In a consultation room in Melbourne's outer suburbs, Dr. Sarah Chen draws up a sublingual dose of ketamine for a patient who has tried four antidepressants without relief. Chen, a general practitioner, has been offering low-dose ketamine therapy for treatment-resistant depression since 2024. Her colleagues call it reckless; she calls it pragmatic. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has issued no guidance on primary-care ketamine, and the Therapeutic Goods Administration (TGA) has approved the drug only for hospital-based use. A 2025 survey of Victorian GPs found that roughly 8% had prescribed ketamine for depression, while 72% of psychiatrists surveyed by the RANZCP in 2024 opposed any primary-care use. The result is a profession divided by a gap of 64 percentage points—between those who see a lifeline for patients stuck on waiting lists and those who fear an uncontrolled experiment in the community.

A GP's Desk, a Ketamine Vial, and a Divided Profession

Dr. Chen's practice serves a catchment area where the nearest psychiatrist is a two-hour drive away. After completing a short training course on ketamine administration—offered by a private organisation, not accredited by any medical college—she began prescribing to patients who had failed at least two adequate trials of standard antidepressants. She uses a fixed protocol: 0.5 mg/kg troche, administered in the clinic under observation for one hour, with a driver required. The cost, about $250 per session, is not covered by Medicare. Patients typically attend six sessions over three weeks.

“I see people who have been suicidal for years,” Chen told me. “They cannot wait six months for a psychiatrist. If I can offer something that gives them a window of relief, I think I have a duty to do so.” But the decision has isolated her from local colleagues. A psychiatrist at the regional hospital refused to take referrals from her, stating in a letter that “GP-led ketamine therapy is not evidence-based and exposes patients to unacceptable risk.” Chen estimates she has treated roughly 40 patients, with about 60% reporting a clinically meaningful drop in depression scores.

The tension between access and safety is palpable. On one side are GPs like Chen, who argue that the status quo—psychiatrist-only access—condemns rural and lower-income patients to years of ineffective treatment. On the other are psychiatrists who insist that ketamine's dissociative effects and potential for abuse require the monitoring infrastructure of a hospital or specialised clinic. Both sides claim the moral high ground of patient welfare. The question is which argument the evidence supports.

The Evidence Base That Pleases No One

The evidence for ketamine in depression comes largely from two small randomised controlled trials conducted in hospital settings. A 2023 Australian study of 68 patients found that intravenous ketamine produced a 50% reduction in Montgomery-Åsberg Depression Rating Scale scores in about 40% of participants, compared with 10% in the placebo group. A second trial, published in 2024, reported similar results with subcutaneous administration. Both studies excluded patients with substance use disorders and required on-site anaesthetic support.

No primary-care specific trial has been published. The longest follow-up data extend to roughly 18 months, drawn from naturalistic cohorts in the United States and Canada. Those cohorts show that about 30% of patients who respond to initial treatment maintain the response with periodic booster doses, but dropout rates are high—around 25% at one year. The Australian TGA, in its 2023 decision not to list ketamine on the Pharmaceutical Benefits Scheme (PBS), cited “insufficient evidence of efficacy and safety in the outpatient setting.”

Off-label prescribing fills the gap. Because ketamine is a registered drug, Australian doctors can prescribe it for any indication they deem appropriate, though without PBS subsidy the cost falls on patients. A 2025 survey of GPs in Victoria found that about 8% had prescribed ketamine for depression, mostly in metropolitan areas. The same survey found that fewer than half had formal training in its use. “We are essentially conducting an unregulated experiment on vulnerable patients,” said Prof. Alan Mackay, chair of RANZCP's ethics committee.

Proponents counter that the evidence, while limited, is stronger than for many off-label treatments routinely used in primary care—such as low-dose quetiapine for insomnia. “We accept uncertainty in other areas of medicine,” said Dr. James Nguyen, a GP in Sydney who runs a ketamine clinic. “Why should depression be held to a higher standard?” The debate hinges on whether the potential harms—dissociation, blood pressure spikes, urinary toxicity, diversion—warrant a higher threshold of proof. For now, the data are insufficient to settle the question.

Why Psychiatrists Fear the GP's Waiting Room

Prof. Mackay's concerns are not abstract. In a 2025 position paper drafted for RANZCP but not yet published, he and colleagues outlined several risks. The most immediate is dissociation: at therapeutic doses, roughly 30% of patients experience transient depersonalisation or derealisation, which can be frightening if not anticipated. In hospital settings, patients are monitored with continuous pulse oximetry and have immediate access to anaesthetic support. In a GP clinic, the nearest emergency department may be 30 minutes away.

“I have seen a patient who became acutely dissociative and tried to walk out of the clinic into traffic,” Mackay told me. “The GP had no protocol for managing that. Fortunately, the patient's partner was there.” He worries that without standardised training, GPs may not recognise or manage adverse events. The Royal Australian College of General Practitioners (RACGP) has no specific curriculum for ketamine therapy. A training module developed by the GPRA (General Practice Registrars Australia) is in development but has not been accredited.

