Review of liver safety in ketamine treatment for mood and anxiety disorders

The question

Does ketamine used as a psychiatric treatment harm the liver? The authors reviewed the published evidence on liver function during ketamine treatment for mood, anxiety and related disorders.

What they did

The researchers searched three research databases (PubMed, Scopus and Ovid) from their start up to August 2025. They looked for randomized controlled trials, observational studies, and case reports or case series that reported liver function results in people given ketamine for psychiatric conditions. Of 635 records screened, 13 studies met the criteria: five randomized trials, three observational studies and five case reports or series, covering 1017 patients treated mainly for major depressive disorder and bipolar disorder.

What they found

Across the randomized trials (879 patients), 75 liver-related adverse events were reported. Most were mild, temporary rises in liver enzymes called aminotransferases, which are markers of liver cell stress. Cases of actual impaired liver function were rare: three were identified in observational studies and one in a randomized trial, flagged by raised bilirubin. No case met Hy’s Law criteria, a lab pattern used to signal serious drug-induced liver injury. Case reports described more severe problems, including bile duct dilation and gall bladder distention, which improved when the dose was lowered or ketamine was stopped.

The fine print

Only 13 studies were found, and five of them were case reports or series, which cannot show how often a problem occurs. Liver testing methods, doses and follow-up times likely varied between studies, and the abstract does not report how long patients were followed. Case reports tend to describe unusual or severe events, so they can exaggerate the impression of risk, while trials may under-report mild lab changes. This summary is based on the abstract only.

What it means

At the doses typically used in psychiatric care, ketamine appears to cause mild and temporary liver enzyme rises in some people, while serious liver injury seems rare. The authors argue that routine liver monitoring during ketamine treatment is still warranted, particularly because higher exposures have been linked to severe liver injury in real-world data.

Evidence grade: Low. A systematic review that summarizes findings narratively across a mix of five randomized trials, three observational studies and five case reports, without pooled analysis, and liver events were not the main focus of most included studies.

This summary is based on the study’s published abstract.