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A MedPage Today commentary published Oct. 11 argues that inconsistent safeguards for off-label ketamine prescribing can leave addiction risks insufficiently assessed. Presley Gerber’s death is under investigation as a suspected overdose, but his official cause of death has not been released; the authors say it is not yet known whether ketamine was involved.
Three psychiatrists writing in MedPage Today on Oct. 11 called for clearer safety standards for ketamine prescribing, pointing to the ongoing investigation into Presley Gerber’s death and broader gaps in oversight. Gerber, 27, died Sept. 20; his death is being investigated as a suspected overdose, but his official cause of death remains pending, and the available reporting does not establish that ketamine caused it.
The commentary was written by Tucker Avra, Renée Sorrentino and Fernando Espi Forcen, psychiatrists who work with addiction and have published on ketamine addiction. They cited friends’ accounts that a doctor had prescribed ketamine to Gerber for months despite knowing about his history of addiction. That account is attributed to Gerber’s friends in the report; the commentary does not establish the final medical or legal findings about his treatment or death.
The authors compared the case with Matthew Perry’s death. Perry’s autopsy identified the acute effects of ketamine as a contributing factor, according to the commentary. A doctor who had prescribed ketamine to Perry later pleaded guilty to distributing the drug without a legitimate medical purpose. The authors said the fatal dose came from another source, rather than from that doctor’s prescription.
Ketamine is approved in the United States as an anesthetic, while esketamine, sold as Spravato, was approved by the FDA in 2019 for treatment-resistant depression. Spravato is subject to a Risk Evaluation and Mitigation Strategy, or REMS. Ketamine itself is also prescribed off-label for conditions including depression, post-traumatic stress disorder and obsessive-compulsive disorder, but the authors say it does not have a comparable mandatory safety program for those uses.
Safeguards Vary Across Ketamine Care
The issue reaches beyond two widely reported deaths because ketamine treatment is expanding while prescribing standards can differ by provider and setting. The authors say there is no single, consistently enforced standard across ketamine clinics and telehealth providers. That variation can affect whether a patient’s substance-use history is reviewed, what monitoring is provided, and whether risks and alternatives are discussed before treatment.
They identify potential malpractice risks that include unsupervised at-home use, inadequate monitoring during intravenous or intramuscular sessions, online prescribing without in-person evaluations, and insufficient informed consent. These are concerns raised by the authors, not findings that apply to every clinic or prescriber. They also report that lawsuits have been brought against some telehealth companies offering at-home ketamine treatments.
The consequences matter for patients weighing a treatment that may be clinically useful but carries risks that require professional judgment. The authors argue that a known history of addiction should prompt careful, documented risk-benefit decision-making. They also say prescribers must be prepared to withhold treatment when its risks cannot be managed, regardless of a patient’s preferences or public profile.
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Two Forms, Different Oversight
The FDA approved ketamine as an anesthetic in 1970. In 2019, it approved esketamine, a specific form of the drug, for treatment-resistant depression under a REMS program. The authors say guidance from the American Psychiatric Association and the Spravato label call for careful assessment when a patient has a history of substance use disorder. For off-label ketamine, they say, the presence and depth of such an assessment may depend on the individual prescriber.
Use is also growing in clinical settings. The authors report that Massachusetts General Hospital’s Ketamine Clinic for Depression has delivered more than 11,000 infusions and quadrupled its treatment volume since opening in 2018. They say research and their experience suggest ketamine use disorder is uncommon in supervised, controlled, in-person depression clinics. They distinguish that setting from a shift toward chronic use, whose effects they say remain largely unknown.
The commentary also cites a rise in people starting treatment for ketamine addiction in the United Kingdom: more than eightfold over the last decade, according to the source. That statistic refers to treatment starts, not the prevalence of addiction, and does not by itself establish what caused the increase. The authors cite U.S. market estimates of more than $5 billion, with a projection above $14 billion by 2035, while noting that the American Society of Anesthesiologists has called for stronger oversight of at-home delivery and ketamine clinics.
“The answer must be a clear, evidence-based response that acknowledges ketamine’s efficacy while balancing the risk to patients.”
— Avra, Sorrentino and Espi Forcen
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Cause of Death Still Pending
Gerber’s official cause of death has not been released, and the investigation is ongoing. The source describes his death as being investigated as a suspected overdose; it does not confirm that ketamine was involved. The account that a doctor prescribed ketamine despite knowing about Gerber’s addiction history is attributed to friends, and the commentary does not provide a full medical record or a final investigation finding.
There are also unresolved questions about the risks of long-term or chronic ketamine use, which the authors say are largely unknown. The commentary does not set out a proposed national standard in detail, establish how many patients are harmed by current practices, or show that all clinics and telehealth providers operate in the same way. Its call for stronger safeguards is an argument by the authors, not a new government rule or formal policy change.
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Standards and Investigation Ahead
The next major development in Gerber’s case is the release of findings, including the official cause of death. Until then, claims about his treatment and the role, if any, of ketamine should remain distinct from confirmed conclusions. The commentary does not identify a date for those findings.
For ketamine care more broadly, the authors call for clear, evidence-based prescribing standards, training in the drug’s risks, and documented risk-benefit discussions when patients have a history of addiction. The American Society of Anesthesiologists’ stated call for closer oversight of at-home treatment and clinics is part of that policy debate. Whether regulators, professional bodies or providers will adopt additional requirements—and what those requirements would include—remains unsettled.
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Key Questions
Has ketamine been confirmed as the cause of Presley Gerber’s death?
No. The source says his death is being investigated as a suspected overdose, but his official cause of death is pending and ketamine involvement has not been confirmed.
What safety gap do the psychiatrists identify?
They say off-label ketamine prescribing lacks a mandatory safety program comparable to the REMS for Spravato, and that assessment and monitoring can vary among prescribers and care settings.
Is ketamine approved for depression?
The source says ketamine was approved in the United States as an anesthetic. The FDA approved esketamine, a specific form of ketamine, for treatment-resistant depression in 2019. Ketamine itself is prescribed off-label for some mental health conditions.
They argue prescribers should carefully assess individual risks and benefits, discuss and document that decision, and withhold treatment when the risks cannot be managed. This is the authors’ recommendation, not a new regulation announced in the commentary.
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