Psychedelics in Psychiatry: A Trip to the Future

Disclaimer: This blog is by no means an endorsement, nor is it advocating illegal activities. It is purely a discussion about the growing interest in psychiatric research on the potential of psychedelics in novel treatment approaches in mental health. It should be noted that the use of recreational drugs such as psychedelics is, under law, a criminal activity. Psychedelics should only be used within the legal framework of one's county and under the supervision of a clinician expert in their use.


 

What would be the first thing to come to your mind if I were to mention psychedelics?


If you’re anything like me, psychedelics probably conjure images of 1960’s trippy hippies, or rave attending teens. So, you can imagine my surprise when I learnt that these substances are seeing a resurgence, not amongst clubbers or hippies, but neuropsychiatrists hoping to find new ways of treating mental illnesses.


The idea that psychedelics can be used as a psychiatric treatment is however, not a new one. Prior to the 1971 ban on these substances, over 130 clinical studies using LSD were funded in the USA. The results from these studies were promising at the time, with some even reporting the benefit of treating alcoholism with psychedelics like LSD and psilocybin (the active substance found in magic mushrooms).


So what happened?


It is largely accepted that the growing anti-government sentiment during the Vietnam war sparked the push to ban psychedelics. With the need to find a source of this anti-war unrest intensifying, psychedelic drugs became the natural target; and so began the war on drugs.


I first became aware of the use of psychedelics in psychiatry when I stumbled upon a YouTube video on the subject; a talk by the author Michael Pollan given at Google. That serendipitous moment sparked my initial interest and led me happily down the psychedelics rabbit hole. What really fascinates me about this topic is both the interaction between politics and medicine, and of course, its potential to revolutionise psychiatry.


Since 1971, psychedelics have been classed as ‘Schedule 1’ substances by the UN Conventions on Drugs and the UK Misuse of Drugs Regulations 2001. This means they can only be prescribed by medics for the purpose of research, which in itself does not block their use in therapeutic clinical trials. The lack of scientific research into the effects of psychedelics on mental illness over the past 50 years instead stems from the stigma surrounding their rebranding as recreational drugs.


Funding for these projects consequently ceased as many sponsors were keen to distance themselves from the public image of recreational drug use. We often talk about stigma in mental health, but I for one, never expected it would have such pervasive power.


Psychedelics have been largely excluded from in the scientific community over the past 50 years. But that is all changing now.


Psilocybin is fast becoming hailed as a wonder drug in psychiatry, seemingly with the potential to treat everything from depression to eating disorders. There are numerous phase 2 trials emerging across the world, including one at King’s College London where psilocybin is being used to treat drug resistant depression. While we may have to wait years until the results of these trials are published, the results from earlier feasibility trials (which essentially ask if it can be done) indicate that a large proportion will likely be successful.


But the wait hasn’t stopped everyone, some people have reportedly been using drugs such as psilocybin to self-medicate in a phenomenon called ‘microdosing’, you can read more about this in a previous blog on InSPIre the Mind.



How do psychedelics work?


There is evidence that psychedelics change your brain. Not only do these substances mimic serotonin (the ‘happy’ neurotransmitter), they have actually been found to interrupt a network within the brain called the default mode network (DMN).


If you are anything like me, the DMN will be one of the most active regions within your brain. That is because the DMN is responsible for daydreaming, introspection, thinking about the past and future. It is the region that is directly opposed to the task focused network; any time you are not focusing on completing a task, the DMN comes alive. However, excessive use of the DMN has been identified across a range of mental health conditions; this is where psychedelics really shine. Interrupting the DMN causes what some refer to as ‘ego dissolution’. One’s ruminations and worries melt away, allowing the brain to form new connections; unlocking new regions and therefore new ways of thinking.


If you are interested in the effect of psychedelics on the DMN, this article provides a great explanation.



What does psychedelic therapy look like?


The experience one has when under the influence of psychedelic substances is highly influenceable. These so-called ‘trips’ can therefore be prompted to go in a particular direction by a therapist before the session has even begun. It is this ability to guide psychedelic trips that makes them ideal for treating past trauma in PTSD, and rumination in depression.


A typical guided therapy session will involve a preliminary session to establish the goals of treatment, and guidance on how to deal with any negative trips. Unlike the recreational use of psychedelics, therapists give set doses under full supervision; section 1 substances can only be sourced from highly regulated producers.


