What Should Usually Come First
Ketamine is a reasonable option for treatment-resistant presentations, and treatment-resistant means something specific: adequate trials that failed, not brief trials abandoned early. A large share of people who describe themselves as treatment-resistant have had subtherapeutic doses, courses stopped at three weeks because nothing had happened yet, or therapy that was supportive rather than protocol-driven. Sorting that out is worth more than any medication decision.
- An adequate antidepressant trial is a therapeutic dose for six to eight weeks
- Stopping at two or three weeks is common and is not a failed trial
- Evidence-based therapy means CBT, EMDR or ERP, not general talk therapy
- Sleep disorders, thyroid disease and anemia mimic depression and are checkable
- Alcohol used nightly will keep depression in place regardless of treatment
Where the Case Is Strongest
The evidence is best for treatment-resistant depression, where the trial literature is largest and most replicated. PTSD is next, with randomized trials run in PTSD populations. Bipolar depression has add-on evidence and requires a mood stabilizer. Beyond that the support thins quickly, and we would rather point that out than let a page imply uniform strength across every indication.
- Treatment-resistant depression: the largest and most replicated evidence base
- PTSD: randomized trials conducted in PTSD patients specifically
- Bipolar depression: add-on evidence, mood stabilizer required
- Anxiety, OCD and chronic pain: real but thinner, each with caveats
- Burnout without depression: no evidence, and not something we treat
When Ketamine Is the Wrong Answer
Some situations call for a different intervention and saying so is more useful than a broad invitation. If you are in crisis, telehealth is not the right level of care. If your pain is the primary complaint, an infusion clinic usually fits better. If you have never had ERP and you have OCD, that is the higher-value step by a wide margin.
- Active suicidal planning needs emergency or inpatient care, not telehealth
- Primary chronic pain is usually better served by an infusion clinic
- OCD without a genuine ERP course should start there instead
- Untreated substance use disorder needs addressing first
- A first depressive episode with no medication trial should start with one
Absolute Exclusions
These are assessed before any payment and are not negotiable. Listing them here rather than in the small print is deliberate.
- Uncontrolled hypertension or significant cardiovascular disease
- Active psychosis, schizophrenia, or untreated bipolar mania
- Active substance use disorder, including alcohol use disorder
- Pregnancy or breastfeeding
- Under 18
- No sober support person available for sessions
How to Answer the Question With Data
Rather than deciding from a marketing page, use the instruments. Screening is scored in your browser, nothing is saved unless you choose to save it, and no payment is required to find out where you stand. If the numbers say something other than what you expected, that is the page doing its job.
- PHQ-9 for depression severity and a baseline to measure against
- GAD-7 where anxiety is the more prominent complaint
- MDQ for bipolarity, which changes the plan substantially if positive
- C-SSRS where suicidal thoughts are present, to determine the right level of care
- All scored in your browser, before any consultation or payment
