After an initial induction series of psychedelic-assisted therapy, many patients ask the same question: what happens next? The honest clinical answer is that for several substance pathways — particularly ketamine and esketamine — booster or maintenance sessions are often required to sustain therapeutic effect. This article is a Canadian guide to what maintenance dosing looks like across substances, what the evidence shows, how to know when a booster is needed, and what insurance and cost considerations are realistic to plan around.

Key takeaways

Maintenance is often required, not optional. For treatment-resistant depression and PTSD with ketamine and esketamine, sustained benefit typically requires ongoing dosing rather than a one-time induction.

Spravato (esketamine) is the only on-label maintenance pathway in Canada: twice-weekly induction for 4 weeks, weekly for weeks 5–8, then every 1–2 weeks ongoing per Health Canada labelling. SUSTAIN-2 (Wajs 2020, PMID 32316080) provides long-term safety and durability data.

Off-label ketamine maintenance is common but variable: induction is typically 4–6 sessions over 2–4 weeks, with maintenance most often once monthly or as-needed, calibrated to symptom return.

Psilocybin and MDMA-AT are not currently maintenance pathways in published RCT evidence. Goodwin 2022 tested 1–2 psilocybin sessions; MAPP1/MAPP2 tested 3 MDMA dosing sessions over 12 weeks. Frequent psilocybin re-dosing is also limited by rapid 5-HT2A receptor tolerance.

Symptom-tracking with PHQ-9, GAD-7, and PCL-5 is the standard way to identify when a booster is clinically indicated.

No outcome promises. Maintenance sustains gains for many patients. It is not a cure; ongoing care is the realistic clinical pathway.

Why this article exists

Most public information on psychedelic-assisted therapy stops at the induction series. Patients are told what to expect across preparation, dosing, and integration of an initial course of treatment, and then the path forward becomes vague. In real clinical practice, the question of whether and how to continue dosing — and at what cadence — is one of the most frequent points of patient confusion in the months after an induction series.

The reason it matters is straightforward. Major depressive disorder, treatment-resistant depression, and PTSD are conditions with relapse-remission patterns. Antidepressant response, psychotherapy response, and psychedelic-assisted therapy response are all subject to waning over time in subsets of patients. A realistic clinical conversation about maintenance is part of informed consent, and is something every reputable Canadian program should be having with patients before they begin.

The induction-then-maintenance model

Across psychiatric medicine, the induction-then-maintenance model is well-established for relapsing-remitting conditions. Antidepressants are induced over 4–8 weeks and then continued at maintenance doses for months to years. Antipsychotics, mood stabilizers, and TMS protocols all follow induction-then-maintenance designs. Ketamine and esketamine, in their psychiatric use, have inherited this structure rather than escaped it.

For psychedelic-assisted therapy specifically:

Spravato (esketamine) has a Health Canada-approved induction-and-maintenance schedule built into its product monograph.
Off-label IV / IM / oral ketamine in clinical practice has adopted similar but less protocolized induction-and-maintenance patterns, supported by the Cohen 2018 ketamine consensus statement (PMID 29870457) and subsequent clinical observation.
Psilocybin and MDMA-AT in current trial evidence are not maintenance pathways. They are course-of-treatment models with 1–3 dosing sessions and longer-duration follow-up rather than ongoing maintenance dosing.

Spravato maintenance: per Health Canada labelling

Spravato (esketamine nasal spray) is Health Canada-approved for treatment-resistant depression as of May 2020 and is the only on-label psychedelic-adjacent maintenance pathway in Canadian psychiatric care. The Health Canada product monograph specifies a structured induction-and-maintenance schedule:

Induction phase (weeks 1–4): twice weekly dosing
Continuation phase (weeks 5–8): once weekly dosing
Maintenance phase (week 9 onward): every 1 or every 2 weeks, calibrated to clinical response

Each Spravato administration occurs in a certified clinic with a minimum 2-hour post-dose monitoring period for blood pressure and dissociation, per the Health Canada Risk Management Plan and the same product monograph that governs the induction schedule.

