Ketamine for Anxiety: How it Works, Effectiveness & How to Try It

What Is Ketamine Therapy?

Ketamine therapy is an FDA-approved psychedelic therapy for treatment-resistant depression and suicidality but is frequently employed beyond its approved use (off-label) to treat several other mental health (e.g., anxiety, PTSD) and medical (e.g., pain) conditions.¹ Sub-anesthetic doses of ketamine are typically administered weekly or biweekly to relieve symptoms. Ketamine can be given orally, intranasally, or by injection (IV, subcutaneous, or intramuscular).¹⁹

How Can Ketamine Therapy Help With Anxiety?

Ketamine has shown efficacy in treating several types of anxiety disorders that have failed to respond to other traditional treatments for anxiety. It is most effective with repeated administrations, as opposed to a single dose or infusion. One study found that anxiety symptoms were reduced by 50%, and this improvement lasted for over seven months post-treatment.¹

Ketamine for Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder (GAD) affects 5.7% of the population at some point in their lives and is characterized by impairing and uncontrollable worry on more days than not for over 6 months.² Often, GAD occurs comorbid with other mood disorders like depression or bipolar disorder. Accordingly, there are few research studies focusing on ketamine’s efficacy with anxiety disorders exclusively, but rather with anxiety symptoms that are comorbid with depression or anxiety symptoms that are comorbid with bipolar disorder.

Ketamine does reduce anxiety symptoms acutely; however, in many cases, the anxiety gradually creeps back over a two-week period. A single treatment can provide relief, but repeated administrations are usually necessary for sustained remission.

In most cases, the anti-anxiety effects of ketamine are temporary, gradually receding over two weeks. However, when combined with psychotherapy, especially in parallel, longer-lasting changes seem to be possible.³

Ketamine for Panic Disorders

Panic disorder affects 4.7% of the U.S. population at some point in their lives. It is accompanied by unexpected, intense feelings of fear together with physical symptoms like heart palpitations, nausea, shortness of breath, and dizziness.⁴ There is currently a lack of research specifically focused on the efficacy of ketamine for panic disorder.

The only clinical evidence suggesting that ketamine can reduce the frequency and severity of panic symptoms is that of anecdotal case reports, not empirical studies. One case report documented an adult woman with panic disorder who, after not responding to several medications, electroconvulsive therapy (ECT), and psychotherapy, was treated with a single infusion of ketamine, which freed her of panic attacks for over 10 weeks.⁵

Ketamine for Social Anxiety Disorders

Social anxiety disorder affects 12.1% of the U.S. population at some point in their lives and involves a persistent, marked fear of social situations.^{6, 7} Ketamine has been shown to reduce social anxiety symptoms (pertaining to fear and avoidance) for the 2 weeks following treatment in 33% of participants; however, it did not reduce performance anxiety.⁸

Can Ketamine Effectively Treat Anxiety?

Ketamine shows potential for treating symptoms of anxiety despite not being FDA-approved for use beyond that for depression with suicidal ideation. Preliminary studies suggest that ketamine can reduce anxiety symptoms by 50%, even when comorbid with other disorders like depression.⁹

It has also shown efficacy in treating disorders that the DSM-5 no longer classifies as anxiety disorders but have an anxiety component, like post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, and eating disorders.¹⁰

How Fast Does Ketamine Work for Anxiety?

Ketamine is fast-acting and starts relieving anxiety in the first 40-60 minutes, depending on the route of administration. The acute effects last for about 45 minutes and are then followed by a come-down phase that can last anywhere from 20 minutes to the rest of the day. Anxiety symptoms may remain quiet for about a week post-treatment but then gradually return.

Combining ketamine treatment with psychotherapy – called ketamine-assisted psychotherapy – increases the likelihood that symptom relief will extend longer and perhaps indefinitely. This is best accomplished when there is an established rapport between therapist and patient before the ketamine treatment begins.¹¹

How Long Do the Benefits of Ketamine for Anxiety Last?

Just how long the benefits of ketamine last is not clear, as the majority of research studies follow up with participants for one year at most. While some studies have reported notable improvement after a single ketamine treatment, most people will require weekly, biweekly, or sometimes monthly maintenance treatments – also called “boosters” – to prolong symptom relief.

Combining ketamine treatment with psychotherapy can increase the likelihood of more lasting improvement. Simultaneous ketamine and psychotherapy in the same session are ideal since the mind is most open to changing how it considers anxiety-provoking stimuli or situations. However, psychotherapy (individual, couples, family, group) in the few days following a ketamine treatment can also be beneficial.

