From LSD and mushrooms to ketamine, journalists are falling all over themselves to proclaim hallucinogens and other less-than-legal drugs the next big thing in psychotherapy. Are they hyped up about psychedelics because they're writers (you know the stereotype), or because there's a massive shift in the way medical professionals approach mental health issues? Are psychiatrists actually switching up the drugs they use to treat patients?
Put another way (to quote Placebo's hit, "Special K"): "Can this savior be for real?" Psychiatrists shared some of their opinions on the state of drugs in treatment.
The current state of antidepressants
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) revolutionized depression treatment, as well as pop culture, in the late 1980s and 1990s. Prior to that, it was kind of the Wild West when it came to mental health treatment.
"Up until the 1950s, there was no good way to treat depression with medicine," says Dr. Peter Kramer, clinical professor of psychiatry at Brown University and author of Listening to Prozac and Ordinarily Well: The Case for Antidepressants. "People would be on opium or amphetamines, and the great breakthrough in the 1950s was drugs developed to treat tuberculosis that perked up people on the sanitorium ward. It's extraordinary that in the past 60 years, we've had effective drugs for depression."
"Our antidepressant responses are barely better than placebo."
"Extraordinary" is probably an understatement, given that people have been living and dying with depression for as long as consciousness has existed. The fact that drugs may help treat that at all is by itself revolutionary, and right now, if you see a psychiatrist for depression, there's a good chance you'll leave with a 'scrip for Prozac, Zoloft, Effexor, or Cymbalta.
Problem is, these drugs sometimes suck at treating depression. "Our antidepressant responses are barely better than placebo," says Dr. James Greenblatt, a psychiatrist and chief medical officer at Walden Behavioral Care in Waltham, Massachusetts. "Their effectiveness is quite limited -- around 50% for mild to moderate depression. And a placebo response is close to 40%."
Dr. Kramer doesn't agree. He believes the studies were flawed. "Some of the studies clearly picked adverse trials and some of the statistical methods are prejudicial to the medicine," he says. "All the important studies have special virtues and special flaws. Because journalists don't like to be on the same side as pharma -- and neither do I -- we like to read about worry more than reassurance."
It's a slippery field to navigate; on the one hand, drug companies make medicines that help a lot of people… but on the other, they don't always make themselves look like the good guys. For these and other reasons, consumers and researchers have concluded that antidepressants aren't helpful, Dr. Greenblatt says, opening the door for treatments that are a little trippier. "The field is desperately looking for alternatives," Dr. Greenblatt says.
So what kind of antidepressant alternatives are out there?
Right now, not a whole lot, at least not legally. This can lead to instances of radical self-treatment. "We hear stories of people taking MDMA at a rave and healing themselves," says Natalie Lyla Ginsberg, policy and advocacy manager for the Multidisciplinary Association for Psychedelic Studies (MAPS). "Sometimes that happens, but sometimes it does not."
"Once the bad is greater than the good, it's not therapeutic."
MDMA -- which you might know as ecstasy, or, in its crystalline powder form, molly -- was synthesized by Merck in 1912. Until the 1980s, when the DEA classified it as a Schedule 1 narcotic, it was a tool for couples therapy, treatment of PTSD, phobias, and more. "Therapists, faith leaders, and doctors who had seen how tremendously healing and safe it was in therapy protested [the DEA's decision]," Ginsberg says, but MDMA has remained a Schedule 1 narcotic.
Some psychiatrists feel MDMA is a double-edged sword: it creates a surge of serotonin that makes users feel better in the short term, but the ensuing serotonin depletion can exacerbate depression, according to psychiatrist Dr. Dion Metzger.
"The issue with controlled substances such as MDMA and other psychedelics is that their harmful effects outweigh the benefits," Dr. Metzger says. "Once the bad is greater than the good, it's not therapeutic."
And there are certainly no examples of other legal prescription medications leading to accidental death or addiction or anything. Oh, wait... there are.
Recently, however, the DEA has approved studies sponsored by MAPS that will test MDMA's efficacy as a psychotherapeutic tool. "Our main priority now is developing MDMA and cannabis into prescription medicines through the FDA process," Ginsberg says.
If all goes according to MAPS' plan, molly might be legal by 2021.
