Shrinks In Sneakers

Tag: psychedelic

  • 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”. 

  • Can Low-Dose LSD Treat ADHD? A New Study Weighs In

    Can Low-Dose LSD Treat ADHD? A New Study Weighs In

    ADHD (Attention-Deficit/Hyperactivity Disorder) affects millions of adults worldwide, with stimulants like methylphenidate and amphetamine being the most effective treatments. But could psychedelics like LSD offer an alternative? A new randomized clinical trial aimed to find out.

    👉 Study Overview:

    • Design: Multicenter, double-blind, placebo-controlled trial (N = 53)
    • Participants: Mean age 37 years, 42% female
    • Intervention: Low-dose LSD (20 μg) or placebo twice weekly for 6 weeks (12 doses total)
    • Primary Outcome: Change in ADHD symptoms using the Adult ADHD Investigator Symptom Rating Scale (AISRS)

    💡 Key Findings:

    • Both groups showed significant improvement in ADHD symptoms:
      • LSD group: −7.1 points (95% CI, −10.1 to −4.0)
      • Placebo group: −8.9 points (95% CI, −12.0 to −5.8)
    • ✅ LSD was safe and well tolerated
    • ❌ No significant difference between LSD and placebo in symptom reduction

    🧠 What This Means:
    While low-dose LSD was safe, it didn’t outperform placebo in treating ADHD symptoms. This challenges anecdotal claims about psychedelics for ADHD and reinforces the need for rigorous placebo-controlled trials in psychedelic research.

    📈 Future research may explore higher doses or alternative mechanisms—but for now, stimulants remain the gold standard for ADHD treatment.

    🔗 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2831639

  • When Expectations Matter: Antidepressant Efficacy vs. Psilocybin’s Unique Impact

    When Expectations Matter: Antidepressant Efficacy vs. Psilocybin’s Unique Impact

    It’s always valuable to challenge our own assumptions, especially in areas as complex as mental health treatment. A secondary analysis of a randomized controlled trial, recently published in JAMA Psychiatry, explored the role of treatment expectancies in the efficacy of psilocybin versus escitalopram for depression.

    I’ve often argued that blinding these studies is challenging, and participants are likely to have higher expectations for psychedelics like psilocybin. However, this analysis provides a nuanced perspective.

    While participants did report higher expectations for psilocybin’s effectiveness compared to escitalopram, expectancy only seemed to impact outcomes in the escitalopram group. A stronger belief in escitalopram’s efficacy correlated with better results for those receiving it. In contrast, expectancy didn’t significantly influence psilocybin’s effectiveness.

    Another intriguing finding: individuals with higher pre-treatment suggestibility showed more significant therapeutic responses to psilocybin—a pattern not observed in the escitalopram group.

    Although this is a secondary analysis and not the final word on the topic, it raises fascinating questions. Could psilocybin’s therapeutic mechanisms be less reliant on patient expectations than traditional antidepressants?

    For now, this remains an open question, but I’ll be closely following future research as it unfolds.

    Link to article: https://pubmed.ncbi.nlm.nih.gov/39653344/

  • Breaking the Anxiety Barrier: LSD a Game-Changer for GAD?

    Breaking the Anxiety Barrier: LSD a Game-Changer for GAD?

    Should LSD be considered a treatment for generalized anxiety disorder (GAD)? The results from MindMed’s Phase 2b study suggest it just might be. While this is only one study, and the FDA’s cautious stance on psychedelic-based treatments like MDMA raises questions about future approval, the findings are worth exploring. So, let’s dive in.

    GAD is a fascinating and somewhat controversial diagnosis. Notably, the study excluded participants with major depressive disorder, a condition frequently comorbid with GAD, which raises interesting questions about the choice to isolate GAD. Some in the psychiatric field even challenge the validity of GAD as a distinct psychiatric disease, arguing it reflects broader distress rather than a discrete disorder.

