As depression rates rise and traditional treatments fail a significant subset of patients, ketamine therapy has emerged globally as a powerful, rapid-acting antidepressant. Countries like the USA, UK, and Australia are already witnessing a paradigm shift, where psychiatrists, not anesthetists, are leading ketamine-based treatment for depression in controlled outpatient settings.

In India, however, adoption has been slow—largely due to concerns around medical supervision and safety protocols. Many clinicians are unsure if anesthesiologist involvement is mandatory. It’s time we clarify, contextualize, and confidently move forward.

🧠 Why Ketamine?

• Rapid onset of action (within hours to a few days)

• Efficacy in treatment-resistant depression, suicidal ideation, and PTSD

• Multiple routes of administration (IV, IM, intranasal, sublingual, oral)

Its psychotropic profile makes it suitable for use in psychiatry, provided monitoring and protocols are in place.

🇮🇳 Is Anesthesiologist Involvement Mandatory in India?

No. There is no law or regulation in India that mandates anesthetist supervision for the use of ketamine in sub-anesthetic doses for psychiatric purposes.

The off-label nature of ketamine in psychiatry necessitates:

• Proper informed consent

• Diligent risk-benefit analysis

• Structured protocols and trained staff

✅ Global Precedents: What We Can Learn

United States

• Most clinics use psychiatrists and trained nurses for IM/IN/IV ketamine at sub-anesthetic doses.

• Continuous monitoring and emergency preparedness are emphasized.

• Esketamine (Spravato) is FDA-approved and administered without anesthetist involvement.

United Kingdom

• The Royal College of Psychiatrists supports use in outpatient settings under psychiatrist-led care, not anesthetists.

• Clinics often run within mental health centers with appropriate monitoring.

Australia

• Similar model: psychiatrists lead therapy with low-dose IM/SL ketamine under medical protocols.

🔧 How India Can Do It – A Stepwise Model

1. Set Up in Controlled Settings

Psychiatry clinics, day care units, and mental health centers can create:

• Dedicated rooms for ketamine sessions

• Emergency kits (oxygen, airway adjuncts, crash cart)

• Quiet recovery areas with 2-hour post-dose monitoring

2. Route Selection for Safety

• Intramuscular (IM) and Sublingual (SL) are safer alternatives to IV and easier to implement.

• Intranasal use (Esketamine) remains unapproved in India but can be considered with regulatory clarity.

3. Train the Mental Health Team

• Nurses and technicians must be trained in:

  • Basic Life Support (BLS)

  • Vitals monitoring (BP, HR, O2 sat)

  • Handling psychotropic experiences

• Psychiatrists must be trained in:

  • Dosing, response prediction, and managing dissociation

  • Screening for cardiovascular risk

4. Use Protocol-Driven Models

Develop Standard Operating Procedures (SOPs) including:

• Pre-ketamine checklist (medical/psychiatric clearance)

• Emergency response algorithm

• Informed consent templates

• Post-session feedback documentation

5. Begin With Carefully Selected Cases

Ideal early candidates include:

• Patients with treatment-resistant depression

• Suicidal ideation unresponsive to SSRIs

• Prior favorable response to ketamine

Avoid in cases with:

• Uncontrolled hypertension

• Recent cardiovascular events

• History of psychosis (relative contraindication)

📜 Regulatory and Ethical Considerations

• Ketamine is a Schedule X and NDPS drug: Maintain strict recordkeeping and storage.

• Ensure documentation of diagnosis, dosing, vitals, and adverse events.

• Use off-label consent forms, just as done for other medications used beyond indication.

🌱 Conclusion: The Time Is Now

India stands at a critical juncture in mental health innovation. Embracing ketamine therapy doesn’t require an anesthetist—it requires a committed psychiatrist, a trained team, a clear protocol, and ethical clinical practice.

By adapting the global best practices to Indian realities, we can:

• Expand access to cutting-edge treatments

• Reduce suicide and suffering

• Position India at the forefront of psychiatry-led neuromodulation care

Let us not let inertia or fear delay what compassion and science already support.