Treatment Through a Trip
Mental health has become a catch-all term. When politicians are asked about the solution to homelessness, gun violence, addiction, suicide, and a host of other problems increasingly prevalent in the United States, the answer is often to address mental health.
However, after decades of using mental health as a hypothetical remedy to society’s ails, there is a lack of effective and accessible treatments for mental illnesses. One out of five Americans battle with a mental illness sometime in their life. When asked why individuals don’t receive treatment, the most common response is a lack of access. And the lack of access to mental health therapies is compounded by the fact that many individuals with conditions like PTSD and major depressive disorder do not respond to traditional therapies. The therapies commonly prescribed for post-traumatic stress disorder and depression date back to the 1960s and the effectiveness of treatments for both — cognitive behavioral therapy and selective serotonin reuptake inhibitors — have been debated ever since and vary widely between individuals.
So, the answer to America’s mental health crisis lies in affordable and effective therapies. Luckily, the Food and Drug Administration has heeded the call to investigate new therapies by supporting research into a currently-illegal class of drugs: psychedelics.
Although these substances were labelled as schedule one illegal drugs in 1970, a shifting tide in public opinion, aimed against pharmaceutical companies for their role in the opioid crisis and increasing drug prices, is starting to unveil the potential therapeutic effects of these perception-altering drugs. So far, the FDA has granted breakthrough therapy status to 2 types of psychedelics: MDMA (or ecstasy) and Psilocybin (magic mushrooms). The FDA grants this designation to drugs in clinical trials when they treat a life-threatening disease or condition and when they exhibit a significant improvement from traditional therapies. The FDA granted breakthrough therapy status to MDMA for its effect on PTSD. In the phase two clinical trial, MDMA was administered to 107 participants in a controlled setting with trained therapists; a procedure called psychedelic assisted psychotherapy (PAP). After 2 or 3 sessions, 61 percent no longer qualified for PTSD symptoms, and one year after the treatments that percentage increased to 68 percent. Typical treatment for PTSD (cognitive behavioral therapy and an SSRIs) requires long term consistency, which leads to high dropout rates and pharmaceutical dependency; whereas the MDMA therapy is effective after just a few doses and has a low risk for dependence or abuse.
Psilocybin has a similar effect on terminal cancer patients battling with end-of-life anxiety. Six months after receiving just one dose of psilocybin, 60 to 80 percent of participants had clinically significant reductions in anxiety and depression — 87 percent reported increased life satisfaction or well-being attributed to the experience.
The distinction in results from traditional therapies, which take months and sometimes years of medication and therapy, and just a few administrations of these psychedelic drugs may be puzzling. After all, the effects of these drugs are pharmacological, like any antidepressant or anti-anxiety medication. Instead of trying to permanently change the brain’s chemistry, the root of the therapy seems to lie in the short term perception-altering effects of these drugs.
The way these drugs are administered highlights and partially explains this distinction. The participants do not take these drugs at home. Instead, the doses are administered in a controlled and comfortable setting; a therapist (or a pair or therapists) are present in a living room-like space to guide the participants through their experience on the drug. The guidance varies based on the drug and study design, but most therapists are instructed to keep the participants focused on an introspective mindset; facilitated by eye shades and gentle, non-directive, instructions. Most models of PAP encourage a self-directed approach; during the session the therapist is not present to probe into the participant’s psyche; rather, they are present to motivate and reassure the participant to explore their thoughts and emotions. The studies also include a variety of preparation and integration therapy sessions before and after the dose to help the participant prepare and make sense of their experience.
Since these therapies are largely self-directed, the mystery of their success lies in what the participants are experiencing while on these drugs. Michael Pollan, author of “How to Change Your Mind” an anthology and person account of psychedelics, has remarked that the medical research into psychedelics is like “fitting a square peg into a round hole.” The importance of set and setting, or the physical environment and attitude of the therapist, highlights the magnifying effect psychedelics have on consciousness and experiences. In general, the psychedelic treatments enable patients to quiet their ego and view their mental condition through a new lens.
It is difficult to define these effects in terms of neurobiology. But with the newfound interest in psychedelics, researchers have begun to develop a road map to describe the therapeutic effects of psychedelic drugs. Studies indicate that psychedelics enhance neuroplasticity, or the brain’s ability to build new connections, by increasing activity in glutamate receptors and raising levels of brain-derived neurotropic factor. This supposed rewiring of the brain may explain the lasting psychological produced by a handful of treatments. Changes in perspective and ego dissolution have been credited to the decreased activity in the part of the brain called the default mode network. The default mode network (DFM) can be considered the bus driver of the ego; it controls the self-referential operations like mental time travel and self-reflection. By decreasing activity in this area of the brain, individuals can experience an egoless perspective rooted in the present moment. This egoless experience allows the patient to experience their trauma or mental condition from a different perspective. From this transcendent event, individuals can begin to work on the psychology that underpins their condition.
