Psychedelics are widely known as recreational drugs of abuse, but they have been used in medical contexts for centuries first in Indigenous healing and in research trials starting in the 1950s and 1960s.1,2 Recently, there has been a resurgence of clinical and research interest in hallucinogens for their potential to be used in psychedelic-assisted therapy for the treatment of people with severe psychiatric disorders. During the Family Medicine Forum 2023 in Montreal, Dr. Kathy Do, a family physician in North York, Ontario delivered an overview of the history and evidence for this emerging treatment modality, and practical insights into how psychedelic-assisted therapy is delivered in the clinical context.
What are psychedelics?
The term psychedelic is derived from two Greek words: ‘psyche,’ which describes the soul, mind, and spirit, and ‘delos,’ meaning to manifest or reveal. Dr. Do described psychedelics as chemicals that can help individuals reveal or amplify hidden or inaccessible thoughts, emotions, and perceptions that are not normally accessible during states of wakefulness. Their ability to alter one’s sense of self and of others, and to increase empathy, optimism, interpersonal trust, and openness to transcendent experience, makes them potentially useful in the context of guided therapy.1
Psychedelics can help the mind reveal thoughts that are not accessible during wakeful states
Three psychedelics are currently available in Canada through a Special Access Program or in the context of clinical research trials. They are principally used in patients with treatment-refractory depression, cancer-related anxiety and depression, alcohol use disorder and post-traumatic stress disorder (PTSD).1 Although the body of evidence is growing rapidly, Dr. Do noted that clinical trials are difficult to conduct due to placebo and expectancy bias, and the lack of standard approach to delivery psychedelic-assisted therapy. Nonetheless, she believes that there is reason for cautious optimism given the considerable burden of disease and limited advancements for treatment of the most recalcitrant cases of severe psychiatric diseases.
Psychedelic-assisted therapy has been investigated in numerous treatment-refractory psychiatric illnesses
Are psychedelics safe?
Although psychedelic agents are physiologically safe, some have been associated with a potential for addiction, but not uncontrollable drug-seeking behaviour.1 According to Dr. Do, it is critically important to educate patients interested in psychedelic-assisted therapy on the importance of context since subjective effects depend on the environment in which it is delivered, treatment expectations, and the approach to supportive therapy.1,2 Importantly, in a non-clinical environment, psychedelics could lead to a “bad trip” or risky behaviour.1 Dr. Do is a medical consultant for a multidisciplinary clinic that delivers psychedelic-assisted therapy, and her role is to carefully vet patients for their candidacy for this approach to ensure there are no contraindications or unacceptable risks of psychological adverse effects (e.g., anxiety, fear, paranoia, and psychosis, which is rare).1
Patients are carefully screened by medical professionals to ensure there are no contraindications to psychedelic-assisted therapy
How does psychedelic-assisted therapy work?
Psychedelics are thought to work by altering the way the brain processes information. According to the theory of predictive processing, the brain is continuously anticipating and predicting the future based on sensory inputs it has received in the past, including perceptions of the self and others.2 In depressed individuals, this process can be harmful when predictions are overly rigid and inflexible, and negatively colour one’s sense of reality (e.g., rumination). Psychedelics, by increasing brain connectivity, can allow for new information to be processed and for old predictions to be revised.2 This underscores the importance of supportive therapy and a clinical context to guide the process of loosening predictions and increasing cognitive flexibility.
Psychedelics act as a catalyst for therapy by increasing cognitive flexibility and openness to new thought processes
Unlike antidepressant medications which are taken chronically and reduce patient responsiveness to emotions and feelings, psychedelics are given for a limited time and they increase responsiveness by addressing the root causes of emotional distress. According to Dr. Do, a key difference between these two treatment modalities, which have both demonstrated a reduction in depressive symptoms and feelings of well-being, is that psychedelic-assisted therapy facilitates active coping whereas antidepressants offer patients a passive coping strategy.
Antidepressants reduce emotional responsiveness whereas psychedelic-assisted therapy increases responsiveness and active coping
How is psychedelic-assisted therapy delivered?
Although there is variability in how different clinics deliver psychedelic-assisted therapy, Dr. Do described a general framework that consists of four key steps: intake and clearance, preparation, psychedelic sessions, and integration.1 During the intake phase, patients are medically cleared by a multidisciplinary team that rules out contraindications and ensures other treatment modalities have been optimized prior to psychedelic-assisted therapy. During the preparation phase, the patient builds a therapeutic relationship with the therapist and treatment expectations and goals are established. Psychedelic sessions are typically delivered in a relaxed environment that allows patients to internalize their thoughts with a therapist present; this can take several hours. Integration sessions are often conducted the day after psychedelic sessions and the therapist guides the patient in exploring their experience and integrating new insights into the patient’s day-to-day life. While not an explicit part of psychedelic-assisted therapy programs, patients are usually encouraged to continue therapy to help them deal with new challenges.
The four phases of psychedelic-assisted therapy: intake, preparation, psychedelic sessions, and integration
The future of psychedelic-assisted therapy
Dr. Do concluded that psychedelic-assisted therapy has shown promising results in a variety of debilitating psychiatric disorders, but more research is still needed. Ultimately, she sees psychedelic-assisted therapy as another potential tool in the clinician’s toolbox for carefully selected patients. Anecdotally, she has observed overall positive results in her practice, noting that the best outcomes have been in patients who have the most support from not only their therapist, but also from their family and social networks since reliving traumatic experiences can potentially be destabilizing for some individuals.
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
