Optimism About Psychedelics and Psychiatry

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Source: Krowdeed, Lifeofpix, public domain

Psychedelics entered our popular culture as recreational drugs decades ago. In the 1960s and 1970s, LSD was widely used by hippies and artists. I remember that time well. As a psychiatry resident, I spent countless hours in the emergency room in the middle of the night trying to help people in the midst of a ‘bad trip’. In the years that followed, the tiny group of advocates who championed LSD as a treatment were considered out on the fringe, their work viewed with suspicion.

Now, we are in a new era. Psychedelics are still highly regulated by federal laws that prohibit their manufacture, distribution and use. At the same time, psychiatry is now looking at them through a new lens. Psychiatrists are researching their potential as treatments for psychiatric disorders and as probes to learn more about the brain by understanding their mechanisms of action. As evidence of this new interest, The American Journal of Psychiatry recently devoted an entire issue to research studies on psychedelics and commentaries about the findings.

Psilocybin (Magic Mushrooms) and Depression

Patients with treatment-resistant depression are those for whom three of more good trials with different anti-depressants have failed, and they need new treatment options. Several studies have shown psilocybin to have significant anti-depressant effects even in this hard-to-treat group of patients.

MDMA (Ecstasy, Molly) and Post-Traumatic Stress Disorder

MDMA is not a classical psychedelic. It is a mind-altering substance that may induce transient feelings that one’s surroundings are not real, but it does not produce hallucinations like LSD. Instead, it produces feelings of good mood, euphoria, love and social connectedness. There is preliminary evidence that in controlled clinical settings, supported by psychotherapy, it is a safe and effective treatment for PTSD.

There is another study, still ongoing, taking advantage of a terrible, but informative, event. Over 4,000 partygoers attended the Nova music festival in Israel on October 7th, 2023. The terrorists murdered 380 people and kidnapped 41 into Gaza as hostages. All the other partygoers observed the slaughter and saved their own lives by frantic escapes. Over 750 survivors have volunteered for scientific studies. The researchers found that over 60 percent of the survivors suffered from symptoms of PTSD even a year later. Many of these survivors had taken mind-altering substances in the hours before the terrorist attack began. The researchers divided their subjects into five groups: those who had taken no substances, those who took a classical psychedelic like LSD, those who used marijuana, those who took stimulants like cocaine, and those who used MDMA. Interestingly, what they are finding is that at the group level, those who had taken MDMA suffered fewer symptoms of PTSD than the other groups, and their clinical condition was significantly better.

New Short-Acting Psychedelics

These are a new set of compounds still in the early phases of being studied. Their advantages are that they begin acting very quickly after being administered, and they act over a short period of time. These characteristics make them much more practical for clinical use.

What Still Needs to Be Studied?

Before psychedelics are ready for prime time and approved as treatments for patients, much still needs to be learned through research studies. The results of existing studies have to be taken with a grain of salt. Many have methodological limitations, such as small sample sizes and the possibility that the researchers and the subjects were not truly blind to what drug was being administered. Current research is using better, stricter methods that will ensure more reliable results.

Unanswered Questions

Is the major change in consciousness characteristic of many these substances truly necessary in producing their positive treatment effects?

What are the right doses?

Are they effective when administered without accompanying psychotherapy? Or, alternatively, is the psychotherapy before, during and/or after their use important and necessary?

How long do their positive effects last?

And, importantly, how safe are they? What is known so far is limited. Mild effects are common, but rarely patients have experienced serious psychiatric decompensation such as new-onset schizophrenia, or an adverse effect on the heart.

Where We Are Now

There is optimism that answers will soon be found. The FDA is demanding more rigorous studies and better data before granting approval for therapeutic use of these substances. Such studies are currently being done. And then psychiatrists will have additional much-needed tools to help the very many people who need them.