GDS2019: The psychedelic revolution in psychiatry and why patient opinion matters so much

Professor Adam R Winstock and Associate Professor Matthew W. Johnson

In the last 12 months a formulation of ketamine has received FDA approval for the treatment of mental health conditions, specifically depression. Psilocybin (the active ingredient in magic mushrooms), MDMA and LSD have shown promise as well, with approval for therapeutic research and early positive results. Findings from this year’s Global Drug Survey suggest that in the same way it has taken policy makers decades to shift their view, time may also be needed to shift public opinion on how ‘abusable’ drugs can also be used to heal rather than harm.

In our study of over 85,000 people recruited as part of GDS2019, we looked at the acceptability of different approaches to treating mental illness in a 2-step process. Initial questions screened for prior drug use and treatment for mental illness, and the level of interest in 3 different intervention types for mental illness (traditional antidepressants, talking therapies and psychedelic based approaches). Those who indicated they would very likely, likely or maybe accept psychedelic based therapies were then asked to complete a further assessment that formed the second part of the study.

In this second section (n >20,000) we explored the acceptability of psychedelic assisted therapies by means of a hypothetical scenario outlining a common mental condition. 11 different potential interventions were described, including antidepressants, talking therapies, mindfulness, and a range of psychedelic assisted therapies including the use of MDMA, LSD, psilocybin, ayahuasca and ketamine. Participants were asked to indicate how likely it would be that they would accept each treatment (accepting equal cost and efficacy), and to describe which factors underpinned their most preferred option.

The results confirm that people prefer talking to medication and that nothing predicts choice more than personal experience. Overall, 70% of the total sample indicated it would be likely or very likely that they would accept the offer of talking treatments (psychological therapies such as CBT). This is significantly higher than the approximately 40% indicating they’d accept traditional psychiatric medications or psychedelics. Worryingly for the psychiatric profession, one third indicated that it would be unlikely or very unlikely that they would accept psychiatric medications such as antidepressants. Given recent concerns over antidepressant discontinuation syndrome and other side effects associated with daily medication, this is a wakeup call for the need to change what’s on offer.

However, our results may also dismay those at the forefront of psychedelic therapies, with almost 40% of the global sample indicating that it would be unlikely or very unlikely that they would accept psychedelic based therapies. The absence of prior experience with psychedelic drugs, fear of brain damage or a bad trip were reasons given and predictive factors for their non selection.

Among those with prior experience of psychedelics, however, there were very high levels of acceptance and indeed preference for psychedelic therapies. Results also suggest that current medication-based approaches such as antidepressants have low acceptance among those have personal experience of psychedelic drugs.

Decades of misinformation and ideologically driven, ‘evidence resistance’ to the potential of psychoactive drugs to cure not harm, will need to be overcome. Our findings suggest that a more useful, informed and honest narrative is required about these drugs and their therapeutic potential. We will need to be careful not to sway the pendulum too far and offer the promise of a panacea to all psychological ills. It is critical to follow the data. Experience, research and reorientation of both services and cultures take time. It is worth taking that time to ensure that potential benefits don’t get waylaid by commercial interests and those with a strong interest to resist change. And we should hold on to the finding that regardless of treatment preference, when asked to rate factors involved in their treatment decision, participants of all types gave consistent high rankings for desire to get the root of their mental health problems and to involve a trained therapist.

Stigma around mental illness and its treatment will be just one of many hurdles those exploring the potential therapeutic benefits of psychedelic drugs will face. Things are changing – but both culture, policy and the medical profession will change in harmony if we are to optimize the benefits that these new treatments offer. Delays to legal access may end up causing more harm than good, with people tempted into unsupervised self-treatment and the appearance of untrained therapists. It is critical that research continue on psychedelic based therapies, and that, if safety and efficacy continue to be shown, that they be approved for use in mainstream medicine. In this framework society can ensure the proper safeguards against the very real risks that psychedelic based therapies entail. Such risks are well known and can include exacerbation of psychotic disorders, potentially dangerous behaviour that can occur during acute panic experiences on these drugs and acute cardiovascular effects like increased blood pressure. Within proper clinical settings we can ensure there is appropriate patient screening, preparation, monitoring and follow up care, which will help to substantially mitigate these risks, providing a risk/benefit package that compares favourably with other treatment methods common in psychiatry.

If these novel therapies are to come more widely available, re-orientation of public perception of these drugs will be required. Understanding more about the acceptability of different treatment options is important in all areas of medicine but is an under researched and hugely important area, especially in psychiatry. The promise of new therapies such as psychedelic assisted psychotherapy offers the opportunity to revisit the concept of the ‘engaged and informed patient as an active decision maker’ in their treatment. They also offer the possibility of providing both practitioner and patient the opportunity of having a ‘shared meaning in the treatment process.’ Psychedelic assisted therapies, therefore, can help lift up a psychiatric profession who had hoped for a chance to understand, communicate and heal to re-orientate away from the prescription pad to something more meaningful.