Set Expectations Against the Depression Data

Most of what is written about ketamine describes depression outcomes. Anxiety has been studied less, in smaller samples, over shorter periods. Glue and colleagues found dose-related reductions in anxiety symptoms among patients with treatment-refractory generalized and social anxiety, which is a genuine finding worth acting on, but it is not the same weight of evidence as the depression literature and should not be presented as though it were.

• Smaller trials, shorter follow-up, fewer patients than the depression research
• Studied populations were treatment-refractory, not first-presentation anxiety
• Response appeared dose-related rather than all-or-nothing
• Anxious depression, where both are present, has better support than pure anxiety
• If a first SSRI has not been tried, that is the more evidence-based next step

The Benzodiazepine Problem

This is the complication specific to anxiety and the reason this page exists separately from the depression page. Benzodiazepines act on GABA and there is reasonable evidence that ongoing use blunts ketamine response. Anxiety patients are the group most likely to be on daily alprazolam or clonazepam, so the medication treating the condition may reduce the effect of the treatment being considered for it. There is no clean answer, only a coordinated one.

• Daily benzodiazepine use may reduce ketamine response
• Occasional as-needed use is a different situation from standing daily dosing
• Abrupt benzodiazepine discontinuation is dangerous and can cause seizures
• Any change is planned with your prescriber, on a taper, never abruptly
• For some patients the honest answer is to address the benzodiazepine first

Somatic Anxiety Versus Cognitive Anxiety

Anxiety presents in two broad ways and they respond differently. Cognitive anxiety is the rumination, catastrophizing and anticipatory dread. Somatic anxiety is the chest tightness, palpitations and gut symptoms. Patients whose presentation is predominantly somatic often turn out to have a cardiac or thyroid workup pending, and that workup should be finished before a psychiatric intervention is added.

• Predominantly somatic presentation warrants a medical workup first
• Thyroid function and cardiac symptoms are asked about during screening
• Ketamine transiently raises heart rate, which somatic patients notice acutely
• Cognitive anxiety patients generally tolerate sessions more comfortably
• Panic disorder specifically is evaluated on its own terms, not as generic anxiety

Screening and Candidacy

GAD-7 gives severity and a way to track change. Where depression is also present, PHQ-9 runs alongside it, because anxious depression has better evidential support than anxiety alone and the combination changes how promising the case is.

• GAD-7 scored before any consultation, repeated to measure change
• PHQ-9 alongside it when low mood is also present
• At least one adequate SSRI or SNRI trial at therapeutic dose and duration
• Blood pressure in range and no unexplained cardiac symptoms
• No active substance use disorder, psychosis, or untreated bipolar mania
• A sober support person present for the full session

What a Session Is Like When Anxiety Is the Problem

Worth saying directly: a dissociative experience is an unusual thing to recommend to someone whose central complaint is fear of losing control. Most anxiety patients tolerate it well, and preparation is the difference. We start conservatively on dose and adjust upward rather than the reverse.

• Conservative starting dose, titrated up only if needed and tolerated
• The experience is explained in detail beforehand rather than discovered live
• A sober support person is required for every session
• Extended booking windows including 12:30 PM and 5:00 PM appointments
• Sessions that go badly are a reason to change the plan, not to push through