LSD and shrooms might be options, too
Like MDMA, LSD currently has no approved medical uses in the United States, but its therapeutic potential has researchers intrigued. In addition to MAPS' work researching the drug, scientists in the United Kingdom earlier this year published the first images of a brain on LSD.
Though it was a small study, anyone can see that the tripping brains were totally lit up, which the researchers described as evidence of a "more unified brain." Basically, LSD seems to allow various parts of the brain to communicate in new ways, which may explain the religious or spiritual description many people give to their trips, as well as the new insights and sense of well-being some people experience following their comedown.
And the drug hits just keep on coming! Also this year, a study in Nature found that psilocybin -- known in dorm rooms as shrooms -- lifts depression in people who have suffered from the disease for, on average, nearly 18 years. Again, it's a small study, but offers a significant amount of hope for people who have found no relief from current drug options.
Clearly there is a long way to go from now to a commercial telling you to ask your doctor if taking acid or molly is right for you, but there's enough promise to get at least a little excited.
If LSD and molly aren't your jam, consider ketamine
So, right now you can't legally roll or trip with your psychiatrist. But they can put you in a K-hole! People who are "treatment-resistant" -- meaning they've tried multiple antidepressants without any results -- are candidates for ketamine therapy: psychiatrist-led IV drips of the dissociative drug. And unlike SSRIs, ketamine therapy actually works for many with depression who don't respond well to other treatments.
"The data is so far very promising as far as ketamine being a fast antidepressant that also can reduce suicidal thoughts," Dr. Metzger says. "That is huge… This is one of the biggest breakthroughs in psychiatry within the past 50-plus years."
"Using an old drug in a new way is showing promise and forward thinking in a field that tends to stay static."
Dr. Theodore Henderson runs a ketamine clinic in Centennial, Colorado, where he's treated more than 400 patients over the past four years. More than 80% of his patients showed improvement, he wrote in a study he authored this year. "We followed these patients for 36 months, and they continue to be symptom-free," Dr. Henderson says. "I have had zero people become addicted to ketamine. It is truly a game-changer in psychiatry."
One of the benefits of ketamine is that, unlike LSD and MDMA, it's been legal and studied as an anesthetic since 1970, and has been found to be both effective and safe enough for kids. "Using an old drug in a new way is showing promise and forward thinking in a field that tends to stay static and repetitive in the way of treatments," says Dr. Wendy Boring-Bray, a professor of behavioral/mental health at the Cummings Graduate Institute for Behavioral Health Studies.
On the down side: ketamine therapy is expensive -- about $800 per treatment at Dr. Henderson's clinic. That may explain why so many people are smuggling K from Mexico, which for the record is a pretty terrible idea for a lot of reasons.
What does it really mean to "fix" a depressed brain?
SSRIs and and SNRIs might have failed due to a fundamental misunderstanding of the brain. Depression has nothing to do with a lack of serotonin, Dr. Henderson argues -- "That's a bunch of malarkey we were sold." -- and everything to do with a degenerative process. "Depression destroys the brain," he says. "Circuits fail. Dendrites break down. If I can reverse that degenerative process with ketamine, I can treat depression. And this is what I have found in my patients."
Reversing the degenerative process is exactly what ketamine does: it's a powerful activator of a brain-healing factor called brain-derived neurotrophic factor (BDNF), Dr. Henderson claims. "BDNF is a brain repair factory," Dr. Henderson says. "When an animal gets BDNF, they start making new synapses."
Where do we go from here?
Because it's still in its early stages as a depression treatment, ketamine usually isn't covered by insurance. As for the psychedelics, most of the research is still in its earliest phases, and there's nowhere near enough data to convince the DEA to change its enforcement policies anytime soon.
"It's definitely too soon to tell [whether psychedelics can treat depression]," Dr. Kramer says. "The real psychedelics -- we don't know at all what is going on with them. The studies are flawed. Ketamine looks promising, but doctors don't know what these medicines look like until they get to use them on a regular basis."
Maybe one day this will change, but in the meantime, it's important to remember psychedelic therapy is just one tool in a mental health professional's wheelhouse.
"[Psychedelic therapy] is not a magic bullet on its own, but it has the potential to shift how an individual looks at their situation and illness," Ginsberg says. "It's about addressing the root cause of the issue and healing instead of numbing. That does involve going through more pain, but I think it's the only way to heal."
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