Shrinks In Sneakers

Category: Op-Eds

Opinion editorials and provocative commentary on psychiatry, mental health policy, and clinical practice.

  • When Culture Moves Faster Than Science: Psilocybin Is Already in Your Clinic

    When Culture Moves Faster Than Science: Psilocybin Is Already in Your Clinic

    Here is what happens when culture moves faster than science.

    Before psilocybin becomes an FDA-approved treatment, before every safety question is answered, before we know how to responsibly scale psychedelic-assisted therapy, millions of Americans are already using it.

    According to a newly published analysis of the 2024 National Survey on Drug Use and Health, approximately 2.8% of Americans age 12 and older reported using psilocybin in the past year, corresponding to roughly 8 million people nationally. The study analyzed survey data from 58,633 respondents, and 2024 was the first year NSDUH included psilocybin-specific questions. 

    This is important, not because every person using psilocybin is doing something dangerous. Not because psilocybin has no therapeutic potential. The emerging research signal in depression, treatment-resistant depression, and substance use disorders is real enough to deserve rigorous study. In fact, the FDA recently announced regulatory actions intended to accelerate development of psychedelic-related treatments, including psilocybin for treatment-resistant depression and major depressive disorder. 

    But the problem is this: public enthusiasm is not the same thing as clinical evidence.

    And right now, the public is not waiting for the randomized controlled trials to finish.

    The survey found that psilocybin use was more common among males, young adults ages 18 to 25, and college-educated individuals. It was also strongly associated with use of cannabis, LSD, ketamine, and MDMA. 

    Most importantly for psychiatrists, psilocybin use was not randomly distributed across the population. People with a past-year major depressive episode were more likely to report psilocybin use. So were individuals with alcohol use disorder. 

    Because this means the people most likely to be experimenting with psilocybin are not necessarily the healthy, psychologically stable adults often imagined in wellness culture. They may be the very patients already sitting in our offices: depressed, anxious, drinking heavily, using cannabis, struggling with treatment resistance, frustrated with conventional psychiatry, or searching for something that feels more meaningful than another medication adjustment.

    This is where psychiatry has to grow up.

    The easy response is dismissal. “It’s illegal.” “It’s recreational.” “It’s just another drug trend.” That response will fail because it ignores what patients are already doing.

    The equally dangerous response is romanticization. “It’s natural.” “It’s ancient.” “It expands consciousness.” “It heals trauma.” That response also fails because it replaces medical evidence with cultural mythology.

    The clinical response has to be more serious than both.

    Psilocybin used in a controlled clinical trial is not the same thing as psilocybin used at home, at a retreat, at a party, in combination with cannabis, alcohol, MDMA, ketamine, or while taking serotonergic medications. Clinical trials involve screening, standardized dosing, structured preparation, psychological support, monitoring, and follow-up. Naturalistic use often has none of those safeguards.

    A patient with depression using psilocybin outside a clinical setting may be doing so because they are desperate, not because they are reckless. But desperation does not eliminate risk. Psychedelic experiences can be psychologically destabilizing. They can worsen anxiety, trigger panic, create prolonged distress, or complicate underlying bipolar spectrum illness, psychosis vulnerability, trauma symptoms, or substance use disorders.

    This does not mean psychiatrists should lecture patients.

    It means we should ask better questions.

    Not: “Are you using drugs?”

    But:
    “Have you used psilocybin, mushrooms, ketamine, MDMA, LSD, or other psychedelic substances in the past year?”
    “What were you hoping it would help with?”
    “What happened during and after the experience?”
    “Did you use it alone or with others?”
    “Were alcohol, cannabis, or other substances involved?”
    “Did it change your mood, sleep, anxiety, impulsivity, suicidal thoughts, or sense of reality afterward?”
    “Are you planning to use it again?”

    That is not endorsement. That is clinical reality.

    Whether psilocybin eventually becomes an FDA-approved psychiatric treatment or not, psychiatrists are going to see more patients who have used it, are considering using it, or believe it has already treated their depression, trauma, addiction, or existential distress.

    We need to be ready for that conversation.

    The future of psychedelic medicine should not be driven by excessive enthusiasm, venture capital, wellness influencers, or reactionary fear. It should be driven by careful science, honest risk assessment, clinical humility, and respect for the fact that patients are already making decisions before the field has reached consensus.

    Culture has moved first.

    Science is catching up.

    Psychiatry needs to be in the room before the narrative is written without us.

    Psychiatry Unfiltered

  • The psychedelic conversation in psychiatry is at an inflection point

    The psychedelic conversation in psychiatry is at an inflection point

    I believe these treatments deserve serious study. In fact, some of the most promising work in modern psychiatry is happening in this space. Psilocybin has FDA breakthrough therapy designation for treatment-resistant depression, MDMA-assisted therapy has shown meaningful promise in PTSD, and ibogaine is generating legitimate research interest in opioid use disorder and traumatic brain injury. 

