Key Takeaways
- Esketamine is FDA-approved for treatment-resistant depression and given only in certified medical settings, while generic ketamine for psychiatric conditions is prescribed off label.
- In October 2023 the FDA warned about compounded ketamine products, including oral forms, used at home for psychiatric disorders without monitoring by a health care provider.
- The DEA describes ketamine as carrying a high potential for psychological dependence, which can develop with recreational use and sometimes with poorly monitored medical use.
- Frequent, long-term ketamine use is linked to ketamine-induced cystitis, a painful bladder condition for which stopping ketamine is the most important treatment.
- Heights Behavioral Health does not provide ketamine, but treats ketamine misuse along with the depression, anxiety, and trauma that often come with it.
Ketamine now lives two very different lives. In one, it is a carefully monitored treatment for depression that has not responded to other options. In the other, it is a party drug, an online purchase, or an at-home prescription that has quietly turned into a daily habit. Ketamine misuse can damage the bladder, build psychological dependence, and deepen the very depression people hoped it would fix. This guide explains the difference between ketamine therapy and ketamine misuse, the risks to know, the concerns about telehealth ketamine, and how treatment works when use has gotten out of hand.
We want to be clear and fair from the start. Heights Behavioral Health does not provide ketamine or esketamine treatment. We have no stake in steering anyone toward or away from it. What we do see is the other side: adults whose use moved beyond what any clinician intended, and families trying to make sense of it.
Ketamine, defined: a dissociative anesthetic that has been a Schedule III controlled substance in the United States since 1999. It is FDA-approved as an anesthetic. A related drug, esketamine (Spravato), is FDA-approved for treatment-resistant depression and is given as a nasal spray only in certified medical settings.
Ketamine Therapy: What Is Approved and What Is Not
Esketamine was approved by the FDA in 2019 for treatment-resistant depression, and in January 2025 it was approved for use on its own, without an oral antidepressant. It is administered in a certified doctor’s office or clinic, and patients are monitored on site after each dose. Those requirements exist because of the risks of sedation, dissociation, and misuse.
Ketamine itself is approved as an anesthetic. When clinics use generic ketamine for depression or other psychiatric conditions, it is being prescribed off label. Some off-label ketamine care is delivered by experienced clinicians with careful screening and monitoring. Some is not. In October 2023 the FDA warned patients and health care providers about the potential risks of compounded ketamine products, including oral formulations, used to treat psychiatric disorders, particularly when used at home without monitoring by a health care provider.
| Feature | Esketamine (Spravato) | Off-label clinic ketamine | Nonmedical ketamine use |
|---|---|---|---|
| FDA approval for depression | Yes, for treatment-resistant depression | No, used off label | No |
| Where it is taken | Certified medical setting only | Clinic, or sometimes at home | Anywhere |
| Monitoring | Required on site after each dose | Varies widely by provider | None |
| Product quality | Approved manufactured product | Varies; may be compounded | Unknown; may be counterfeit or contaminated |
Telehealth Ketamine Concerns
During the pandemic, federal rules were loosened so controlled substances could be prescribed by telemedicine without an in-person visit. Those flexibilities have been extended several times, most recently through December 31, 2026. That has allowed some companies to prescribe ketamine lozenges or tablets for home use after a video visit.
The concern is not telehealth itself. It is what can get lost: in-person screening, someone present during dosing, and close follow-up when use starts to escalate. The FDA has also taken action against websites selling ketamine online without requiring a prescription, warning in June 2026 letters about the significant risks of unapproved ketamine products, especially without appropriate medical supervision, and noting they may be contaminated, counterfeit, or vary in strength.
Questions worth asking about any ketamine program:
- Was I evaluated for substance use history, psychosis risk, and blood pressure before starting?
- Is someone with me, or monitoring me, when I take a dose?
- Is there a clear limit on how much and how often, and a plan to stop?
- Is ketamine part of a broader plan that includes therapy?
- What happens if I start wanting it between sessions?
Integrated Dual Diagnosis Care
Has ketamine use gone beyond the plan?
A confidential assessment can sort out what is happening without judgment.
Ketamine Misuse and Dependence
The DEA describes ketamine as having a moderate or low potential for physical dependence but a high potential for psychological dependence. In practice that looks like cravings, using to escape low mood or stress, needing more for the same effect, and using more often than planned. It can happen to people who started recreationally and to people who started in treatment.
Signs that ketamine use has become a problem include:
- Using between scheduled treatments, or sourcing extra ketamine
- Needing larger amounts to feel the same effect
- Memory problems, trouble concentrating, or feeling detached for long stretches
- Low mood that worsens between uses
- Bladder or abdominal pain, or needing to urinate far more often
- Hiding use from family, a partner, or a prescriber
Ketamine overdose can cause unconsciousness and dangerously slowed breathing, according to the DEA, and the risk climbs when ketamine is combined with alcohol, benzodiazepines, or opioids. Our article on polysubstance use explains why combinations are more dangerous than either drug alone.