What To Expect During Ketamine Treatment for Anxiety

Ketamine therapy starts with a comprehensive evaluation to determine if ketamine therapy is appropriate for the individual. The individual is then prepped on what to expect during and after the administration. The therapeutic effects experienced during the active phase are followed by the post-treatment phase, and a determination is made if maintenance therapy is needed to sustain symptom relief.

Ketamine therapy for anxiety involves the following stages:

Initial Assessment & Evaluation Process

A psychiatry practice that does offer ketamine therapy will begin the process with a standard psychiatric evaluation. Ketamine is usually only recommended when a patient has not responded to other anti-anxiety medications or it’s determined that other medications are not a safe option.

During this preliminary phase, the psychiatrist will obtain information from the patient to assess eligibility and ensure they do not have any contraindications that would disqualify them. The psychiatrist will also explain what treatment entails, including the frequency of in-office visits (ranging from once per month to several times per week), as well as the various administration methods.

Preparation Phase

During this phase, the psychiatrist administering ketamine, who may or may not be the individual’s regular psychiatrist, may consult (with permission) with a patient’s other healthcare providers, including their regular psychiatrist, psychologist, and any other physicians treating the patient for existing medical conditions (e.g., cardiologist, internist, etc.).

Sometimes, joint sessions between a psychiatrist and psychologist are arranged so that a ketamine-assisted psychotherapy session can be scheduled. Such sessions have the potential to achieve more progress than either ketamine or psychotherapy alone.¹¹

The psychiatrist and patient will also set intentions for the ketamine session, select auditory stimuli (e.g., background music, progressive or guided meditation), positioning (i.e., sitting vs. laying down), and address any concerns the patient may have as well as explain what to expect during the active session.

Instructions are given in advance for things to do — like taking one’s routine medication, especially for blood sugar and blood pressure if necessary— and things to avoid — like eating within 4 hours of treatment. It’s also very important that arrangements are made in advance for an individual’s transportation home after each session.

Active Treatment Phase

During this phase, the psychiatrist will administer ketamine. A ketamine session typically lasts around 75 minutes, with the main thrust of the drug’s effects beginning about 15 minutes after the full dose and lasting an additional 45 minutes.

The administration room may vary between practitioners, but it’s often set with dim lighting, limited ancillary sounds, and comfortable furniture for sitting or lying down. If an individual has a history of sexual trauma, it is recommended to have a friend or family member present during the treatment.

When performed in a medical setting, it is typical for the physician on staff to regularly monitor the patient’s blood pressure and vital signs and regularly check in to see if they feel any side effects. Sometimes, during a ketamine procedure, a patient will be unable to verbalize their responses and may need to respond with a head or hand gesture.

Not everyone experiences ketamine in the same way. Since ketamine leads to a dissociative state, the sense of losing control may be anxiety-provoking and unpleasant for some, especially for those seeking treatment for anxiety relief. Side effects like nausea and dizziness may be more aversive for some people as well. Typically, a psychiatrist will administer a low dose first to see how the person responds before giving the full therapeutic dose.

Post-Treatment Phase

The come-down phase of a ketamine session begins just as the peak effects start to diminish and can last anywhere from 20 minutes to the rest of the day. When effects are experienced after the day of a session, it is sometimes called the “afterglow” phase. During this period, a person is more amenable to changes in their thinking and behavior than usual.

It is not uncommon for the afterglow period to extend for several days following treatment.  During this time, one’s ketamine provider and psychologist may check in with the patient to assess their mood and physical state, and this is an excellent period for a therapy session of any kind — individual, group, or couples – to work on changing how one engages with sources of anxiety.

How is Ketamine for Anxiety Administered?

Ketamine (and its variants like esketamine) can be administered in several ways, including non-invasively through oral (sublingual, pill, lozenge) and nasal routes and invasively through injection (subcutaneous, intramuscular, intravenous). There are pros and cons to consider for different routes of administration, including bioavailability, onset and duration time, environment (clinic, hospital, office, home), and expense.

Regardless of the administration route, treatments are usually given as biweekly 2-3 hour sessions for 2-3 months, although further maintenance sessions may be required thereafter to keep anxiety symptoms at bay. It is recommended to have psychotherapy sessions before one’s first ketamine therapy session, during treatment if possible, and after the last ketamine treatment session for as long as symptoms linger.

Dosages of Ketamine for Anxiety

Dosage will depend on the route of administration and ketamine formulation (racemic, esketamine, arketamine, etc.), among other factors. A typical dose range for treating anxiety symptoms is 0.5-1 mg/kg for subcutaneous and intravenous routes.