The SUSTAIN-2 long-term safety study (Wajs et al. 2020, Journal of Clinical Psychiatry, PMID 32316080) followed patients on Spravato maintenance for up to 52 weeks. SUSTAIN-2 provides the best available durability and long-term safety data for esketamine maintenance: the safety profile across the year of dosing was consistent with the shorter-term induction trials, and the maintenance phase preserved response in a substantial proportion of patients who had achieved remission during induction. SUSTAIN-2 is the empirical backbone of the maintenance schedule that the product monograph now codifies.

Practical implication for Canadian patients: if you are on Spravato, maintenance dosing is the expected pathway, not an exception. The decision to space dosing every week vs. every two weeks during maintenance is made by the prescribing physician based on response patterns, side-effect profile, and tolerability.

Off-label ketamine maintenance: less protocolized

Off-label ketamine (IV, IM, oral, sublingual) for psychiatric indications is widely used in Canada within off-label prescribing principles, but it is less protocolized than Spravato. Induction is typically 4–6 sessions over 2–4 weeks, consistent with the Cohen 2018 ketamine consensus (PMID 29870457) and broadly with the older Murrough and aan het Rot infusion-series literature.

Maintenance dosing for off-label ketamine is highly variable:

Once monthly is a common cadence in Canadian KAP and infusion clinics.
Every 2 weeks is used in patients with shorter-duration response.
As-needed booster — re-dosing only when symptoms return to a defined threshold — is used in patients whose response durability is longer than the typical interval.
Some patients move to monthly dosing for several months and then taper to every 6–8 weeks; others remain on a stable monthly cadence for years.

The reason for the variability is that off-label ketamine maintenance has no Health Canada-approved schedule. It is calibrated patient-by-patient by the prescribing physician based on response duration, symptom return, side-effect profile, and tolerability. The Cohen 2018 consensus emphasizes that maintenance schedules should be individualized rather than protocolized rigidly.

This is not a flaw of the approach — it is appropriate clinical reasoning for an off-label psychiatric medication. But it does mean that patients should not expect a fixed schedule, and should expect ongoing collaboration with their prescriber to adjust cadence over time.

Psilocybin: not typically a maintenance pathway

Psilocybin in current RCT evidence is not a maintenance pathway. The Goodwin 2022 COMP001 trial (NEJM, PMID 36322843) tested a single 25 mg psilocybin dosing session with structured psychological support before and after, with measurement at week 3 as the primary endpoint. Earlier Carhart-Harris 2016 (PMID 27210031) and Carhart-Harris 2021 (PMID 33852780) trials used 1–2 dosing sessions. None of these protocols incorporates ongoing maintenance dosing.

Two factors limit frequent psilocybin re-dosing:

Rapid 5-HT2A receptor tolerance. Psilocybin acts primarily through 5-HT2A receptor agonism, and 5-HT2A receptors downregulate quickly with repeated agonist exposure. Within days, the subjective and likely the therapeutic effects of a repeat dose are substantially attenuated. This is well-documented in classical psychedelic pharmacology and is a defining feature of the receptor system.
Trial design and SAP framing. Canadian Special Access Program (SAP) authorizations for psilocybin are issued on a case-by-case basis for specific clinical indications and are not structured as ongoing maintenance.

In Canadian practice, psilocybin in SAP is typically a course of treatment — one or two dosing sessions with substantial preparation and integration — rather than an ongoing maintenance pathway. Patients who have completed a psilocybin SAP course and whose symptoms return are generally considered for re-application, alternative substances (including ketamine or esketamine for relapse), or non-psychedelic treatment options, rather than scheduled maintenance dosing.

MDMA-AT: not a maintenance pathway in published RCT evidence

MDMA-assisted therapy in the published phase 3 RCT literature is also not a maintenance pathway. The Mitchell 2021 MAPP1 trial (PMID 33972795) and Mitchell 2023 MAPP2 trial (PMID 37640273) both used 3 dosing sessions over approximately 12 weeks, with substantial preparation and integration sessions surrounding each dosing session. Follow-up data extends beyond the 12-week trial window, but maintenance dosing is not part of the protocol.

In Canada, MDMA-AT remains accessible only via Health Canada's Special Access Program; SAP authorizations follow MAPP-style protocols and are similarly course-of-treatment rather than maintenance designs.