Ketamine Bladder Damage: A Risk People Rarely Hear About
Frequent, long-term ketamine use is linked to a condition called ketamine-induced cystitis. A review in the Tzu Chi Medical Journal describes symptoms that often start as an irritable bladder and progress to urgent, frequent, and painful urination and a shrunken, ulcerated bladder. In severe cases, damage can extend to the kidneys.
The same review is clear about the most important treatment: stopping ketamine. Symptoms usually return if use resumes, and the most severe cases have required major surgery. Anyone using ketamine regularly who notices urinary pain or frequency should tell a physician about their ketamine use specifically.
Treatment for Ketamine Misuse
There is no FDA-approved medication specifically for ketamine use disorder, so treatment focuses on therapy, medical care, and the conditions underneath. That last part matters a great deal. Many people who misuse ketamine have depression, PTSD, or anxiety that brought them to ketamine in the first place, and stopping can bring those symptoms back to the surface. Integrated dual diagnosis treatment treats both together.
Effective care often includes:
- A clinical assessment of ketamine use, other substances, mood, and physical symptoms
- Coordination with a physician or urologist for bladder or kidney symptoms
- Evidence-based therapies such as CBT, DBT, and trauma therapies like EMDR or cognitive processing therapy
- Structured outpatient programming that rebuilds routines and coping skills
- Family involvement, so loved ones understand what recovery requires
If you started ketamine for depression and are now worried about your use, that is not a personal failure. It is information. A careful reassessment can look at what has and has not helped, and what other treatment options exist. Some people also find our piece on cross-addiction useful, since one substance can quietly replace another.
How Heights Can Help
Heights Behavioral Health is an outpatient practice in the Houston Heights serving adults. We do not offer ketamine or esketamine, and we do not provide detox or emergency care. We provide substance use treatment including partial hospitalization, intensive outpatient programs with evening options, individual and group therapy, trauma therapies, dual diagnosis care, and family programming, and we coordinate with medical providers as needed.
Crisis notice. If someone is unresponsive or breathing slowly after using ketamine, especially with alcohol or other sedatives, call 911 now. For poisoning questions, call Poison Help at 1-800-222-1222. Heights Behavioral Health provides scheduled outpatient care and is not an emergency service. If you are having thoughts of suicide or are in crisis, call or text 988.
Frequently Asked Questions
Is ketamine addictive?
It can be. The DEA describes ketamine as carrying a high potential for psychological dependence. Cravings, tolerance, and escalating use can develop with recreational use and sometimes with poorly monitored medical use.
Is at-home ketamine safe?
The FDA has warned about compounded ketamine products, including oral forms, used at home for psychiatric conditions without monitoring. Esketamine, the FDA-approved option for treatment-resistant depression, is only given in certified medical settings.
Can ketamine damage your bladder?
Yes. Frequent, long-term use is linked to ketamine-induced cystitis, which causes painful, frequent urination and can permanently damage the bladder. Stopping ketamine is the most important treatment.
Does Heights offer ketamine therapy?
No. Heights does not provide ketamine or esketamine. We treat ketamine misuse and the depression, anxiety, and trauma that often come with it, using therapy and structured outpatient care.
Sources
- Drug Enforcement Administration. Ketamine Drug Fact Sheet. dea.gov
- U.S. Food and Drug Administration. FDA Warns Patients and Health Care Providers About Potential Risks Associated With Compounded Ketamine Products, Including Oral Formulations, for the Treatment of Psychiatric Disorders. fda.gov
- U.S. Food and Drug Administration. Warning Letter: Ketamine Troche Store, June 23, 2026. fda.gov
- Tzu Chi Medical Journal. Pathophysiology, Clinical Presentation, and Management of Ketamine-Induced Cystitis. tzuchi.com.tw
- Holland and Knight. DEA and HHS Extend Telemedicine Prescribing Flexibilities Through 2026. hklaw.com
Written and Reviewed by Licensed Clinicians
Joni Ogle is a Licensed Clinical Social Worker (LCSW) and Certified Sex Addiction Therapist (CSAT) with over 37 years of clinical experience in mental health and addiction recovery, dual diagnosis treatment, behavioral addictions, and family intervention. She is the founder of Heights Behavioral Health and Heights Mentoring in Houston, Texas, where she leads a team of licensed clinicians.
Texas LCSW #37376 · Verify license
Deborah Darnell-Drake, LCSW-S, ACSW, LMFT is the Chief Clinical Officer at Heights Behavioral Health and a clinical reviewer. With more than five decades of experience in mental health and substance use disorder treatment, Deborah specializes in addiction, co-occurring mental health conditions, family dynamics, and behavioral addictions including gambling and technology addiction.
Texas LCSW-S #14508 · LMFT #1125 · Verify license
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