    Psychedelics like LSD are surging to the forefront of psychiatric research, largely because the field is starved for innovation. Decades of research and sophisticated drug development have yielded limited breakthroughs in understanding or treating psychiatric conditions. Meanwhile, society often clings to the hope that complex human behavior and mental health challenges can be reduced to something as simple as a pill you take every 12 weeks. The appeal of psychedelics lies in their potential to disrupt this paradigm—but can they deliver?

    Key Findings:

    1. Dose-Dependent Response:
      • Patients receiving a higher dose (200 µg) of MM-120 showed rapid and sustained improvements in anxiety symptoms.
      • The reduction in anxiety symptoms was statistically significant compared to the placebo group.
    2. Speed of Onset:
      • Improvements were observed as early as two weeks post-dosing, suggesting a rapid therapeutic effect.
    3. Duration of Effect:
      • The anxiety-reducing effects lasted up to 12 weeks following a single administration, indicating long-lasting benefits.
    4. Safety Profile:
      • The treatment was generally well-tolerated, with mild to moderate adverse effects such as headache, nausea, and transient emotional changes. There were no reports of severe adverse events related to the study drug.
    5. Mechanistic Insights:
      • MM-120 appears to modulate serotonin 5-HT2A receptors, leading to enhanced neuroplasticity and emotional processing, which may underlie the observed clinical improvements.

    I’m always interested in the study population and if the researchers selected a group of patients with prior psychedelic use. Here is what I found 

    Participant Screening and Inclusion:

    1. Prior Psychedelic Use:
      • Some participants may have had previous experiences with psychedelics (e.g., LSD, psilocybin, MDMA), as long as such use did not interfere with the integrity of the study (e.g., recent or habitual use, which might influence tolerance or expectations).
      • Individuals with significant past psychedelic use might be excluded to minimize potential biases in response to the trial drug.
    2. Psychedelic-Naïve Participants:
      • The trial likely included a substantial proportion of participants who were psychedelic-naïve, meaning they had never used substances like LSD or psilocybin before.
      • This approach helps ensure that the observed therapeutic effects can be attributed to MM-120 rather than prior familiarity or psychological preparation for psychedelic experiences.

    Why Prior Use Matters:

    • Expectation Bias:
      • Participants with past psychedelic experiences may anticipate certain effects, influencing subjective outcomes like anxiety reduction.
    • Safety and Tolerability:
      • Previous exposure to psychedelics might affect how participants tolerate or respond to the treatment.
    • Generalizability:
      • Including both psychedelic-naïve and experienced individuals helps make the findings applicable to a broader population.

    Implications:

    This study suggests that psychedelic-assisted therapy, especially with compounds like MM-120, has significant potential as a novel treatment for GAD, offering rapid and durable relief after just one dose. These findings pave the way for further research and larger-scale trials.

  • Hallucinogens: A Trip Not Everyone Should Take

    Hallucinogens: A Trip Not Everyone Should Take

    The recent JAMA Psychiatry study, Emergency Department Visits Involving Hallucinogen Use and Risk of Schizophrenia Spectrum Disorder, explored a notable increase in emergency department (ED) visits related to hallucinogen use, with a focus on potential links to the onset of schizophrenia spectrum disorders.

    Key Findings:

    1. Rise in Hallucinogen-Related ED Visits:
      • The number of ED visits due to hallucinogens, including LSD, psilocybin, and MDMA, has significantly risen, particularly among younger populations. This aligns with changing perceptions of these substances in some parts of society.
    2. Connection to Schizophrenia Spectrum Disorders:
      • Individuals who presented at EDs for hallucinogen-related issues were found to have a higher risk of later developing schizophrenia spectrum disorders. The study suggests a potential association between hallucinogen use and triggering or exacerbating underlying psychiatric vulnerabilities.
    3. Demographic Insights:
      • The rise in hallucinogen use and related health complications appears to disproportionately affect young adults and men. These groups may face greater risks due to higher consumption rates and potential genetic predispositions to mental health disorders.
    4. Clinical Implications:
      • Emergency physicians and mental health professionals are encouraged to screen for hallucinogen use during ED visits, particularly in individuals showing early signs of psychosis. Early identification and intervention may help mitigate long-term mental health outcomes.

