Ketamine Costs $1. Patients Pay $1,000.

Ketamine clinics sprouted across the United States with almost no rules. Between 500 and 750 now operate in the country, billing $600 to $1,000 per infusion for a treatment that costs clinics about $1, serving a market Grand View Research valued at $3.1 billion in 2022 and projects to reach $6.9 billion by 2030. The FDA approved an esketamine nasal spray in 2019 for treatment-resistant depression, but generic ketamine for mental health remains off-label — meaning clinics set their own dosing, monitoring, and follow-up standards. "Ketamine is the Wild West," as Dustin Robinson, a managing principal at the venture firm Iter Investments, put it to NPR. That is the market into which Massachusetts General Hospital is now introducing a structured clinical trial.

Researchers at MGH have received IRB approval for a study evaluating psychedelic coaching — provided by the nonprofit Fireside Project — as an add-on to routine ketamine treatment for depression. The trial, conducted at MGH's Ketamine Clinic for Depression, will test whether coaching improves feasibility and acceptability of hospital-based ketamine care. Coaching, in this context, means psychological support before and after infusion sessions: helping patients prepare for the dissociative experience and make sense of what arises during it. The intervention is optional and does not alter medication protocols or clinical decision-making.

"Many patients receiving ketamine treatment for depression report meaningful and sometimes challenging subjective experiences," said Dr. Maren Nyer, a psychologist at MGH's Depression Clinical and Research Program and co-principal investigator on the trial. "This IRB-approved study allows us to evaluate whether offering structured psychedelic coaching as part of standard hospital-based ketamine care is feasible, acceptable, and responsive to patient needs."

Dr. Franklin King, a psychiatrist at MGH's Center for the Neuroscience of Psychedelics and the trial's other co-principal investigator, was measured: "Ketamine has expanded treatment options for individuals with depression who have not benefited from conventional antidepressants. Understanding how adjunctive support may complement this care is an important next step."

The study builds on a prior survey conducted at the same clinic assessing patient perspectives on preparation and integration support. Findings from that survey, still under analysis, will inform the trial's design. Results will be used in grant applications and to shape larger clinical trials.

Fireside Project, founded in 2020, has handled over 33,000 callers through its Psychedelic Support Line and launched a telehealth coaching certification program in 2024. Its coaches complete a 30-step, 300-hour training process. The organization is providing the coaching service for the MGH trial; data collection falls under IRB oversight with HIPAA-compliant systems.

The underlying question the trial is really asking is whether the subjective experience matters. Ketamine can lift severe depression within hours, according to a 2024 meta-analysis in Translational Psychiatry that found a significant reduction in suicidal ideation within the first day after treatment across 14 studies and 1,380 participants. That rapid effect has driven the clinic boom. But the drug also produces dissociative, sometimes hallucinogenic experiences at the doses used for depression — and clinicians are divided on whether those experiences are therapeutic noise or part of the mechanism.

Some patients describe the trip as essential. Others get the infusion, feel relief, and leave. The MGH trial is designed to start distinguishing between those two possibilities. If coaching moves outcomes — not just patient satisfaction, but actual symptom reduction — it would reframe ketamine from a pharmacological intervention into something closer to assisted therapy. That distinction has real stakes for how the field develops, how insurers think about coverage, and what a startup is actually building when it raises money for a ketamine clinic.

The trial is small. It will enroll a limited number of patients at one hospital. It is a feasibility and acceptability study, not a definitive efficacy trial. But it is happening at one of the most respected psychiatric research centers in the world, with structured coaching from an organization that has fielded 33,000 support calls — and that matters for credibility. Whether it changes practice depends on what comes after.