The future of psychedelic psychiatry
If psychedelic compounds become approved for the treatment of psychiatric conditions, psychiatrists will likely be responsible for prescribing them and managing patients who receive them.21Table 211,21-24 summarizes practical considerations for psychiatrists who may someday be prescribing psychedelic drugs. Areas of psychedelic treatment in which psychiatric expertise is necessary include:
- screening for patients at increased risk for a challenging or adverse experience or “bad trip”
- conducting a thorough informed consent process in which the risks are discussed and the patient’s wishes regarding potential situations are elicited
- managing acute medical and psychiatric complications, including agitation and violent behavior
- ensuring the use of trained guides during sessions.
Psychiatrists who are interested in providing psychedelic-assisted therapy should understand the concept of “set and setting,” which was defined by Timothy Leary in the 1960s and is thought to play an important role in determining the types of experiences that arise during a psychedelic session.25 “Set” refers to an individual’s mindset going into a session, and “setting” refers to the environment in which the session occurs. Typical elements of each are summarized in Table 3.7 Psychiatrists will play a critical role in assessing and preparing the “set” by screening patients appropriately, assessing patient goals, and providing a thorough informed consent procedure. Psychiatrists should also be mindful of the “setting,” providing a comfortable, safe, familiar environment and access to appropriate music and eyeshades, if desired. Due to time restraints, psychiatrists are not likely to be responsible for guiding patients through sessions, and should educate themselves about ethical practices of psychedelic guides,if they are in the position to hire guides.23,24
Psychiatrists may also play a role in providing psychotherapy to patients receiving treatment with psychedelics. These substances can induce both transcendent and terrifying experiences. Patients therefore require “integration” therapy sessions to assist with processing the content of their psychedelic treatment and incorporating the experiences into day-to-day life. In an online survey of nearly 2,000 individuals who used psilocybin recreationally, 7.6% reported that they had to seek treatment for enduring psychological symptoms that they attributed to their psilocybin use, including persistent anxiety, fear, paranoia, and depression.26 Integrative psychotherapy sessions may help reduce the risk of persistent negative effects from therapeutic psychedelics, as well as enhance their beneficial effects.
CASE CONTINUED
Mr. P is enrolled in the academic medical center study assessing the effect of psilocybin on terminal illness-related anxiety and depression. During a 5-hour, 30-mg psilocybin session, he initially experiences distorted visual cues, with vivid, colorful geometric patterns collapsing into each other. He then loses the concepts and experience of time, space, and his body, as his visual distortions convert to darkness. After what seems like a decade within the darkness, he sees himself lying in a hospital bed with loved ones surrounding him. He watches himself take his last breaths and his family members weep as he dies. As he regains his senses, Mr. P feels that he is being reborn.
In the therapy sessions that follow the psychedelic session, Mr. P reports feeling “finally freed” from the fear, sadness, and anger that he has felt throughout his life. He comes to accept his impending death with gratitude and peace. In his final days, he no longer experiences depression or anxiety. Mr. P’s friends and family members comment that he seems to be the best version of himself in the months that lead up to his death.
Related Resources
• Nutt D. Psychedelic drugs-a new era in psychiatry? Dialogues Clin Neurosci. 2019;21(2):139-147.
• Garcia-Romeu A, Kersgaard B, Addy PH. Clinical applications of hallucinogens: a review. Exp Clin Psychopharmacol. 2016; 24(4):229-268.
Drug Brand Names
Amitriptyline • Amitril, Elavil
Bupropion • Wellbutrin
Fluoxetine • Prozac
Sertraline • Zoloft
Bottom Line
Psychedelics are a class of consciousness-altering agents that have become a potentially promising source of new treatments for psychiatric illness. Although more evidence is needed, compounds such as psilocybin may one day become FDAapproved for conditions such as terminal illness–related depression and anxiety, and substance use disorders. When this occurs, psychiatrists should be responsible for prescribing psychedelics and managing patients who receive treatment.