    But promise is not proof.

    In my new Psychiatric Times article, I make the case that psychedelics deserve real science, not political shortcuts, podcast-driven enthusiasm, or regulatory acceleration built on weak evidence. The core issue is not whether we should study these compounds. We should. The issue is whether observational data, open-label studies, and viral claims are being asked to carry more weight than they should. 

    When a treatment has real risks, especially one like ibogaine with known cardiac concerns, the answer cannot be to lower the evidentiary bar. It has to be to raise the quality of the research. That means adequately powered randomized trials, careful safety monitoring, standardized outcomes, and enough humility to admit what we do not yet know. 

    Psychiatry does need better tools. Our patients need them badly. But if we want innovation that lasts, it has to be built on rigor, not hype.

    My latest piece in Psychiatric Times: “Psychedelics Deserve Real Science”. 

  • We say we care about mental health in America

    We say we care about mental health in America

    We say we care about mental health in America.
    But the data—and my front-line experience—say otherwise.

    We are overmedicating, underfunding, and pathologizing poverty, trauma, and stress.
    Instead of addressing why people are sick, we throw pills at symptoms.

    🧠 In my latest article for Psychiatric Times, I make the case that we’ve built a system that profits off disease—not health.
    We’re not solving the problem. We’re institutionalizing it.

    If we want to make America healthy again, we need to stop doing the wrong things.

    👉 Read the full piece here: https://www.psychiatrictimes.com/view/if-we-want-to-make-america-healthy-again-we-are-doing-the-wrong-thing

  • Understanding Psychiatry: Science vs. Skepticism

    Understanding Psychiatry: Science vs. Skepticism

    🧠 “Psychiatry is a scam.” “Big Pharma controls your brain.” “Mental illness isn’t real.”

    You’ve heard the takes. Now here’s the truth.

    In my new article for Psychiatric Times, I dive headfirst into the controversy:
    👉 Understanding Psychiatry: Navigating Skepticism and Science
    https://www.psychiatrictimes.com/view/understanding-psychiatry-navigating-skepticism-and-science

    I don’t dodge the hard questions—about overmedication, broken trust, and bad science—but I also push back against lazy anti-psychiatry takes that ignore the very real suffering of patients.

    If you care about the future of mental health care, this one’s worth your time.

  • Reject dogma—embrace nuance in Psychiatry

    🔹 Psychoanalysis should not be treated as sacred doctrine. Freud was a clever and influential thinker, but not a prophet.


    🔹 Biological psychiatry is equally vulnerable to dogma. Not every symptom signals a disease, and not every distress warrants medication.


    🔹 That said, evidence-based pharmacology has its place—especially when medications show clear, replicable benefits in defined clinical conditions.

    The future of psychiatry lies in balanced thinking, not blind allegiance—to Freud, to biology, or to any single model of mind.

  • The Importance of Distinguishing Suicidal Behaviors

    The Importance of Distinguishing Suicidal Behaviors

    This is the subject of a recent discussion I had with a colleague regarding the differences between a suicide attempt and a suicide gesture. Though these terms are sometimes used interchangeably in casual conversation or even in clinical documentation, they carry fundamentally different meanings—both in terms of patient risk and in how we, as clinicians, should respond.

    Our conversation emerged from a case involving a patient with borderline personality disorder who presented to the emergency department after ingesting a small quantity of over-the-counter medication. The intent was unclear. Was this a serious attempt to end her life? Or was it a gesture—an act of desperation without the intention to die, but rather to communicate emotional distress?

    The question is not academic. Our interpretation of the event determines our risk formulation, our documentation, our treatment planning, and even how we communicate with the patient and their support system. Yet, it is precisely in these gray areas that clinicians often struggle, and where outdated or stigmatizing language can do real harm.

    Defining the Terms: Clinical and Functional Differences

    A suicide attempt refers to an act of self-harm with at least some intent to die. The degree of lethality may vary, but what distinguishes an attempt is that the individual believed the act could result in death and engaged in it with that goal in mind—even if ambivalence was present. The National Institute of Mental Health (NIMH) and the Columbia-Suicide Severity Rating Scale (C-SSRS) define this with some specificity: any potentially self-injurious behavior with non-zerointent to die, regardless of outcome.

    In contrast, a suicidal gesture is a behavior that mimics suicidal behavior or appears life-threatening but is typically not intended to be fatal. The function is often communicative or affect-regulating rather than aimed at death. Classic examples include superficial wrist-cutting, ingesting a sub-lethal dose of medication, or tying a noose but not tightening it. These acts often occur in interpersonal contexts and can be seen as efforts to signal pain, elicit help, or assert control in the face of perceived abandonment.

