Ketamine Therapy for PTSD and Depression: Navigating Coverage and Legal Standards in Alabama Workers’ Compensation
By: Delaney Holmes
We often encounter post-traumatic stress disorder (PTSD) and depression diagnoses in workers’ compensation claims but treatment options often present problems. Although counseling and daily prescription medications can be effective, such treatments often provide limited lasting results. Thus, the recent advent of “off label” use of ketamine as an alternative treatment option for PTSD and depression appears promising. The question, at least for workers’ compensation claims in Alabama, is whether such use of ketamine is appropriate and should be covered under the Alabama Workers’ Compensation Act (the Act).
To address these questions, it is first important to understand ketamine and its history. Ketamine is a potent dissociative1 anesthetic and, since the 1970s, physicians in the United States used ketamine as a short-acting injectable medication for pain relief.2 However, the same properties which make ketamine an effective sedative, also render it subject to abuse and illegal sale under common street names such as "Special K," "K," and "Vitamin K." In fact, ketamine was classified as a Schedule III non-narcotic controlled substance under the Controlled Substances Act in 1999.3 Moreover, long-term use/abuse of ketamine can cause memory problems, depression and severe bladder damage, while combined use with alcohol, opioids or benzodiazepines can significantly increase the risk of respiratory depression, which can be fatal.
More recently, in 2019, esketamine, a ketamine derivative marketed as Spravato, received FDA approval for use in patients with treatment-resistant depression so long as the drug is administered in certified clinical settings.4 Today, although physicians continue to use ketamine for short-term sedation and anesthesia,5 no form of ketamine is FDA approved for the treatment of PTSD.6 Despite the absence of FDA approval, there is a growing trend in the medical community for “off-label” use of ketamine for the treatment of PTSD and depression.
Given the “off label” trend, from a practical, workers’ compensation perspective, the question of an employer’s responsibility to cover ketamine prescribed by the authorized treating physician (ATP) for a work-related mental health condition in Alabama becomes complex. Under Alabama law, an employer is generally obligated to provide medical care recommended by an ATP. At the same time, the Act allows an employer to decline payment for treatment which is not “reasonably necessary.”7 The applicable statute further provides medical necessity may include services or procedures with “scientifically established medical value.”8 Thus, the lack of FDA approval for a specific use does not automatically relieve an employer of the obligation to cover treatment if it is otherwise accepted in the medical community.
However, this standard can be challenging to apply in the case of ketamine, as the medical literature addressing the use of ketamine for PTSD and depression appears mixed. The Alabama State Board of Medical Examiners recently issued guidance recognizing while ketamine is not currently FDA-approved for the treatment of any mental health condition, including PTSD, treatments such as esketamine may be appropriately administered in specific medical facilities by qualified professionals.9
Because the Act requires approval of treatments deemed “reasonably necessary” but allows employers to decline them when they are not, determining the appropriate process for dispute resolution is important. Thankfully, Alabama law provides a procedure for challenging recommended treatment under such circumstances by allowing an employer to submit a request to utilization review.10 If the utilization review determines the treatment is not recommended under the specific circumstances, the employer may rely on this determination to deny the request as not reasonably necessary.11 These determinations are not final, however, as a plaintiff can request a ruling from a judge who has the authority to compel treatment.12
Despite the risks, ketamine or ketamine derivative therapy is an emerging treatment option within the workers’ compensation context. Coverage decisions are highly fact-specific and require careful consideration of medical evidence, including the recommendations of treating physicians and applicable legal standards. While no definitive rule governs the approval of such treatments, these factors collectively form the framework for assessing each request.
1 Dissociative drugs are a class of hallucinogen which distort sight and sound perception and sound and producing feelings of detachment from the user’s environment and self.
2 U.S. Drug. Enf. Admin., Ketamine, DEA.gov, https://www.dea.gov/sites/default/files/2020-06/Ketamine-2020.pdf (last visited March 3, 2026).
3 Id.
4 Id.
5 Id.
6 Alabama State Board of Medical Examiners, Position Statement and Guidance on the Off-Label Use of Ketamine for Treatment-Resistant Depression in Outpatient Settings, https://www.albme.gov/uploads/pdfs/Ketamine_Position_Statement_and_Guidelines-_Jan_15_26_Revised.pdf (last visited March 3, 2026).
7 Ala Code § 25-5-77(a).
8 Id.
9 Alabama State Board of Medical Examiners, Position Statement and Guidance on the Off-Label Use of Ketamine for Treatment-Resistant Depression in Outpatient Settings, https://www.albme.gov/uploads/pdfs/Ketamine_Position_Statement_and_Guidelines-_Jan_15_26_Revised.pdf (last visited March 3, 2026).
10 Ex parte Southeast Med. Ctr., 835 So. 2d 1042, 1051 (Ala. Civ. App. 2002).
11 Id.
12 Brown v. Wal-Mart Stores, Inc., So. 2d 1100, 1104 (Ala. Civ. App. 2002).
Attorney Contact Info
Delaney Holmes
delaney.holmes@swiftcurrie.com
205.314.2411