The key to psilocybin therapy arguably lies in its follow-up integration session, during which the patient is helped to incorporate the psychedelic experience into their life. The pre-treatment and post-treatment integration sessions are time consuming yes, but form the framework of this therapeutic model which clinical trials are currently testing. The profound experience one has whilst on a psychedelic trip has the ability to alter mood for months, even years after the session. Compare this to antidepressants which must be taken daily to continue having effect, and you can see why I am so excited by the therapeutic potential of psychedelics. No more weight gain, sexual dysfunction or regular blood tests — common side effects of antidepressants.


It all sounds too good to be true, doesn’t it? Surely these substances are addictive or harmful in some way, otherwise they wouldn’t be so tightly controlled? These were questions that I too had when delving into the available resources online. Yet it seems that the intense experience of a psilocybin trip is not actually as addictive as we may presume. The fact is that guided psychedelic therapy is incredibly safe. As noted by Imperial College London’s Professor David Nutt, LSD and ecstasy are far safer than alcohol or indeed horse riding; a position that led to his removal from the government advisory board on drugs.


The tight regulations surrounding the production and distribution of Schedule 1 drugs does however mean that patients can only access psilocybin through clinical trials. The effects of the law on research has been neatly outlined by Professor David Nutt in an article for the Lancet that you can read here. The limited number of said trials recruiting patients has led to a growing number of underground therapists to spring up all over the world, offering guided therapy sessions using psilocybin — which for now, is illegal. Read or watch the reports from patients who have participated in underground psilocybin therapy. Most will say it was a positive experience, many even say it triumphed where conventional treatments have failed.


The issue with sourcing psilocybin outside of clinical trials is that the product itself is unregulated, making effective doses hard to establish. I worry that this leaves patients vulnerable to unscrupulous ‘therapists’ who themselves may be unlicensed and undertrained, and potentially dangerous substances purporting to be psilocybin. Moreover, the uncontrolled way in which psychedelics are administered outside of a research setting means that the testimonies of the patients they help cannot be considered as evidence of their efficacy. This does nothing to progress science or the future of psychiatry.


I refuse to accept that forcing patients to break the law in order to seek treatment for their mental illness represents the future of psychiatry. However, with legislation currently as it is, I see this only continuing to happen.


So what does the future of psychedelics look like?


Unlike some working in this field, I do not agree that psychedelics like psilocybin should be legalised for the general public to use. As Michael Pollan says in his fascinating book on the topic, psychedelics are not recreational drugs. They can have profound effects on one’s life and as such should only be taken under the supervision and guidance of trained professionals. I do, however, hope that the growing evidence from clinical trials will culminate in their down-regulation from Section 1 to Section 2; allowing for regulated prescription and administration in the same vein as medical marijuana.


We must ask ourselves how much influence we will allow government policy to have over scientific innovation. Psilocybin and the blood thinner warfarin can both be derived from plants (mushrooms and grasses respectively), and both have therapeutic properties. Yet, only one is accepted as a medicinal treatment. By educating ourselves on where this stigma has come from, we can advocate for it to change. As future psychiatrists, we cannot be afraid to explore new ways of helping our patients, however unconventional or strange they seem.

 

Special note from the editors: This is the ninth blog of our series, The future of mental health as seen by the future leaders in mental health, written by the 2020 ‘Psych Stars.’ Selected by The Royal College of Psychiatrists, Psych Star ambassadors are a group of final year medical students awarded for their particular interest and commitment to psychiatry. During the year-long scheme as Psych Stars, students are nurtured in their interest in psychiatry through the assignment of mentors, by gaining access to learning resources and events, and by becoming part of a network of like-minded students. More information on the Psych Stars scheme can be read here. We have decided to invite each of the Psych Stars to write a blog on how they envision the future of mental health by choosing an area in which they are passionate. We have decided to run the series as a celebration of these student’s success and to provide an outlook for each of the awardees to share their passion. With a new blog published each Friday, the series will run over the next few months.

If you enjoyed today’s blog by Isabella, be sure to head over to InSPIre the Mind and check out the previous blogs in our Psych Star series covering topics such as compassion, the mind-body interaction, the future of child & adolescent psychiatry, gender inequality, global health, male mental health, neuropsychiatry, and telepsychiatry.