Psilocybin and ketamine — using different pathways for different situations

The fundamental difference: ketamine is dissociative — you leave the ordinary sense of self by going into a kind of floaty detachment. Psilocybin is psychedelic — the ordinary sense of self dissolves or expands into something larger. The experience of ketamine is strange and spacious. The experience of psilocybin is penetrating and often directly confrontational with what matters. They're not comparable as experiences.

When ketamine makes more sense: Acute crisis or active suicidality — ketamine works within hours. When insurance coverage is a factor (esketamine/Spravato is often covered). When someone isn't ready for the intensity of a psychedelic experience. When maintenance dosing is practical (ketamine clinics are more widespread than Oregon service centers).

When psilocybin makes more sense: When psychological and meaning-based work is the goal, not just symptom relief. When previous ketamine courses haven't produced lasting benefit. When one or two intensive experiences fit the person's life better than repeated infusions. When the patient is interested in and prepared for the experiential depth of psilocybin.

Sequential use: there's no pharmacological reason not to use both at different times. I use ketamine for acute stabilization — when the depression is severe enough that I need rapid symptom reduction to function. I use psilocybin for the deeper work — understanding what's driving the depression, changing how I relate to it, developing the insights that change behavior. They're not competitors. They're different tools for different jobs.