Nasal esketamine (i.e., Spravato) can range from 28 mg (i.e., one set of sprays in each nostril) to 84 mg (i.e., 3 sets of sprays), though it is not uncommon for 140 mg of Spravato (i.e., 5 sets of sprays) to be administered. Oral forms (lozenge, tablet, sublingual) have lower bioavailability (20-25%) than intravenous (close to 100%) or intranasal esketamine (50%).¹⁵ Such higher doses (sublingual doses of 150-250mg) due to lower bioavailability, however, can result in increased adverse side effects.

Side Effects of Ketamine for Anxiety

At sub-anesthetic doses, most side effects of ketamine are transient and usually resolve in an hour. The most common side effects are sleepiness, dizziness, and blurred vision.

Side effects will vary with dose, route of administration, and the individual.  It is possible, though rare, that a patient may experience fainting during treatment (especially if they had not eaten at all that day).

Potential side effects of Ketamine treatment include:

• Sleepiness
• Dizziness/Lightheadedness
• Blurred vision
• Palpitations
• Flushing
• Poor concentration
• Nausea
• Paresthesia (pins and needles sensation)
• Dry mouth
• Headache
• Dissociation
• Perceptual distortions
• Psychotic-like symptoms
• Elevated blood pressure
• Increased heart rate
• Respiratory depression
• Urinary and bladder symptoms
• Memory impairment
• Psychiatric events
• Ketamine misuse
• Interactions with other comorbidities and medications

Is Ketamine Therapy for Anxiety Safe?

The FDA does not approve ketamine to treat any of the anxiety spectrum disorders, and like any treatment, it comes with its share of risks. Despite this, several psychiatrists have been using it off-label and found it to be fairly safe and well-tolerated with proper monitoring.

Ketamine should only be used during in-person visits and only in the presence of a certified, experienced healthcare provider. A responsible provider will educate you about the process, as well as potential risks and precautions, to increase the likelihood of treatment success and reduce the risk of injury afterward.

Risks & Precautions of Ketamine Therapy for Anxiety

Ketamine is not predictable; that is, it doesn’t reliably yield the same effect across experiences or individuals. Sometimes, even an experienced ketamine patient may unexpectedly have an unpleasant session amidst several positive sessions, potentially even falling into a K-hole. A ketamine provider will try to increase the likelihood of a positive or productive experience by controlling the set (i.e., mindset, expectations) and setting (i.e., physical and social environment) as much as possible.

Who May Not Be A Good Fit for Ketamine Treatment?

Ketamine therapy is not a good fit for everyone. It may not be safe for people with certain medical or mental health conditions (including psychosis and substance misuse) or who are undergoing other treatment regimens. Aside from medical contraindications, some people may not like or tolerate the dissociative sensation that ketamine can induce, and ketamine therapy can feel anxiety-provoking or aversive.

Extra caution should be taken with individuals with panic symptoms since some of the physiological side effects of ketamine – like increases in heart rate and blood pressure – can be similar to feelings experienced during a panic attack.

Individuals who should not take ketamine treatment include:

• People with high blood pressure
• People with cardiovascular disease
• Individuals at risk for psychosis (e.g., schizophrenia)¹⁸
• People who can not be monitored by medical staff during treatment (e.g., telehealth compounded prescriptions)
• Those who are anxious about dissociating
• Very young or very old individuals

Microdosing Ketamine for Anxiety

Microdosing involves taking a daily dose so low that it doesn’t elicit psychotropic effects (e.g., dissociation, perceptual distortions, etc.). However, ketamine therapy is currently intended as a weekly or biweekly treatment, not daily. Daily use of ketamine outside of a certified clinic or physician’s office carries the risk of dangerous side effects.

Another reason why ketamine micro-dosing may be uncommon is that a “consensus among researchers and practitioners seems to be forming around the need for a psychedelic/dissociative/trance experience to be achieved during a psychedelic-assisted session (regardless of which psychedelic drug is used) for it to achieve maximum efficacy.”¹¹ However, such a ‘psychedelic/dissociative/trance experience’ is not possible with microdoses of ketamine, and thus, larger doses are likely required to obtain the intended antidepressant effect.

How to Know If Ketamine Therapy for Anxiety Is Right for You

While some providers see utility for ketamine therapy earlier in treatment for certain severe cases, for most people, it’s an intervention considered only after other more traditional treatments have failed. As there are many factors to consider for best-treating anxiety, the first step would be to find a healthcare provider to help you evaluate if ketamine treatment is right for you.