    This study emphasizes the importance of public health strategies addressing hallucinogen use, including education on potential risks and the establishment of protocols to identify and treat associated psychiatric conditions.

    Link to the article: https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2825649

  • Embracing the End: Why Psychedelics Are the Future of Compassionate End-of-Life Care

    Embracing the End: Why Psychedelics Are the Future of Compassionate End-of-Life Care

    One of the earliest and most logical places to introduce psychedelic medicine is for end of life and palliative care. It does not come with the same problems as treating patients with depression or other psychiatric disorders as the treatment will be time limited. 

    Here are some of the benefits based on the current research

    1. Psychological Benefits

    • Reduction in Anxiety and Depression: Several studies, particularly those using psilocybin, have demonstrated significant reductions in anxiety and depression in patients with terminal illnesses like cancer. These effects are often long-lasting, with benefits persisting for months after a single treatment session.
      • A notable 2016 study published in The Journal of Psychopharmacology showed that 80% of cancer patients treated with psilocybin experienced significant reductions in anxiety and depression, with some reporting a renewed sense of life meaning.

    2. Spiritual and Existential Distress

    • Psychedelics, especially psilocybin and LSD, are reported to induce mystical or transcendent experiences, which many patients describe as spiritually meaningful. This has been associated with reduced existential distress and increased acceptance of mortality.
      • Participants in several trials often report a greater sense of interconnectedness, enhanced life meaning, and a reduced fear of death.

    3. Enhanced Quality of Life

    • Beyond symptom relief, psychedelics have shown potential in improving overall quality of life. Patients often report improvements in emotional well-being, social connections, and the ability to engage with their loved ones, which are critical in end-of-life care.
      • In studies, patients often describe a greater ability to process emotions related to their diagnosis, leading to enhanced peace and emotional resilience.

    4. Safety and Low Abuse Potential

    • When administered in controlled, therapeutic settings, psychedelics like psilocybin are generally well-tolerated with minimal side effects. This contrasts with the stigma and misconceptions surrounding their use. Studies also emphasize the low risk of dependence or misuse, particularly in these clinical contexts.

    5. Mechanism of Action

    • Psychedelics are believed to work by temporarily disrupting the default mode network (DMN) in the brain, which is involved in self-referential thinking and rumination. This disruption may facilitate shifts in perspective, reducing the obsessive focus on illness and death that can fuel anxiety and depression in terminal patients.

    6. Therapeutic Process

    • Psychedelics are not stand-alone treatments but are typically administered in the context of guided therapy sessions. These sessions help patients integrate their psychedelic experiences, allowing them to explore their fears, emotions, and relationships in a supportive environment.

    7. Legal and Regulatory Considerations

    • Despite promising results, the legal status of psychedelics limits widespread use. However, growing clinical interest has led to “compassionate use” cases and expanded research protocols under FDA guidelines, signaling potential shifts in policy.

    Overall, the evidence suggests that psychedelics, particularly psilocybin, could provide significant psychological and existential relief for individuals facing end-of-life distress, although more research is needed to fully understand the scope of benefits. 

  • The Dirty Little Secret They Won’t Tell You About Psychedelics

    The Dirty Little Secret They Won’t Tell You About Psychedelics

    It’s obvious to me, but I think the public, including many of our patients, remains unaware of a crucial truth: Psychedelics will not cure your depression, your PTSD, or your difficult life circumstances.

    There’s a growing wave of enthusiasm around psychedelics as miracle cures for mental health conditions, but the hard reality is that the evidence just doesn’t back it up—at least not yet. Even if you find yourself on the hopeful side, believing we desperately need alternatives to alleviate people’s suffering, the reported benefits of these substances have not been validated by large, rigorous, randomized controlled trials. The buzz around psychedelics often overshadows the fact that they lack the necessary scientific backing to support their mainstream use in treating complex mental health issues like depression or PTSD.

