A Maze of Clinics: Navigating Ketamine’s Rapid Rise

When Aliyah Economos lifted a ketamine nasal spray to her nose and settled into her therapist’s plush grey couch, a candle flickered nearby. Images flooded her mind — Medusa, dragons and fire. Emotions swirled: rage tangled with arousal, failure mixed with shame. Over many sessions, those fragments sharpened into long-buried memories of sexual abuse.

“At first, I had a lot of denial,” said Economos, now 51. “There were many, many moments where it was overwhelming and I’d shut back down for weeks sometimes. I did not have the capacity to feel the depth and the pain of what my body was holding back without ketamine.”

She’s part of a growing wave of patients turning to ketamine when nothing else helps.

For decades, the drug has lived in two very different worlds. In hospitals, it’s a reliable, inexpensive anesthetic — fast-acting, safe enough for children. In clubs, it’s a hallucinogen that can send users into a dissociative haze.

More recently, psychiatrists have prescribed it for treatment-resistant depression. Unlike traditional antidepressants, which can take weeks to work, ketamine can provide relief in hours — even snapping people out of suicidal spirals.

“It really is a potentially life-saving drug for many people,” said Gerard Sanacora, a professor of psychiatry at the Yale School of Medicine. “The best evidence by far is for people with major depressive disorder.”

The market for ketamine really took off after 2019, when the U.S. Food and Drug Administration approved esketamine, a chemically related compound, for patients with treatment-resistant depression. Clinicians also prescribe ketamine off-label for everything from anxiety to chronic pain.

As demand has grown, so has concern about uneven oversight: the number of ketamine clinics nationwide jumped from 60 in 2015 to 1,500 today, according to a 2024 industry report.

In the Bay Area, clients might land in a spa-like East Bay center, a soft-lit therapy office in San Francisco, or a strip-mall infusion suite down the Peninsula. But behind those doors, protocols differ widely — from dosing and monitoring to whether any psychological support is offered — leaving patients with a patchwork of practices and protections.

“There’s more and more of these clinics that are popping up that are touting ketamine as a treatment for depression, PTSD, OCD and more without it actually being currently in practice guidelines,” said Smita Das, an addiction psychiatrist at Stanford Medicine. “There’s a lot of hope. However, just because there is a study of a small handful of people, we still don’t know how effective that medication is in the long term.”

The crash before the breakthrough

Economos carries herself as though nothing could come undone. She dresses in relaxed, flowing clothes, gold rings stacked just so, her long brown hair falling in loose waves. Yet, for most of her life, she felt flat on the inside — cycling through antidepressants for 15 years. Then, about six years ago, she crashed.

“My body really just shut down entirely on me,” she recalled. “Like I’d just run a marathon and yet I hadn’t. I couldn’t get out of bed. Light was painful. I fainted all the time.”

The mother of three threw herself at every possible fix: cardiologists, neurologists and rheumatologists. MRIs and blood work came back normal. She tried a trauma specialist, naturopaths and elimination diets. Hormone regimens. At one point, she said, she was swallowing as many as 38 pills a day — antibiotics, supplements and thyroid meds.

Then she tried ketamine-assisted therapy at a tranquil clinic in Berkeley. Clients sipped tea in the waiting room, yoga mats lined the corner and treatments could be paired with acupuncture, sound therapy or craniosacral work. Each three-hour session is $1,100.

With each appointment, more memories started to unlock, and slowly over nearly three years, Economos said her health began to improve.

“Ketamine has this remarkable ability to help people tolerate emotional pain that they previously couldn’t,” said Genesee Herzberg, the psychologist guiding Economos’ therapy. “It’s almost like the emotions and memories that were previously dissociated because they were too much become more accessible because of the kind of softening that ketamine does.”

As a dissociative anesthetic, ketamine disrupts normal communication patterns in the brain.

“It seems shortly after giving a dose of ketamine, there’s an increase in the brain’s ability to form new connections that could be sustained,” Sanacora said. “And we think that is likely to be one of the primary mechanisms. I’m sure there’s many different things that contribute to it, but we think that’s the main thing.”