    Why the Distinction Matters

    It might be tempting to dismiss suicidal gestures as “attention-seeking” or “manipulative,” but this framing is both clinically dangerous and ethically fraught. Individuals who engage in gestures often experience intense psychological suffering, and repeated gestures are a well-established risk factor for future suicide attempts and completed suicide.

    From a risk assessment standpoint, gestures should be taken seriously, especially when they become part of a pattern. While the intent to die may not be present in a given gesture, intent can shift quickly, particularly in individuals with mood disorders, personality pathology, or under the influence of substances.

    From a treatment perspective, understanding the function of the behavior—whether it is to relieve affective tension, to communicate distress, or to punish oneself—is crucial to tailoring interventions. For instance, dialectical behavior therapy (DBT) explicitly targets self-harm and suicidal gestures as part of its hierarchy of treatment priorities, recognizing the urgency and potential danger of these behaviors even when lethality is low.

    Conclusion: Clarify, Don’t Categorize

    Ultimately, the conversation with my colleague reminded me that the real clinical challenge is not to label a behavior as a suicide attempt or a gesture, but to understand its meaning in the life of the patient. Both require empathy, structure, and a willingness to engage with complexity. Whether a patient wants to die or wants their suffering to be seen and acknowledged, both deserve serious clinical attention.

    By sharpening our definitions and approaching these behaviors with nuance, we can better serve patients in crisis and avoid the pitfalls of assumptions—especially in emotionally charged clinical environments like emergency rooms, inpatient units, or high-acuity outpatient settings.

  • RFK Jr. Claims He’ll Identify the Cause of Autism by September

    RFK Jr. Claims He’ll Identify the Cause of Autism by September

    In a bold statement this week, Robert F. Kennedy Jr. announced that he will reveal the definitive cause of autism by September. Kennedy, a longtime critic of childhood vaccine programs, did not provide specific scientific details or a research plan, but implied that his administration would prioritize transparency and independent investigations into the condition’s origins.

    The claim has sparked immediate controversy. Autism is a complex neurodevelopmental condition with a strong genetic foundation and a wide range of potential environmental influences—none of which have yielded a singular, definitive cause. The scientific consensus, built over decades of rigorous research, continues to support a multifactorial model rather than a simplistic explanation.

    Many highly intelligent and dedicated scientists have spent years studying autism without identifying a single, unifying cause. One of the recurring issues that arises when politics intersects with science is a resistance to the idea that these are nuanced, multifaceted conditions. It’s not the most satisfying explanation—but it is consistent with the best evidence we have. My fear is that this type of investigation, under political pressure, could prematurely identify a false causal agent—such as vaccines—and reignite a harmful narrative that has already been thoroughly debunked.

    Kennedy’s history of promoting vaccine-autism links adds further concern. The CDC, WHO, and a vast body of peer-reviewed research have all concluded there is no credible evidence connecting vaccines to autism. Suggesting otherwise not only undermines public trust in science and medicine—it risks the health of entire communities by fueling vaccine hesitancy.

    For families and individuals affected by autism, the promise of discovering its origins is understandably compelling. But it’s critical that we approach that pursuit with scientific integrity, not political expediency.

  • Major Federal Healthcare Cuts: What Physicians Need to Know and How We Can Respond

    Major Federal Healthcare Cuts: What Physicians Need to Know and How We Can Respond

    A devastating blow to public health: More than $12 billion in federal grants—funding that supported infectious disease tracking, mental health services, addiction treatment, and other critical programs—has been canceled as part of recent federal budget cuts.

    These cuts threaten early detection of outbreaks, access to psychiatric care, and lifesaving addiction treatment programs—all areas where we, as physicians, see the impact daily.

    Key Areas Affected:

    🚨 Infectious Disease Surveillance – Reduced ability to track emerging threats like COVID-19, flu, and antibiotic-resistant infections.
    🧠 Mental Health Services – Fewer resources for crisis response teams, community mental health centers, and psychiatric services.
    💉 Addiction Treatment – Less funding for MAT (medication-assisted treatment) and harm reduction programs at a time when overdose rates remain high.
    🏥 Public Health Preparedness – Cuts to pandemic readiness and emergency response training for healthcare workers.

    What Can We Do?

    🔹 Advocate – Contact legislators, professional organizations (APA, AMA, ACP), and demand restoration of funding.
    🔹 Educate – Inform patients and communities about how these cuts impact their care.
    🔹 Mobilize – Work with hospital leadership and local organizations to find alternative funding sources.
    🔹 Collaborate – Strengthen interprofessional partnerships to sustain services despite budget constraints.

    We’ve seen what happens when public health is underfunded—it costs more lives and more money in the long run. We can’t afford to be silent.