Why PTSD Is a Stronger Case Than Most
Most ketamine indications rest on depression trials with the results extended by analogy. PTSD does not. Feder and colleagues ran randomized controlled trials in patients carrying a PTSD diagnosis, using PTSD rating scales as the endpoint, and found significant symptom reduction against an active control. That is a meaningfully different quality of evidence, and it is the reason PTSD is one of the presentations we evaluate most readily.
- Randomized trials conducted in PTSD populations with PTSD endpoints
- Effect measured on core symptom clusters, not just co-occurring low mood
- Repeated dosing studied specifically, rather than assumed from single-dose data
- Benefit appears within hours to days rather than the weeks an SSRI requires
- Depression riding alongside the PTSD tends to respond in the same course
What Ketamine Does Not Do for Trauma
Ketamine reduces symptom intensity. It does not process the memory. The neuroplasticity window it opens is an opportunity for trauma-focused therapy to do its work more easily, and patients who use that window tend to hold their gains, while patients who treat ketamine as a standalone intervention frequently drift back toward baseline. If you are not in therapy and have no intention of starting, expect the benefit to be temporary and say so during your consultation.
- Symptom reduction is not memory reconsolidation
- EMDR, CPT and prolonged exposure remain the treatments with durable outcomes
- The plasticity window is a reason to schedule therapy, not to skip it
- Standalone ketamine typically requires ongoing maintenance to sustain effect
- We ask about your therapy arrangements because the answer changes the plan
Dissociation Deserves a Direct Answer
Patients with trauma histories are right to ask about this. Ketamine produces dissociation, and dissociation is also a PTSD symptom, so the obvious worry is that the treatment reproduces the thing being treated. In practice the two are different experiences: ketamine dissociation is dose-dependent, time-limited and resolves fully, whereas trauma dissociation is involuntary and untethered. That said, patients with dissociative subtype PTSD or a dissociative disorder need individual evaluation, and some are not candidates.
- Ketamine dissociation is dose-related, predictable, and ends with the session
- Set and setting matter more here than in any other indication we treat
- A sober support person is required, not encouraged
- Dissociative subtype PTSD is evaluated individually and sometimes declined
- Dose is adjusted downward when dissociation is poorly tolerated
Screening and Candidacy
PCL-5 gives a baseline severity score and a way to measure change that does not depend on recall. We use it before treatment and through the course. Severity alone does not decide candidacy; stability, support and current substance use matter as much.
- PCL-5 scored before any consultation, and repeated to track change
- Adults 18 and over with a PTSD diagnosis or a clear trauma-linked presentation
- Blood pressure within range, since ketamine raises it transiently
- No active psychosis, untreated bipolar mania, or current substance use disorder
- Active suicidal planning requires a higher level of care than telehealth provides
Medications That Interact With the Plan
Several drugs common in PTSD care change how a ketamine course should run. Benzodiazepines are the most consequential: there is reasonable evidence that ongoing benzodiazepine use blunts ketamine response, which matters when someone is taking lorazepam or clonazepam daily for the same condition. Prazosin for nightmares is generally compatible. Every medication is reviewed individually.
- Daily benzodiazepines may reduce response and are discussed before starting
- Prazosin for trauma nightmares is usually continued without change
- SSRIs and SNRIs prescribed for PTSD are typically maintained
- Alcohol used for sleep is a safety issue and is asked about directly
- Nothing is stopped without coordination with the prescriber who started it