Why effects can wane and patients return

Several factors contribute to symptom return after an induction series, regardless of substance:

Stress reactivation. Major life stressors — bereavement, job loss, relationship rupture, illness — can re-activate depressive or PTSD symptoms even after a strong induction response.
Underlying neurobiology. Treatment-resistant depression and chronic PTSD have baselines of biological vulnerability that do not disappear with a single course of treatment.
Life-event triggers. Anniversary reactions, trauma-cue exposure, and developmental transitions (parenthood, retirement, ageing parents) can re-surface symptoms.
Chronic conditions follow relapse-remission patterns. PTSD and treatment-resistant depression are not single-episode acute illnesses for most patients. They have natural histories of relapse and remission, and treatment response participates in that natural history rather than overriding it.

Naming this clearly with patients is part of honest informed consent. Maintenance is not a sign of treatment failure; it is the realistic shape of care for chronic relapsing-remitting psychiatric conditions.

How to know when a booster is needed

The standard way to identify when a booster session is clinically indicated is scaled measurement of symptoms over time, supplemented by clinical interview. Canadian clinics commonly use:

PHQ-9 (Patient Health Questionnaire-9) for depressive symptoms
GAD-7 (Generalised Anxiety Disorder-7) for anxiety symptoms
PCL-5 (PTSD Checklist for DSM-5) for PTSD symptoms

A typical maintenance-monitoring approach is:

Baseline measure at end of induction. PHQ-9 / GAD-7 / PCL-5 scored at the end of the induction series establishes a post-induction baseline.
Periodic re-measurement. Weekly or every-two-weekly self-report through the first months of maintenance, then monthly once cadence is established.
Threshold-based re-dosing. A defined increase from the post-induction baseline — for example, PHQ-9 rising by 5 points or crossing back into moderate-to-severe range — triggers a clinical conversation about a booster session.
Clinical interview overlay. Scaled measures do not capture everything. Functional impairment, sleep disturbance, suicidal ideation, and trauma re-experiencing are evaluated in clinical conversation alongside the measures.

This combination — scales plus clinical interview — is the standard of practice for measurement-based mental health care and is the framework ATMA CENA uses for maintenance monitoring.

Insurance considerations for maintenance

Maintenance coverage in Canada differs substantially across substances and pathways.

Spravato

Spravato is typically covered ongoing through prior authorization by Canadian private insurers and some public formularies, where the patient meets the criteria for treatment-resistant depression and the prescriber can demonstrate continued response. Coverage is generally tied to documented response (often a defined PHQ-9 reduction at re-authorization) and is renewed periodically. See PSHCP / Canada Life Spravato Coverage for the federal-employee pathway specifically.

Off-label ketamine

Off-label ketamine is typically out-of-pocket for Canadian patients. Some private insurers may cover psychotherapy hours associated with KAP under psychotherapy benefits, but the medication and its administration are generally not covered by standard private insurance.

Important exceptions exist:

Workers' Compensation Boards (WSIB and provincial equivalents) may cover off-label ketamine maintenance for compensable mental-health conditions. See Workers' Compensation and Psychedelic-Assisted Therapy.
Veterans Affairs Canada (VAC) has, in specific cases, authorized ketamine treatment for veterans with service-related mental-health conditions. See VAC Coverage for Psychedelic-Assisted Therapy.

In both compensable contexts, maintenance coverage requires documentation of induction response and ongoing clinical need, and is decided case-by-case.

Psilocybin and MDMA-AT

Psilocybin SAP and MDMA SAP courses are not generally covered by Canadian private insurance. Because these are not maintenance pathways in the usual sense, the maintenance-coverage question is largely moot — the patient is paying for a course of treatment rather than ongoing dosing.

For a comprehensive Canadian coverage map, see Insurance Coverage for Psychedelic-Assisted Therapy in Canada.

Cost considerations for sustained maintenance

Cost planning for maintenance is a legitimate and clinically important conversation. For off-label ketamine in particular, the math of monthly maintenance over years is substantial, and patients should plan for it explicitly rather than assume an open-ended trajectory.

