Psychedelics in Mental Health

Greg Thorkelson, MD with Ryan Reagan, PhD(c), LPC

Depending on your level of interest in certain subject areas of psychology, you may be aware that there is renewed interest in psychedelics as a potential treatment option for chronic mental illness. If you were unaware, you will likely hear much more about this in the coming years.  The recent success of Michael Pollan’s (yes, the food guru guy) How to Change Your Mind has placed psychedelics back on mainstream culture’s radar.  What this generally means is that research has been building over the past decade.  In fact, there was a healthy body of research that started to emerge in the 1950’s and 60’s, prior to the counterculture revolution.

Research in this area was significantly curtailed by the federal government in response to widespread and sometimes problematic misuse of these substances.  Many are surprised to find out that LSD was once thought to be a potential cure for alcoholism and that Bill W, the founder of Alcoholics Anonymous, was an early advocate.  MDMA, the chemical often referred to as ecstasy, was synthesized early in the 20th century and actually used in conjunction with psychotherapy in the 60’s and 70’s. Unfortunately, no clinical research was conducted.

Clinical research on LSD and MDMA is presently underway, and arguably there is justification to be cautiously optimistic. There is a reason that we are approaching this topic delicately.  The science has not firmly established matters of safety, dosage, and efficacy.  It is not clear who and what diagnoses benefit and why, because it is not entirely understood how and what these chemicals do in the brain. This is why the scientific literature often contains an abundance of caution and lines like “the precise mechanisms are not yet understood.”  

The argument in favor of a conservative approach is that the widespread misuse of these substances in the 60’s and 70’s created a backlash that all but shut down research for decades.  This is unfortunate because treatment resistant depression and PTSD are enormous personal and societal burdens. It is important that we get the approach right.  Psychedelics are not without risk.  They appear to act on the brain in the same regions where people experience deeply spiritual phenomenon.  

This can be profoundly transformative.  Some of the accounts are reminiscent of the stories you hear in Alcoholics Anonymous, which also has a strong spiritual dimension.  But this is also a reason for being cautious, AA does not work for everyone.  Psychedelics likewise may not work for everyone.  It is important to be realistic with our expectations. Human beings have a great fondness for the idea of “miracle cures.”  Take articles like “The Coming Revolution…” with a grain of salt.   On the other hand, be optimistic that we are probably at the next wave.  Neuroscience has rapidly filled gaps in our knowledge of the brain since the 1960’s.  

Why should we be optimistic? For one, SSRI’s have been the traditional approach to treating depression and anxiety.  Depression and anxiety are common and can take many paths, culminating in the diagnosis of a specific disorder. For some patients SSRI’s either fail to alleviate symptoms or achieve only partial remission.  We still don’t know enough to accurately predict response; it is therefore not uncommon to try multiple medications before finding one that is highly effective.

Where does this leave us in terms of psychedelics?  Well, for one, they absolutely do not operate in the same way as SSRI’s.  We understand even less about how psychedelics work on the brain.  This is uncharted territory.  A few of the commonly used psychedelics are found in the natural world.  Mescaline, psilocybin, and ayahuasca have been used in religious ceremonies by indigenous societies probably for thousands of years.  LSD, MDMA, and ketamine were chemically synthesized in laboratories, in some cases unintentionally.

We should spend a moment clarifying what we are referring to as “psychedelics,” since the term gets applied so broadly.  You will sometimes even find marijuana mentioned in this category for its “psychedelic properties.”  However, cannabis is much less potent than other psychedelics and often occupies a place of its own in the taxonomy of still-illicit-in-some-places substances.  In terms of substances psychedelic refers to a “drug that produces hallucinations and an apparent expansion of consciousness.”

We will spend more time in the coming posts unpacking what this all means.  This area is developing rapidly, and research has not kept pace.  The state of Oregon recently legalized the use of psilocybin for mental health treatment in supervised settings.  The second wave of psychedelic medicine has arrived.  In the next post we will discuss ketamine which actually does have a significant body of research data within the medical field, since it has been used for decades as an anesthetic.  During the past 20 years ketamine has been gaining attention for its potential to treat chronic depression.  This will be discussed in greater detail in the coming week.

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