controlled hypertension, untreated coronary disease, or a history of heart attack, it's a different conversation. Same with active psychosis or untreated bipolar mania, where the dissociative experience can destabilize symptoms rather than help them. Pregnancy, untreated substance use disorder involving stimulants, certain liver conditions — each of these moves you out of the "good candidate" column and into a conversation about whether we can address the underlying issue first, or whether you'd be better served by a different treatment entirely.

I tell patients this directly: the people I turn away are the ones I'm protecting. If I miss something on screening, the consequences land on you, in your living room, away from a hospital. So I'd rather have an awkward "let's wait and treat your blood pressure first" conversation than send medication into a situation that isn't ready for it.

What we ask you to do before the first session

The week before your first dose, you'll do a few things that may feel like busywork but each exists for a reason.

You'll measure your own blood pressure at least three times across different days, and we use those readings to confirm that what you reported on the questionnaire holds up day to day. White-coat hypertension is real; I'd rather see your at-home numbers than a single reading taken in a stressful office.

You'll identify a sitter — a sober adult who will be present in your home for the duration of the session and the recovery hour after. This isn't optional. The sitter is your in-room safety net for the things that monitoring equipment can't do at distance: making sure you don't try to walk to the bathroom while still dissociating, calling me if something doesn't feel right, being a reassuring presence if anxiety surges. We talk to your sitter beforehand so they know what to expect, and there's a detailed guide for them here.

You'll have your phone, charged, and within reach. During the session you should be lying down with eyes closed, but the phone is there because it's how I'm reaching you and how you're reaching me.

And we'll review every medication and supplement you take. Ketamine has fewer dangerous interactions than people fear, but a few matter — certain blood pressure medications, some stimulants, occasionally something a patient forgets to mention because it's been part of their routine for years. The reconciliation is unglamorous but it's where I catch most of the things that could go sideways.

What the day of treatment actually looks like

You'll dose at home, in a quiet room you've prepared. Eye mask, music if you've set it up, lights dim. The medication takes effect within fifteen to twenty minutes and the experience itself runs forty-five to ninety minutes depending on dose and individual response.

I'm not in the room — that's the honest part of "at-home telemedicine." But I'm reachable, your sitter is present, and we know how to find you. For your first session in particular, I want to know roughly when you're starting so I can be available if you call.

What I want patients to understand is that the dissociative experience itself, while it can feel intense, is the medicine working — not a complication. The treatment dose is well below anesthetic dose. You won't lose consciousness. You'll likely feel disconnected from your body, time may stretch or compress, emotions may surface. None of those are emergencies. The things that are emergencies — chest pain, a sudden severe headache, vomiting that won't stop, a blood pressure reading you've taken yourself that's frighteningly high — those are rare, and we've gone over what to do for each one before you ever take a dose. For the full side-effect profile, we walk through what's expected versus what warrants a call.

The hour after — and the next 24 hours

After the experience subsides you'll feel groggy for an hour or two. This is the window where the sitter matters most. You're not allowed to drive for at least six hours after a session, and I tell most patients to plan for the rest of the day to be quiet — no important meetings, no major decisions, no operating anything sharper than a kitchen knife.

The next morning we check in. Some of that is monitoring — how did you feel afterward, any lingering dissociation, blood pressure today, sleep — and some of it is the part of the treatment that ketamine alone doesn't do. Ketamine creates a window of neuroplasticity. What you do with that window in the days that follow — therapy, journaling, sleep, sunlight, talking to people you love — is where the lasting change comes from.

Where most of the safety actually lives

If you go back through everything I just described, you'll notice that the high-tech parts — the medication itself, the dose calculation, the timing — are the smaller share of the safety story. The bigger share is the boring stuff. The careful screening. The blood pressure logged across days. The sober sitter. The medication reconciliation. The phone within reach. The drive ban.

This is consistent with what the published literature on serious adverse events shows: when something goes wrong with at-home ketamine, it's almost never the molecule. It's a missed contraindication, an unsupervised patient, an interaction nobody asked about, or a fall during the recovery window. Each of those failure modes has a corresponding boring protocol, and we run all of them.

What we do that you don't see

Behind the scenes, every session is documented in your chart. If something noteworthy happens — a higher-than-expected blood pressure reading, a difficult emotional response, a question about whether to dose-adjust — that becomes part of how we plan your next session. I review patterns across patients quarterly to look for anything that should change in our protocols. The protocol you're getting today isn't the protocol I would have written two years ago, and won't be the one I'm writing two years from now. That's intentional.

I also coordinate with your existing prescribers when you ask me to. If you have a primary care doctor, a psychiatrist, or a therapist, I'd rather they know what we're doing and can flag anything from their side than try to operate as a closed system. Most patients consent to this; some don't, and that's fine — but the offer is always there. (For specific demographic safety considerations: seniors over 60, healthcare workers, first responders with PTSD.)

What this all comes down to

Ketamine therapy at home is safe when it's run as carefully as it would be run anywhere else, and unsafe when it isn't. The model isn't "the same as a clinic but with worse equipment." It's a different model with its own discipline — and the discipline is what I sign my name to.

If you're considering treatment, the questionnaire is the first conversation. We'll either find a path forward together, or I'll tell you honestly why this isn't the right time. Either answer is the right answer if it's the true one.

— Dr. Ben Soffer

Related reading: safety and side effects, the support person's role, driving and activity restrictions, medical supervision standards (for providers), what the treatment day looks like.