A realistic conversation with your prescriber will cover:

Per-session cost of your specific ketamine modality (IV, IM, oral, sublingual)
Expected cadence — monthly, every two weeks, as-needed
Anticipated duration — six months, one year, longer
Whether benefits coverage applies — psychotherapy benefits, WSIB, VAC
Tapering options if cost is a constraint — moving from monthly to every six weeks, layering in additional psychotherapy

For Spravato, costs are predominantly the medication itself and the in-clinic monitoring time; if covered through prior authorization, out-of-pocket cost is much lower than off-label ketamine maintenance.

Choosing maintenance frequency

Maintenance frequency is a clinical decision made between patient and prescriber, calibrated to:

Patient response patterns. How long does benefit last after each dose? Patients with 6-week response windows do not need 2-week dosing; patients with 2-week response windows likely will not maintain on monthly.
Side-effect profile and tolerability. Dissociation, blood pressure response, post-session fatigue, and any cumulative effects are factored into how often dosing is sustainable.
Functional measures. Work, family, and self-care functioning are part of the equation, not just symptom scales.
Life context. Major upcoming stressors (a court date, a move, a medical procedure) may warrant a temporary increase in cadence.

The principle is the lowest effective frequency that sustains response — not maximum dosing, not arbitrary intervals.

Tolerance considerations

Tolerance — diminishing subjective and therapeutic effect at the same dose over time — is a real consideration in maintenance dosing.

Psilocybin has rapid 5-HT2A receptor tolerance (within days), which is one of the central reasons psilocybin is not a frequent-dosing maintenance pathway.
MDMA also has acute tolerance with frequent dosing, alongside cumulative neurochemical considerations that contributed to MAPP-style protocols spacing dosing sessions multiple weeks apart.
Ketamine and esketamine have a different tolerance profile. Therapeutic effect on depressive and PTSD symptoms is often sustained over months to years of regular dosing in a substantial proportion of patients, though some patients experience diminishing response and require dose adjustment, cadence change, or a treatment break.

Honest framing: tolerance does occur for some patients on long-term ketamine maintenance, and is a reason to reassess regularly rather than assume indefinite stability.

Cumulative ketamine use considerations: bladder

A specific cumulative consideration in long-term ketamine use is ketamine cystitis — a chronic inflammatory condition of the bladder also called ketamine-induced uropathy or ketamine-induced interstitial cystitis. The condition was first formally described in the recreational-use literature (Shahani et al. 2007) at chronic high-dose recreational ketamine levels and is well-documented in the urology literature in heavy recreational users.

At clinical dosing levels, ketamine cystitis is not typically observed. Clinical KAP and Spravato dosing are orders of magnitude lower in cumulative exposure than the heavy chronic recreational use described in the cystitis literature. That said, it remains worth screening for in long-term maintenance patients:

Urinary frequency, urgency, dysuria, pelvic pain, or haematuria warrant clinical assessment.
Pre-existing bladder conditions warrant documentation at induction and ongoing monitoring.
Concurrent recreational ketamine use materially increases cumulative exposure and warrants direct clinical conversation.

ATMA CENA's standard of care includes baseline urinary symptom screening and ongoing monitoring for patients on long-term ketamine maintenance, alongside the standard cardiovascular and dissociative-symptom monitoring.

The honest answer about maintenance

For patients on ketamine and esketamine pathways in particular, here is the honest clinical answer that informed-consent conversations should cover:

Maintenance is often required. A meaningful proportion of patients who respond to an induction series will need ongoing dosing to sustain benefit.
It is not curative. Psychedelic-assisted therapy is not a one-time fix for chronic relapsing-remitting psychiatric conditions, any more than antidepressants, mood stabilizers, or psychotherapy are.
Ongoing care is the realistic clinical pathway. Maintenance, periodic reassessment, and integration of psychedelic-assisted therapy into a broader care plan — psychotherapy, lifestyle, social support, sometimes additional medication — is the realistic shape of treatment for most patients.

Framing maintenance as ongoing care rather than treatment failure is part of how ATMA CENA talks about long-term outcomes. It is also closer to how the underlying conditions actually behave.

Coordinated care during maintenance

ATMA CENA's coordinated care model is built specifically around ongoing care relationships and is well-suited to the maintenance phase.

