Coastwise Health Blog
Updated May 23, 2026
Written by the Coastwise Clinical Team
Ketamine has been studied in psychiatry for over 25 years, but the way it gets delivered is anything but standardized. Two clinics offering "ketamine therapy" can mean two completely different experiences depending on how the medication is given. The route of administration changes the bioavailability, the onset, the duration, the cost, and what the clinical session actually feels like.
This post walks through the formats you'll encounter when researching: sublingual lozenges, intramuscular (IM) injection, intravenous (IV) infusion, and intranasal Spravato. We also explain why oral pills aren't typically used.
A sublingual ketamine lozenge is a flavored tablet held in the mouth and dissolved over 10 to 15 minutes. The medication absorbs through the membranes under the tongue and inside the cheeks.
Anything swallowed during the dissolve period has lower bioavailability, so clients are coached to hold the dissolved liquid before letting it go down. Bioavailability ends up around 25 to 30 percent. Onset is 15 to 30 minutes after the lozenge dissolves, and sessions typically last 90 minutes to 2 hours.
Lozenges are the most common form used in ketamine-assisted psychotherapy (KAP) at clinics that pair the medication with on-site therapy. They're also what most at-home ketamine companies prescribe by mail. The lozenge format itself is fine. The mail-order context is where the FDA raised concerns in October 2023 (see our companion post on clinical vs. at-home ketamine for the full explanation).
Lozenges do well at: lower cost than IV, easier to integrate with talk therapy in real time, less medical equipment needed. Limitations: lower bioavailability means individual response varies more, and onset is slower than injection or infusion.
IM ketamine is delivered as a single shot, usually in the shoulder or thigh, with a bioavailability of about 93 percent.
Onset is fast, typically within 5 to 10 minutes. The dissociative experience peaks at 20 to 30 minutes and fades over the following hour. Sessions are typically 1.5 to 2 hours total, including preparation time, the active dosing window, and integration discussion afterward.
IM injection is common in KAP because it hits faster than lozenges, gives a more predictable dose effect, and doesn't require placing an IV line. It is delivered by a physician or qualified medical provider in the clinical setting.
IM does well at: predictable dose response, faster onset, no IV equipment needed, well-suited to therapy integration. Limitations: requires an on-site medical provider, more clinical infrastructure than mail-order lozenges.
IV ketamine is delivered as a slow drip over 40 to 60 minutes, with the dose titrated by a medical provider in real time. Bioavailability is 100 percent.
The medical provider can adjust the rate during the session, which gives the most precise dose control of any format. IV infusion is also the format used in most of the ketamine-for-depression clinical trials, including the foundational research by Berman (2000) and Zarate (2006). It's the format with the longest published safety record.
IV infusion is delivered most often in dedicated ketamine infusion clinics, frequently run by anesthesiologists. Many of these clinics focus on the medication alone and don't include psychotherapy. KAP-focused practices more typically use lozenges or IM.
IV does well at: precise dose control, the longest research track record for treatment-resistant depression and PTSD, full medical oversight throughout the session. Limitations: highest cost (often $400 to $700 per session, sometimes higher), requires placing an IV line, longer total session time, less integration with talk therapy in many infusion clinics.
Spravato is FDA-approved esketamine, the S-enantiomer of ketamine. It is delivered as a nasal spray and was approved in 2019 for treatment-resistant depression.
Spravato is administered in certified clinics under FDA REMS (Risk Evaluation and Mitigation Strategy) rules, which require 2 hours of monitoring after each dose. It is technically a different molecule from racemic ketamine and is the only ketamine-class medication FDA-approved for depression in the United States.
Most "ketamine therapy" clinics use racemic ketamine off-label, which is legal and well-established, rather than Spravato, because Spravato has more prior authorization complexity and a more rigid protocol. Spravato is real medicine, FDA-approved, and covered by insurance for treatment-resistant depression. It is a different track from KAP but worth knowing about when researching options.
