REFERRAL FORM

Inclusion Criteria for IV Ketamine

● Adult patients 18 years of age and older.
● Patients with documented *Treatment Resistant Depression as defined below, who have current moderate to severe depressive symptoms will be considered for ketamine.
● The current primary diagnosis, as defined by the DSM-5, is Major Depressive Episode (MDD), or Bipolar 1 disorder or bipolar 2 disorder depressive phase. The patient may have another DSM-5 diagnosis, but this diagnosis cannot be the primary condition or focus of treatment.
● Individuals who have suicidal ideation during the current episode of MDE and meet
the above criteria.
● Individuals who have had previous ECT or rTMS and meet the above requirements are
eligible.
● All patients must complete a medical form and be cleared for intravenous
ketamine by the TKC anesthesiologist. The anesthesiologist will review the
completed medical form prior to the first infusion and any identified medical
concerns will be addressed. The patient may be declined from receiving ketamine
treatment based on their medical history.
● All patients must have capacity to sign a written informed consent for treatment.
● Individuals Post Traumatic Stress Disorder (PTSD) or Obsessive-Compulsive Disorder (OCD) will be considered on a case-by-case basis

*Treatment Resistant Depression (TRD):

Treatment resistant depression the patient has failed at least two guideline concordant trials of antidepressant therapy for major depressive disorder or bipolar depression, as recommended in either the CANMAT MDD Guidelines 2016, Florida Medicaid Guidelines 2019, or the CANMAT ISBD Guidelines for BD 2018

Exclusion Criteria for IV Ketamine

● Patients with a primary diagnosis other than MDD or bipolar 1 or 2 diagnosis.
● Patients who are diagnosed with psychosis , even if it is a symptom of an MDE.
● Patients with neurocognitive disorders , including dementias.
● Patients who have traumatic brain injury that is symptomatic.
● Patients who, within the previous three months, meet the DSM-5 criteria for Alcohol Use
Disorder , or other Substance Use Disorder.
● Patients who do not meet the DSM-5 criteria for Substance Use Disorder, but who use illicit
substances, must stop all illicit substances for a minimum period of 1 month prior to the first
infusion at TKC and remain free from substance use during the treatment time.
● Patients who are unable to provide a written informed consent for ketamine treatment.
● Patients who are not able to abide by the pre-treatment and post-treatment clinic protocol
such as: food intake, abstaining from certain medications, unable to remain in the clinic posttreatment for a minimum of 20 minutes or longer for observation, those who insist on driving
immediately post-treatment, and cannot provide TKC with the name and phone number of the
party who will pick them up post-treatment.
● Patients with: uncontrolled hypertension, epilepsy, allergies to ketamine, a previous reaction to
ketamine, Body Mass Index greater than 35, are pregnant or planning to become pregnant
within 12 weeks of treatment completion, hepatic impairment, history of recent heart attack,
vascular disease, or any other medical conditions that may be deemed by the anesthetist as a
contraindication to receiving ketamine.
● Individuals who are symptomatic for infection, or who have had contact with someone with
an acute contagious illness.
● Individuals who are not Canadian residents or do not have a most responsible
physician (MRP) in Canada.
● Individuals who demonstrate verbal, physical or emotional aggression toward TKC staff or
other patients.
Patients who need to miss an appointment, and do not notify the clinic at least 48
hours before, will be charged a $200 cancellation fee.

Inclusion and Exclusion Criteria Agreement

Referral Request

Referring Physician Contact Information