Another concern is misuse and diversion. Ketamine is a Schedule 8 controlled drug in Australia, meaning it has a recognised medical use but also a potential for abuse. In 2024, the Australian Criminal Intelligence Commission reported a rise in ketamine seizures at borders, though domestic diversion from medical sources remains unquantified. Psychiatrists worry that GP clinics, with less robust inventory controls than hospitals, could become a source of leakage. “We have seen what happened with prescription opioids,” Mackay said. “We should not repeat those mistakes.”

The blurred line between therapy and experimentation troubles many psychiatrists. Some GP-led clinics advertise ketamine as a “breakthrough” for depression, using language that critics say overstates the evidence. “This is not a cosmetic procedure,” said Dr. Lisa Tran, a psychiatrist in Brisbane. “We are dealing with a serious mental illness. Patients deserve treatments that have been rigorously tested, not marketed.” Yet for patients who have exhausted standard options, the promise of relief—even uncertain—can be hard to resist.

The Access Argument: Who Gets to Decide?

Access to psychiatrists in Australia is notoriously uneven. In major cities, the median wait for a new patient appointment is about four weeks. In rural and remote areas, it can stretch to six to twelve months. For patients with treatment-resistant depression, that delay can be devastating. “I had a patient who attempted suicide while waiting for a psychiatrist,” Chen said. “After that, I decided I could not wait for permission.”

GP-led care could theoretically cut that wait to weeks. Chen's practice reports that 40% of patients achieve a 50% or greater reduction in PHQ-9 scores after six sessions—a figure comparable to hospital-based trials. But critics note that these are uncontrolled, open-label data, subject to placebo effects and regression to the mean. “Anecdote is not evidence,” Mackay said. “We need randomised trials in primary care before we can say this is safe and effective.”

The equity argument cuts both ways. Rural patients who cannot access psychiatrists are also less likely to have a GP trained in ketamine therapy. A 2025 analysis by the Australian Institute of Health and Welfare found that only 12% of GPs in remote areas had any postgraduate training in mental health, compared with 40% in cities. Expanding ketamine access without addressing training disparities could widen the gap rather than close it.

Dr. James Nguyen has proposed a middle ground: shared-care models where a psychiatrist supervises multiple GPs, reviewing each patient's eligibility and monitoring progress remotely. Such models are used for opioid substitution therapy and are being trialled for ketamine in Western Australia through a program led by the WA Department of Health. “It is not perfect, but it is better than nothing,” said Nguyen. “We need to meet patients where they are.” The question is whether the profession can agree on a framework before the market decides on its own.

Regulatory Limbo: TGA, Medicare, and the Void

The TGA's 2023 decision not to list ketamine on the PBS was a major setback for advocates. Without a PBS listing, ketamine must be prescribed privately, costing patients between $200 and $400 per session. Some clinics charge up to $800 for intravenous infusions, putting treatment out of reach for many. “We are creating a two-tier system where only the wealthy can access this therapy,” Chen said. “That is not equitable.”

Medicare item numbers cover only psychiatrist visits for ketamine therapy. A GP consultation for the same purpose attracts only the standard rebate, leaving patients to pay the full cost of the drug and monitoring. The Department of Health has not indicated any intention to change this. A 2024 senate inquiry into psychedelic-assisted therapies recommended that the government review funding for ketamine, but no action has followed.

The regulatory void has pushed some care underground. Online forums and social media groups share advice on buying ketamine from overseas pharmacies or using veterinary-grade products. “We are seeing patients who have self-medicated with street ketamine because they could not afford the clinic,” Tran said. “That is a public health disaster waiting to happen.” The TGA has issued warnings about unregistered products but has limited capacity to enforce against individual importation.

Regulatory inertia also stifles research. Without PBS listing, pharmaceutical companies have little incentive to fund large-scale trials. The few Australian studies underway are small, investigator-initiated projects struggling for funding. “We are caught in a chicken-and-egg problem,” Mackay said. “We need evidence to change policy, but we cannot get evidence without policy support.” Until that cycle breaks, clinicians and patients remain in limbo.

What Patients Report: Relief, Risk, and Ambivalence

L.M., a 34-year-old teacher in rural Victoria, had been on antidepressants for eight years before trying ketamine. She had attempted suicide twice. “I was at the end of my rope,” she said. After three sessions with Chen, she reported a dramatic lift in mood. “It was like a fog lifted. I could think clearly for the first time in years.” She continues with monthly booster doses and has returned to work. “I know it is not a cure, but it gave me my life back.”

Not all experiences are positive. Another patient, who asked not to be named, described transient depersonalisation during her first infusion. “I felt like I was outside my body watching myself. It was terrifying. I almost stopped.” She completed the course but remains ambivalent. “I am better, but I am not sure the fear was worth it.” Such accounts are common in online forums, where patients share mixed reviews.