Existing therapist remains primary. Your psychotherapist or psychiatrist remains your primary therapeutic relationship through induction and into maintenance. ATMA CENA's role is to add the dosing pathway, not replace your existing care.
Ongoing integration work. Maintenance is not just dosing. The integration work — translating insights and shifts into sustained behaviour change — continues across the full maintenance period and is generally where the largest functional gains accumulate over time.
Periodic reassessment. Patient, prescriber, and therapist re-evaluate the maintenance plan periodically — typically every 3–6 months — to adjust cadence, taper, pause, or change pathway as the clinical picture evolves.

For pathway detail across substances and treatment phases see The Preparation Phase of Psychedelic-Assisted Therapy, The Integration Phase of Psychedelic-Assisted Therapy, and Dosing Protocols Across Substances.

Frequently asked questions

Will I need maintenance dosing forever? Not necessarily. Some patients taper off maintenance after a sustained period of remission and stable functional gains; others remain on a stable maintenance cadence for years. The plan is reassessed periodically with your prescriber based on response, side-effect profile, and life context.

How do I know when I need a booster? Symptom return is the primary signal, identified through scaled measures (PHQ-9, GAD-7, PCL-5) and clinical interview. A defined increase from your post-induction baseline triggers a conversation with your prescriber about a booster session.

What is the difference between Spravato maintenance and off-label ketamine maintenance? Spravato has a Health Canada-approved induction-and-maintenance schedule and is the only on-label maintenance pathway in Canada. Off-label ketamine maintenance is calibrated patient-by-patient, with no fixed protocol, and is typically once-monthly or as-needed. Coverage and cost differ substantially as well.

Are psilocybin and MDMA-AT maintenance pathways? No. Current RCT evidence for psilocybin (Goodwin 2022) and MDMA-AT (MAPP1/MAPP2) tested course-of-treatment designs with 1–3 dosing sessions, not ongoing maintenance. Psilocybin re-dosing is also limited by rapid 5-HT2A tolerance.

Is long-term ketamine maintenance safe? The best long-term safety data is the SUSTAIN-2 study (Wajs 2020, PMID 32316080) for esketamine, which followed patients for up to 52 weeks of maintenance dosing. Long-term off-label ketamine safety is supported by clinical observation but with less RCT-level data. Cardiovascular monitoring at each session, periodic assessment of dissociative symptoms, and screening for urinary symptoms are part of standard maintenance care.

What about ketamine and bladder problems? Ketamine cystitis is well-documented at chronic high-dose recreational levels (Shahani 2007) but is not typically observed at clinical dosing. ATMA CENA screens for urinary symptoms at baseline and ongoing during long-term maintenance.

Is maintenance covered by insurance? Spravato is typically covered ongoing via prior authorization. Off-label ketamine is typically out-of-pocket, with case-by-case exceptions for WSIB and VAC. See Insurance Coverage for Psychedelic-Assisted Therapy in Canada.

Can I take a break from maintenance? Yes — planned breaks are part of how maintenance is calibrated. Your prescriber may suggest a taper trial, a pause, or a substitution with intensified psychotherapy and reassessment. This is a clinical decision rather than an all-or-nothing one.

Does maintenance mean the induction did not work? No. Maintenance is the standard shape of care for chronic relapsing-remitting conditions like treatment-resistant depression and PTSD. Needing ongoing care is not a sign of treatment failure; it is the realistic clinical pathway.

Compliance disclaimer

This article is educational. Psilocybin and MDMA are Schedule III and Schedule I controlled substances in Canada respectively; clinical access in Canada is via Health Canada's Special Access Program on a case-by-case basis. Ketamine is a Health Canada-approved anaesthetic; psychiatric use is off-label and within Canadian off-label prescribing principles. Esketamine (Spravato) is Health Canada-approved for treatment-resistant depression. Nothing in this article should be construed as a clinical recommendation for a specific individual; clinical decisions about induction, maintenance, taper, or discontinuation belong with a qualified prescribing physician.

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Last updated: 2026-05-06

Booster and Maintenance Sessions in Psychedelic-Assisted Therapy: What the Evidence Says