How to Find a Ketamine Therapist for Anxiety

Like any medication, ketamine must be administered by a physician (e.g., psychiatrist) or nurse practitioner. While psychologists cannot prescribe medication, some do collaborate with psychiatrists to conduct psychotherapy sessions during ketamine treatments.

If you have a long-term relationship with a therapist that you trust, you can ask if a ketamine-assisted psychotherapy session to treat your anxiety would be possible. An established relationship is ideal for such sessions. However, if it is not, you can find a therapist using an online therapist directory or find a medical ketamine practitioner through directories like The American Society of Ketamine Physicians, Psychotherapists, and Practitioners directory.

Cost of Ketamine Treatment for Anxiety

The cost of ketamine treatment for anxiety can vary greatly with administration route (IV, oral, intranasal) and frequency. Since ketamine is not FDA-approved to treat anxiety, insurance will likely not cover the cost unless it is comorbid with treatment-resistant depression and suicidality, and only for adults.

As a reference, telehealth companies charge $100-200 per session, but the FDA issued a risk warning with at-home ketamine therapy that you may want to consider.¹⁴ Psychiatrists administering intranasal esketamine charge $150-$1,000 for a session ranging from 60 to 90 minutes. Some psychiatrists may offer talk therapy during the session, while others may collaborate with a psychotherapist who may charge for a session separately.

Other Treatment Options for Anxiety

Ketamine therapy for anxiety is not ideal for everyone, and there are other alternative treatment options for anxiety that are effective, even if they may take longer to work. Medications, psychotherapy, and neuromodulation treatments offer a buffet of options.

Other treatment options for anxiety include:

• Cognitive behavioral therapy (CBT): CBT for anxiety is typically the first line of treatment and focuses on modifying one’s thought pattern, behavior, and physiological response to triggering stimuli. CBT utilizes techniques like exposure with response prevention therapy and cognitive restructuring, and for resistant cases, it can be combined with ketamine or other pharmaceutical treatments.
•  Exposure therapy: Exposure therapy for anxiety is a CBT technique that involves presenting an individual with the most extreme, realistic scenario for one’s fear (e.g., placing several spiders on a person with arachnophobia), paired together with relaxation (often induced by a breathing technique and/or muscle relaxation exercises) and cognitive restructuring. This psychotherapeutic method is highly effective for anxiety and can be used in conjunction with medication.
• Acceptance and commitment therapy (ACT): ACT for anxiety is an offshoot of CBT that integrates aspects of transcendental meditation awareness into treatment. ACT approaches anxiety symptoms from the view that uncomfortable thoughts and fears are a normal part of being human, but by accepting their presence and changing the way one engages with the thoughts, one can learn to live without being disrupted by them.
• Medications: There are several medications for anxiety besides ketamine, with selective serotonin reuptake inhibitors (SSRIs) being the frontline choice. Other pharmaceuticals, like off-label antidepressants, benzodiazepines, antipsychotics, and anti-convulsants, may be prescribed in severe, resistant cases.
• Psilocybin-assisted therapy: Psilocybin is another psychedelic drug like ketamine. While they share many common side effects, there is a lower risk of addiction and misuse with psilocybin. However, psilocybin therapy is not widely legal or available in most municipalities at this time. This may change in the coming years as there is a push to legalize it for medical use.
• Vagus nerve stimulation: By stimulating the vagus nerve, a major nerve connecting your brain and body, signals that give rise to anxiety can be modulated and calmed. While there are invasive devices for severe cases, non-invasive methods like humming, applying a cold compress, or other vibratory applications may help calm anxiety symptoms.
• Transcranial magnetic stimulation (TMS): TMS is a non-invasive treatment option for those with comorbid anxiety and depression, especially when other less intensive treatments have been ineffective. TMS for anxiety is intensive, typically requiring daily 20-minute sessions, usually for several weeks.
• Transcranial direct current stimulation (tDCS): As a non-invasive neuromodulation technique (no surgery necessary), weak electric current is delivered to specific brain areas through electrodes placed on the scalp surface. There are mixed results regarding its efficacy with anxiety, though as with TMS, ongoing research to fine-tune parameters (e.g., stimulation intensity, brain area targeted) may improve response rates in the future.
• Deep brain stimulation (DBS): DBS is an invasive neuromodulation technique (requiring surgery) whereby stimulating electrodes are placed over specific target brain areas. The FDA does not approve this method for treating anxiety disorders, but is for OCD – which historically has been considered an anxiety-related disorder – as per a Humanitarian Device Exemption. DBS should only be considered for severe, stubborn symptoms.