Upon reviewing these neurological mechanisms, it is apparent to many researchers that psychedelics may be applied as therapies to a host of other mental illnesses. The stage-three clinical trials currently in progress represent only a small portion of the research being done into the therapeutic applications of these drugs. A variety of psychedelics, ranging from DMT to LSD to Ibogaine, are employed in studies researching the effects of psychedelics on Obssesive Compulsive Disorder, drug addiction, suicide, eating disorders, social anxiety in autistic adults, and the mental health of otherwise healthy adults.
There is not one single psychedelic drug that corresponds to each of those potential therapies; instead, PAP may be used to treat multiple conditions (although some drugs seem to be better-suited to treat certain disorders, like ibogaine’s effects on drug addiction). This use of a drug contradicts pharmacological determinism: the idea that a certain drug is uniquely suited to solve the neurological ailment associated with a certain disorder. Psychedelic treatments approach disorders as a complex condition tied to a host of other traumas instead of reducing the condition to its neurochemical components.
Drugs like psychedelics may open the door to a new way of thinking about mental illnesses. Instead of fitting mental illnesses into rigid categories and prescribing medication to treat chemical deficiencies, psychedelics pinpoint a commonality among many harmful psychological conditions: destructive, rigid and persistent thought patterns that lead to conditions psychologists label depression, anxiety, and PTSD.
Conclusions like these are not just acknowledged in psychedelic research, they are also recognized in the general practice of cognitive behavioral therapy and mindfulness meditation. The general thesis in these holistic approaches is to reshape thought patterns and therefore reshape a patient’s relationship with their mental illness. PAP therapy adapts this outlook and amplifies it for the patient.
So, the question remains: how will psychedelics change mental healthcare in America?
To answer this question, I spoke with Brad Burge, the Director of Strategic Communications for the Multidisciplinary Association of Psychedelic Science (MAPS). Ketamine, an anaesthetic that produces dissociative psychedelics effects, is the closest drug to compare to psychedelics in clinical usage. The drug has been proven to decrease symptoms of depression and other mood disorders in treatment resistant individuals. Up until recently, the sole approved use of ketamine was as a general anesthetic, but it has long been prescribed off-label as a psychoactive therapy.
When I asked Mr. Burge if there is any fear psychedelics will be prescribed off-label, for uses they were not approved for by the FDA, he responded “it is not a fear but a certainty.”
FDA clearance on specific usage of medication is a long and costly process. The process is normally backed by pharmaceutical companies interested in procuring the patent for the drug, which is granted to organizations that fund the clinical trials. However, these drugs will likely be used in clinical settings beyond what is initially cleared by the FDA. After a drug is cleared for clinical use, psychiatrists can rely on medical research to use the drug as a treatment for other conditions.
Off-label prescriptions may prove incredibly important for the use of psychedelics in a variety of other therapies.
The nature of psychedelic therapies makes them unattractive to profit-seeking pharmaceutical companies.
Drugs that are consistently prescribed over long periods of time are more profitable than drugs that reduce symptoms after a handful of doses.
So, the bill for clinical trials has been handed off to MAPS, the nonprofit leading the charge on psychedelic research. If the stage three trials for MDMA in PTSD treatment are successful, MAPS will own the patent for the drug. After five years, MDMA will become a generic drug. The second psychedelic in stage three clinical trials, psilocybin, is naturally occurring in certain mushrooms, so it cannot be patented.
The patents for these two substances will be held by a nonprofit and mother nature, which will minimize the cost of treatment. And the benefits of PAP will not be isolated to a few mental health disorders, the off-label prescription process will allow psychiatrists to prescribe the psychedelic treatment to individuals based on prevailing medical research. This will further establish the drug as a cost-effective treatment, as it will bypass the expensive and lengthy clinical trial process normally funded by pharmaceutical companies and paid for by consumers.
However, psychedelics still face an uphill battle. Convincing the FDA, and the public at large, that psychedelics are more than street drugs necessitates large-scale research. Identifying the potential benefits, while acknowledging the embattled history and need for controlled administration, must be the keystone of public conversation in order for these drugs to make an impact on America’s mental health crisis.
