Q: If patient doesn’t have a therapist listed yet (at the initial consultation), what do I do?
A: Inform the patient to complete the get matched form in their Portal as soon as they’re able to, and continue the consultation as normal. You may still prescribe at the initial intake, but the client should be instructed to not do KAP until they have a therapeutic alliance in place. They need to follow the guidelines including only doing KAP with their member therapist.
- Once the matching form is completed by the patient, the care coordinators will review and filter our network to find potential matches. They will send an email/message to the patient with matches for the patient to review, and once the patient selects a therapist, the patient will notify the care coordinators who will link their accounts so that the therapist shows up under their care team.
- **You can still prescribe at the initial consultation, but they need to be matched before starting dosing sessions and before their follow up. Instruct the client: Do NOT take ketamine until matched with a therapist. Schedule your dosing sessions after you’ve met and had a preparation session with your member therapist.
Q: What is the maximum/most frequent session frequency allowed?
A: Twice/week is the max we will allow because we want to ensure there’s enough time for integration between. We usually allow patients to do KAP up to once/week regardless of CGI- as far as twice/week, we’d want to check on the plan with the therapist to ensure they can do integration between each dosing session.
Q: What to do if a client is missing KAP session documentation when they’re following up?
A: If they’re only missing one item, or the majority of their completed sessions are documented, that is okay. You can gently remind the therapist in the therapist communication section of your documentation to please include documentation for all completed KAP sessions moving forward. If they’re missing all documentation, please message the therapist directly (including the patient’s initials) and ask them to submit the documentation (noting that prescriptions may be held if you're unable to review the session information due to safety and ongoing monitoring needs). You can make note of what the patient reports in your documentation (ie, “client states they’ve completed 5 in-person sessions, no adverse reactions. Client reports taking vitals before and after their dosing sessions. Messaged the member therapist to ask for documentation to be completed for these KAP sessions”) and let the patient know that you'll need to confirm session information with their member therpaist before you're able to send the prescription. Complete all education like normal, and mark the status as "pending" while pending the information from the therapist. Once the therapist confirms the sessions and documents the information needed, you may file an interim note to update the status and send the prescription.
Q: Bipolar and Personality Disorders - when to prescribe?
A: Personality disorder is contraindicated when it would significantly impair the formation of the therapeutic alliance. People are often misdiagnosed with bipolar disorder because of having a labile mood, and there are many cases that do not have a true bipolar disorder.
Unstable personality disorder: people who don’t identify with the diagnosis, those who are unpredictable or impulsive, may be early on in their treatment
BPD - risks are potentially having interpersonal issues that could impair their therapeutic alliance; chronicity of SI; possibility of psychotic episodes
Bipolar with mood stabilized - no evidence for higher risk of having a manic or hypomanic episode.
You can follow your judgment with these patients - making sure they’re consistently following protocol and discussing risks/benefits/options. You can also discuss with Brigitte and Kyle if you have specific concerns or questions about a situation.
Q: Substance use and abuse - when to know if it’s appropriate to prescribe or not
A: In general, anyone with a history or current substance use disorder should be stable, with their use under control for at least 6 months before they’d be eligible for KAP. Due to additional risk factors, it’s recommended to be able to withstand at least 48 hours without substances. Once someone is at this point in their recovery, the medical team will be able to discuss the person’s individualized potential risks and benefits to determine a treatment plan. There’s a lot of evidence to support ketamine’s utility in addiction.