It was supposed to be ‘the answer’ but went sideways

Jennifer Siegel was grappling with a divorce, her brother’s suicide and a fractured relationship with her father that worsened before he died.

Her familiar self-doubt had calcified into a constant self-critic, reminding her she’d failed and was running out of time. By then, her antidepressant had been augmented with an antipsychotic to boost its effect, but the medications had stopped working and were fueling stress-eating.

“I felt like I was paralyzed in my own body,” Siegel said. “I lost faith in antidepressants — like they weren’t strong enough anymore.”

Encouraged by a psychiatrist who said esketamine “would be the answer,” the 57-year-old signed up for 10 sessions at an Oakland clinic, which were covered by her insurance.

But, she soon learned sessions can go sideways without the right support.

She entered a sparse treatment room: a recliner, a box of tissues, a nearly empty jar of Jolly Ranchers. A technician drifted in and out to cuff Siegel’s arm and log her blood pressure. When the session began, the esketamine nasal spray dripped down her throat, numbing her mouth and tipping her into panic. The psychiatrist offered little reassurance, even as Siegel began to sob.

“I was feeling really helpless, really scared — like he just didn’t care at all,” she said. “I felt like he was just there to make sure I didn’t die.”

Still, the drug cracked something open. She touched the grief she’d been white-knuckling, and that access, however rough, motivated her to return. But the second session was no better; the psychiatrist kept his distance as she wept, and she canceled the rest.

Siegel switched to a Berkeley psychologist who offers ketamine-assisted therapy. Because off-label care isn’t covered, she paid about $5,000 for a package.

“There was the same kind of grief, tears and helplessness, but the therapist had her hand on my arm the whole time,” Seigel said. “She was really connected. It was exactly what I had been looking for.”

Soon she noticed real shifts: her days began trending “good to great,” and her self-criticism finally relented. Treatment, as Siegel learned, can differ dramatically from one room to the next.

The risks

Patients can even skip clinics altogether by logging on to telehealth sites, where providers ship ketamine lozenges for about $75 a dose. Operators like Michael Petegorsky, former chief strategy officer at Mindbloom, a ketamine telehealth platform, insist that clients undergo psychiatric evaluations, begin with small doses, have a peer present during sessions and follow other protocols to ensure it’s safe.

“This is not drive-by medicine or ketamine through the mail,” he said, arguing the model is more structured than critics assume.

Yet, a 2023 survey found that more than half of people who tried ketamine at home said they took more than the recommended dose, sometimes by accident, sometimes on purpose. The FDA warned in 2023 against compounded ketamine products, which are commonly used in mail-order services, because they may not be safe or effective.

“Some of my patients have developed a dependence because they were able to access ketamine so easily,” Das said. She’s also seen trauma survivors rattled by the drug’s dissociative pull. “Suddenly, you’re not in control of your body, and that can be profoundly destabilizing.”

While research suggests ketamine doesn’t create the kind of physical dependence seen with opioids or alcohol, the long-term risks are still unknown. Heavy use has been linked to bladder damage and cognitive issues.

The dangers also grabbed national attention two years ago when Matthew Perry, the longtime star of Friends, died from the acute effects of ketamine. He had been receiving medically supervised infusions, but the Los Angeles County Medical Examiner found the levels in his body when he died could not have been from his most recent treatment about a week earlier.

Economos has avoided those pitfalls, thus far. Under her psychologist’s guidance, she takes a relatively low dose and she says she’s not worried about addiction. Ketamine, she said, “gave me a gentle opportunity to meet myself in those really awful experiences without my mind having to turn it back off.”

She no longer relies on antidepressants, her body doesn’t hurt and her energy has returned. But her path took resources most people don’t have — tens of thousands of dollars and a skilled therapist to guide her through months of hard emotional work.

Ketamine can be a lifeline when standard treatments fail, but it can also be a costly gamble in a marketplace with little oversight and uncertain health risks.