When Ketamine Is Not Appropriate

Ketamine demonstrates therapeutic potential for treatment-resistant depression, PTSD, anxiety, and chronic pain. However, responsible clinical practice demands recognizing situations where ketamine is contraindicated. ## Medical Contraindications **Psychosis or Schizophrenia History** Ketamine's perceptual alterations can destabilize patients with psychotic disorders, potentially exacerbating "hallucinations, paranoia, or disorganized thinking." **Uncontrolled Hypertension and Cardiovascular Issues** Since ketamine temporarily elevates heart rate and blood pressure, patients with severe uncontrolled hypertension, recent cardiac events, or arrhythmias require stabilization first. **Liver Dysfunction** Moderate to severe hepatic impairment contraindicates use, as ketamine processes through the liver and may accumulate unpredictably. **Pregnancy and Breastfeeding** Cautious avoidance is recommended due to potential fetal transfer or breast milk transmission. ## Psychiatric Contraindications **Bipolar Disorder Without Mood Stabilization** Unmedicated bipolar patients risk mania, agitation, or "mixed states (which carry exceptionally high suicide risk)" when given ketamine. **Acute Suicidality** Active intent with accessible means requires hospital-based intervention before outpatient ketamine becomes appropriate. **Active Substance Use Disorder** Patients actively misusing alcohol, stimulants, or opioids should stabilize before ketamine treatment, as the drug may reinforce addictive patterns. ## Environmental and Support Requirements **Safe Home Environment and Peer Supervision** Ketamine requires a physically present, trusted adult during treatment to prevent unsafe movements and provide reassurance during dissociation. **Psychological Support Systems** Patients need therapeutic resources and integration support to process emotional material surfaced during treatment. ## Additional Contraindications **Medication Conflicts** Benzodiazepines, high-dose stimulants, clozapine, and recent MAOIs require careful evaluation, as they may reduce efficacy or increase cardiovascular risk. **Recreational Seeking** Ketamine prescribed as a "psychedelic experience" rather than clinical treatment is inappropriate. **Allergy or Hypersensitivity** Represents an absolute contraindication. **Disclaimer:** Compounded ketamine for anxiety, depression, PTSD, and chronic pain is not FDA-approved. This information is educational; ketamine therapy requires medical evaluation, and results vary individually.