    Let’s not ignore the financial stakes here either: The people promoting these drugs stand to make billions of dollars. There’s a lot of money on the table, and many in the academic community are rallying behind these companies. But we should ask ourselves—are they doing so because of solid science or because of the potential financial windfall?

    These drugs have been around for decades, yet one consistent truth I’ve observed in every person I’ve known who’s used them is this: You must use them repeatedly, and they almost always experience a relapse of symptoms over time. There’s no permanent fix here, just a temporary reprieve, if even that.

    We can draw parallels with other treatments like ECT (electroconvulsive therapy) and ketamine. Both have shown promise in certain cases, but I’ve yet to see anyone cured by these treatments. We often perform maintenance ECT and maintenance ketamine therapy for this very reason. Just like psychedelics, they might offer temporary relief, but they don’t provide long-term solutions without ongoing interventions.

    I understand this may come off as cynical, but I’ve seen too many people fall for the hype, only to be disappointed later. People far more charismatic than me will try to convince you that psychedelics will cure everything that ails you—for a hefty price tag. Don’t buy into it without questioning the science and the motives behind the push.

  • Psilocybin Outshines Escitalopram: A Breakthrough in Depression Treatment

    Psilocybin Outshines Escitalopram: A Breakthrough in Depression Treatment

    The article Effect of psilocybin versus escitalopram on depression symptom severity in patients with moderate-to-severe major depressive disorder: observational 6-month follow-up of a phase 2, double-blind, randomised, controlled trialreports findings from an extended observation period on the comparative effects of psilocybin and escitalopram in treating depression. Here are the key points:

    Study Design: This was a 6-month follow-up of a Phase 2, double-blind, randomized controlled trial. It compared the effects of psilocybin (a psychedelic compound) and escitalopram (a common SSRI) on depression symptoms in patients with moderate-to-severe major depressive disorder (MDD).

    Participants: Patients with moderate-to-severe MDD were randomly assigned to either psilocybin or escitalopram groups. Both treatments were administered in a controlled clinical setting

    Primary Outcome: Depression symptom severity was measured using the QIDS-SR-16 (Quick Inventory of Depressive Symptomatology–Self-Report) scale at various time points, including baseline, during the treatment phase, and at the 6-month follow-up.

    Results:

    Both groups showed improvement in depression symptoms, but the psilocybin group had a greater reduction in symptoms compared to the escitalopram group.

    The effects of psilocybin were found to be more rapid and sustained over the 6-month period.

    Remission and Response Rates: A higher proportion of patients in the psilocybin group achieved remission and clinically significant response compared to those in the escitalopram group.

    Safety and Side Effects: Both treatments were generally well-tolerated. However, psilocybin was associated with transient, mild-to-moderate side effects, mostly during the acute phase of treatment (e.g., perceptual disturbances).

    Conclusion: Psilocybin demonstrated more pronounced and longer-lasting antidepressant effects compared to escitalopram at the 6-month follow-up. This suggests that psilocybin could be a viable alternative treatment for moderate-to-severe depression, but further research is necessary to confirm long-term safety and efficacy.

  • Matthew Perry’s Doctors Charged

    Matthew Perry’s Doctors Charged

    Everyone told me not to comment on this situation a few months ago and here we are:

    Recent developments in the case of Matthew Perry’s death have taken a serious turn as two doctors have been charged with the illegal distribution of ketamine. The charges allege that these physicians were involved in prescribing the powerful anesthetic, known for its potential misuse as a recreational drug, outside the bounds of medical necessity.

    This case has raised significant concerns about the role of medical professionals in the broader issue of prescription drug abuse. Ketamine, while valuable in certain psychiatric contexts such as treatment resistant depression, carries a high risk of abuse and dependence, making its distribution tightly regulated.

    The charges against Perry’s doctors highlight the ongoing challenges in ensuring that powerful medications are prescribed responsibly and underscore the need for stricter oversight in the medical community. The legal proceedings will likely shed more light on the extent of the alleged misconduct and its impact on Perry and others.