Ketamine swallowed as an oral pill has low bioavailability, around 17 to 24 percent, because the liver metabolizes most of the dose before it reaches the brain (first-pass metabolism). Sublingual lozenges absorb through the mouth and bypass much of the liver, which is why they reach roughly 25 to 30 percent bioavailability instead. Some compounding pharmacies produce oral ketamine capsules, but the format isn't standard for psychiatric treatment.
| Format | Bioavailability | Onset | Typical setting | Approximate cost per session |
|---|---|---|---|---|
| Sublingual lozenge | ~25 to 30% | 15 to 30 min | KAP clinic or at-home | $200 to $400 |
| IM injection | ~93% | 5 to 10 min | KAP clinic with on-site MD | $300 to $500 |
| IV infusion | 100% | 2 to 5 min | Infusion clinic | $400 to $700+ |
| Intranasal Spravato | ~48% | 10 to 20 min | REMS-certified clinic | Insurance-covered, varies |
| Oral pill | ~17 to 24% | 30 to 60 min | Not standard | n/a |
It depends on what you're treating, what's available locally, what your insurance covers, and what you're hoping to get out of the experience.
If you have treatment-resistant depression that hasn't responded to multiple medications, IV infusion has the longest research track record. Spravato may also fit, especially if your insurance covers it.
If you're looking for ketamine combined with therapy (KAP), lozenges and IM are the standard formats. The therapy integration is what makes KAP different from a standalone infusion: the medication is paired with a trained therapist who guides preparation, the dosing session, and integration afterward.
If you're considering at-home ketamine via a telemedicine company, the format itself isn't the safety problem. The lack of structure and integration is. Read our companion post on clinical vs. at-home ketamine for the details.
At Coastwise, we offer ketamine-assisted psychotherapy using sublingual lozenges and intramuscular injection. Our therapists are trained in preparation, dosing-day support, and integration. A physician oversees medication management.
We don't offer IV infusion on-site. If your clinical picture calls for IV, we can refer you to trusted infusion partners in the Los Angeles area and continue therapy support around those sessions.
The therapy sessions associated with KAP are covered by most major insurance plans. The ketamine medication itself is often out of pocket. Spravato is covered when prior authorization criteria are met, usually a documented history of failed antidepressant trials. Our admissions team verifies what your specific plan covers. Call (424) 536-3002 or verify your insurance online.
If you're considering ketamine therapy and trying to figure out which format fits, a free phone consultation with our admissions team can help. We'll talk through what you're treating, what you've already tried, what your insurance covers, and what makes sense as a starting point. If we're not the right fit, we'll tell you that and point you somewhere that is.
Call (424) 536-3002 or request a consultation online. Monday through Saturday, 9:00 AM to 8:00 PM.
Located at 1366 W 7th Street, San Pedro, CA.
A ketamine lozenge is held under the tongue and absorbed through the mouth, with a bioavailability of roughly 25 to 30 percent. An intramuscular (IM) injection is given as a single shot in the shoulder or thigh, with a bioavailability of about 93 percent. The injection has a faster onset and more predictable dose response. Lozenges are easier to combine with talk therapy in real time and don't require an injection. Both are used in ketamine-assisted psychotherapy (KAP).
It depends on what is being treated. IV infusion has the longest research track record for treatment-resistant depression. Lozenges and IM injection are the most common formats in ketamine-assisted psychotherapy (KAP), where the medication is paired with talk therapy. Spravato (intranasal esketamine) is FDA-approved specifically for treatment-resistant depression. The right format depends on diagnosis, prior treatment history, and whether psychotherapy will be paired with the medication.
Spravato is FDA-approved esketamine, the S-enantiomer of ketamine. It is delivered as an intranasal spray under the FDA REMS program, which requires administration in a certified clinic with 2 hours of post-dose monitoring. Most other ketamine therapy uses racemic ketamine off-label, which is legal and well-established. Spravato is the only ketamine-class medication FDA-approved for depression.
Oral ketamine has low bioavailability, around 17 to 24 percent, because the liver metabolizes most of the dose before it reaches the brain. Sublingual lozenges absorb through the mouth and bypass much of the liver, giving better bioavailability than swallowed pills. Most clinical ketamine protocols use sublingual, IM, IV, or intranasal routes rather than oral pills.
The therapy sessions associated with KAP are usually covered by most major insurance plans. The ketamine medication itself is often out of pocket. Spravato is covered when prior authorization criteria are met, typically a documented history of failed antidepressant trials. Our admissions team verifies what your plan covers.
Coastwise Counseling Center offers ketamine-assisted psychotherapy using sublingual lozenges and intramuscular injection, paired with trained therapists and physician oversight. We don't offer IV infusion on-site. If your clinical situation calls for IV, we coordinate with infusion partners in Los Angeles.
The first call is free, confidential, and without pressure. We'll help you figure out whether KAP fits, and if not, we'll point you somewhere that does.
Call (424) 536-3002 Get Started Online