NEI Podcast E276 - PsychopharmaPearls: Choosing Ketamine Treatment with Dr. Lisa Harding
Feb 25, 2026
Dr. Lisa Harding, a Yale-affiliated psychiatrist specializing in interventional treatments for treatment-resistant depression. She contrasts IV ketamine and intranasal esketamine. Short, practical talks cover patient selection, monitoring and safety, access and cost, clinic operations, and risks of unsupervised at-home use.
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Route Determines Bioavailability And Predictability
- Route affects bioavailability and clinical predictability: IV is 100% bioavailable, intranasal ~50%, sublingual ~20%, and IM variable up to ~80%.
- That pharmacokinetic variability explains why dosing and side effects differ across administration routes.
Match Route To Patient Physiology And Preference
- Individualize choice of IV ketamine versus intranasal esketamine based on patient factors like needle phobia, blood pressure lability, nasal congestion, and preferences.
- For patients with fluctuating hypertension, Lisa Harding prefers IV so the infusion can be paused; for severe needle fear, intranasal may be better.
Prepare Operational Infrastructure For IV Ketamine
- Plan the operational and monitoring resources before offering IV ketamine: trained staff, IV skills, pumps, sharps disposal, BP checks, and pulse oximetry.
- Building a high-safety IV ketamine practice can cost practices hundreds of thousands (estimated ~$750k) for monitoring and infrastructure.