The Promises and Pitfalls of Psychedelics

There has not been a mental health subject that has gotten more attention in recent years than psychedelics. It seems like they are a cure for everyone. In the medical literature, we are seeing positive results in many patient populations, from treatment-resistant depression, to drug addiction and post traumatic stress disorder. Outside of medicine, people are using psychedelics both recreationally and for self-improvement. Here, psychedelics are touted to help you connect to the divine and to an empathy and compassion that previously had been out of reach. Because I am so aware of the limitations of psychiatry, it is hard not to get my hopes up. For this reason, I have been very receptive to learn more and increase my exposure to psychedelics. This has included talking with patients, friends and colleagues about their experiences, both personally and professionally.

With what I have gathered so far, I am still hopeful for the change psychedelics could bring, but I am also conflicted. There are more caveats to these substances than I anticipated. For example, you get different results with different doses. There is microdosing where the amount is so low as to be imperceptible, and then there is the transformational dose, a much higher amount given to achieve a psychedelic experience, or "a trip". And then there are the doses in between. I also did not realize how the outcomes from psychedelics are so variable and unpredictable in large part based on the context in which a person is taking these substances.

People who take larger amounts of psychedelics in a safe environment and surrounded by people they trust, stand to gain more than those who take psychedelics in any other circumstances. Among clinicians who work with psychedelics, it is understood that they work best and have the most profound impact when paired with a specific kind of human connectedness during and after the experience. This can be in a group setting with others who have used psychedelics, known as an integration circle, or in individual therapy, known as psychedelic-assisted psychotherapy. It has been said that this kind of therapy is like doing regular therapy but on steroids. Gains that take years can take place over 4-6 sessions when psychedelics are involved.

But these conditions are not so easy to achieve and are then only accessible to a privileged minority. Everyone else is using psychedelics recreationally and at frequencies and doses not well-researched. We therefore have no information on the benefits here or the longer term effects. The burden of this ignorance falls to our most vulnerable: youth and marginalized groups.

In the past year, I have treated two separate, unrelated patients with their first episodes of psychosis in the context of a single high dose of psilocybin. Both of these patients took the drug with their romantic partners, both of whom happened to be physically abusive. Both patients became psychotic, but their presentations were very unusual compared to other first episode patients. First, they were female, and second, when they recovered from the acute intoxication, even on antipsychotic treatment, their psychotic symptoms never went away. These women were able to return to work and function in their lives, but the violent intrusive thoughts and auditory hallucinations stayed with them. In these cases, increasing access to psychedelics will exacerbate vulnerabilities, and for the worse. This means for those living with violence and instability, who seek solace or escape with psychedelics, may find instead their worst fears magnified.

So here in lies the conflict. It does not seem fair to promote a treatment that disproportionately harms our worst off. It is also not fair to withhold good, effective treatment from those who could benefit. Being with and in the middle of these two populations can feel like an uncomfortable, unplacatable co-existence. Interest in psychedelics is coming up with increased frequency in all of my patients from all backgrounds. And though it would be simpler to serve just one of these populations, to do so comes at the expense of other, typically more vulnerable groups. The conversation around psychedelics has put a spotlight on how careful we need to be around the messaging and availability of psychedelics. We also can not afford having psychedelics take resources and individual accountability away from tried and true health care measures that are more universal in their benefit with much less harm. These interventions include regular exercise and a healthy diet; less screen time; improving housing stability and affordability; and investing in planetary health and the environment. They take more work and are less sexy, but they work to create the foundation of good individual and societal mental and physical health, where psychedelics do not.