Dropout rates in GP-led cohorts are around 15–20%, according to unpublished data from three clinics. Common reasons include lack of response, cost, and side effects. No deaths have been reported in Australian primary care, but adverse events are likely underreported. The TGA's adverse event reporting system relies on voluntary submissions, and GPs may not recognise or report events such as urinary tract symptoms or mild hypertension.

Patients often express gratitude mixed with caution. One patient, who asked to remain anonymous due to stigma, said: “I am grateful to my GP for trying. But I wish there was more oversight. I felt like I was part of an experiment.” That ambivalence mirrors the profession's own. For every patient who credits ketamine with saving their life, there is another who wonders if the risks were adequately explained. The lack of long-term data means no one can say with confidence what happens after five or ten years of use.

International Comparisons: Lessons from the US and UK

Australia is not alone in grappling with this question. In the United States, ketamine therapy for depression has exploded in the private sector, with hundreds of clinics offering intravenous, intramuscular, and sublingual treatments. The US Food and Drug Administration has approved esketamine (a nasal spray derived from ketamine) for treatment-resistant depression, but only under a restricted distribution program that requires administration in a certified healthcare setting. Off-label ketamine remains unregulated, and a 2024 analysis by the RAND Corporation estimated that over 1,000 clinics operate with varying standards. Adverse events—including severe hypertension, dissociative episodes, and one death linked to improper dosing—have been reported to the FDA's adverse event database, though underreporting is likely.

In the United Kingdom, the National Institute for Health and Care Excellence (NICE) issued guidance in 2023 recommending that ketamine for depression be used only in research settings, citing insufficient evidence for routine clinical use. The Royal College of Psychiatrists has similarly advised that ketamine should be prescribed only by specialists with appropriate training. Despite this, a small number of private clinics have emerged, and the UK's Medicines and Healthcare products Regulatory Agency has issued warnings about unlicensed products.

New Zealand offers a contrasting model: the country's drug funding agency, Pharmac, has not funded ketamine for depression, but a pilot shared-care program in Canterbury allows GPs to prescribe ketamine under the supervision of a psychiatrist, with mandatory training and data collection. Early results from the pilot, presented at a 2025 conference, show response rates similar to Australian hospital studies, with no serious adverse events in 50 patients. “The New Zealand model shows that shared care can work,” said Dr. Nguyen, who has studied the program. “But it requires investment in training and oversight.”

These international experiences highlight both the potential and the pitfalls of expanding ketamine access. The US example warns of a commercialised, uneven landscape where profit motives can overshadow safety. The UK approach errs on the side of caution, but risks leaving patients without options. New Zealand's middle path suggests that regulation and access are not mutually exclusive—but only if the political will and funding exist to support them.

Where the Profession Might Land

The RANZCP is considering a pilot supervision framework that would allow GPs to prescribe ketamine under the remote oversight of a psychiatrist. The model, similar to one used in New Zealand for clozapine, would require GPs to complete a credentialing program and submit regular outcome data. “It is not ideal, but it is a pragmatic step,” a RANZCP working group member told me on condition of anonymity because deliberations are ongoing.

The GPRA has developed a training module covering patient selection, dosing, monitoring, and adverse event management. The module has been submitted for accreditation to the RACGP but has not yet been approved. If accredited, it could become a standard for GPs wishing to offer ketamine. “We need to move from a Wild West to a regulated environment,” said Dr. Nguyen, who contributed to the module.

Shared-care models are being trialled in Western Australia, where a telehealth psychiatrist reviews each patient's eligibility and reviews progress monthly, while the GP handles day-to-day administration. Early results from a pilot of 30 patients show similar efficacy to hospital-based care, with no serious adverse events. “This could be a template for the rest of the country,” said the pilot's lead investigator. But scaling up would require funding for the psychiatrist's time, which Medicare does not currently cover.

Real-world registry data could eventually settle the debate. The Australian Ketamine Registry, launched in 2025, aims to collect outcomes from all patients treated in primary care. With over 200 patients enrolled, early data suggest that response rates are in line with hospital studies, but attrition is higher. “We need at least 1,000 patients with one-year follow-up to draw meaningful conclusions,” the registry's director said. Until then, clinical equipoise rules.

The path forward will likely require a combination of regulatory reform, professional consensus, and investment in research. The TGA could facilitate access by listing ketamine on the PBS with strict conditions—such as mandatory training, patient registries, and restricted prescribing—as it has done for other high-risk therapies. The RANZCP and RACGP could jointly develop accredited training programs and clinical guidelines. And the government could fund a large-scale randomised trial comparing GP-led care with specialist care, to generate the evidence that all sides say they want.

None of these steps is easy. They require political will, financial resources, and a willingness to compromise. But the alternative—continued regulatory limbo, uneven access, and unmonitored practice—serves no one. Patients deserve treatments that are both accessible and safe. The profession has an opportunity to build a framework that delivers both, but only if it acts before the market fills the void on its own terms.

This article is for informational purposes only and does not constitute medical advice. Individuals considering ketamine therapy should consult a qualified healthcare professional.