At a time when medical marijuana and recreational marijuana are being approved across the country, it is no surprise that a resurgence has occurred in modern medicine to form research centers to evaluate the efficacy of psilocybin and MDMA, among other psychedelics, in the treatment of such pervasive mental health conditions such as addictions, PTSD, resistant depression and anxiety.

Some preliminary studies demonstrate that even a single dose or two of a psychedelic can at times provide for efficacy around a month’s duration, without any additional psychedelic treatment. Research into the additive role of psychotherapy shows possible benefits in combining psychedelic treatment with psychotherapy.

There is not currently a test available to determine which antidepressant will best treat an individual’s depression. It has traditionally been apparent that any single antidepressant will work only 70% of the time for the treatment of a patient’s depression. Therefore, if the first pill doesn’t impact depression, another pill should be prescribed, and on and on until the “right” pill is found. Furthermore, this antidepressant daily pill treatment response may take 6 to 8 weeks to demonstrate efficacy, a long time to wait when one is suffering from a severe depression.

Unlike antidepressant pharmacotherapy, psychedelic interventions may act as quickly as within one week after treatment, and last as long as 12 months after only one or two doses. A research article by Gukasyan, et al., at the Johns Hopkins Center for Psychedelic and Consciousness Research notes that “future research is needed to explore the possibility that efficacy of psilocybin treatment in MDD (Major Depression Disorder) may be substantially longer than the 12 months observed in the present study, (and) as has been suggested in a study that documented decreases in depressive symptoms up to 4.5  years following psilocybin treatment in patients with cancer-related distress.”

In the 1980s, psychiatry residents in training were often taught to treat a depressed patient with about 40 psychotherapy sessions and that, if there was no response, an antidepressant would then be warranted. It had once been accepted that psychotherapy with antidepressant medication is more effective than either medication or therapy alone. The former head of the NIMH, Tom Insel, however, has communicated that traditional non-evidence based psychotherapies, such as the intense therapy of four or five times a week psychoanalysis, is not effective. However, when I was trained in psychiatry, it was the prevailing view that therapy and medication together were more effective than either alone.

Some studies now purport that therapy alone is more effective than medication treatment separately. Others believe that medication is more effective than In depth therapy. Certainly Big Pharma wishes to propose this view because of the billions of dollars they reap from FDA approved mental health drugs. One area of further contention is that Insel loudly renounced the DSM Diagnostic Manuel as essentially a sham, decrying that it is not based on science or the structure of the brain. The American Psychiatric Association publicly complained, motivated largely by the millions of dollars each year that the publication drives.

Further complicating the role of medication treatment, whether provided with or separately from psychotherapy, is the fact that some study results are buried by PHARMA if they don’t support the study hypothesis that a medication class or treatment is more effective than the control group. Confirmation bias can occur ubiquitously, where medical scientists see what they expect to see, or report the desired result even if the study doesn’t.

Therefore, in the context of evidence-based treatment, there is still disagreement in the profession about which therapy might be most effective, and which medication might be best augmented by, or augment, the treatment of a patient’s depression. The research on psychedelics, if proven that they are more effective more expeditiously, and after fewer treatments, could have a dramatic impact on the way that psychiatry is practiced. It would be considered unethical to withhold psychedelic treatment from a patient if the research supported using this treatment either alone, or with, psychedelic psychotherapy and if the research demonstrated superior efficacy over all other treatment modalities.

In a Netherlands study, ayahuasca demonstrated acute symptom improvement with a single dose for up to seven days. The persisting positive effects were also demonstrated to occur after only two sessions using psilocybin, with efficacy lasting up to 6 months.

The mechanism of action is still being explored. Psychedelics may exert their effect by resetting the circadian rhythm, or biological clock, in the brain, and the sleep and wake cycles. A hallmark of depression is early morning awakening. By resetting the biological clock, depressed patients may respond to an enhancement of the cognitive behavioral processing system, even enhancing mood in healthy and non depressed patients. Psychedelics are also thought to exert their effect through their interaction with the serotonin receptors in the brain.

There is also evidence that supports the role of the gut microbiome in the efficacy of psychedelic treatment. The microbiome consists of microorganisms throughout the body, leading scientists to proclaim that the human body is composed of more “bugs” than it is human cells. It is thought that there is a two direction communication between the brain and the gut that leads to cerebral impact. CNS function can be influenced by the gut microbiome and the gut microbiome can be influenced by the cerebral brain.

In a study with rats that are free of a gut microbiome population, it was discovered that transplanting a portion of the microbiome from depressed human patients, results in symptoms of depression in the rats. This biological connection between stomach and brain is intuitive, as most people have noticed that when they are under stress it can negatively impact stomach function by causing or exacerbating stomach upset or indigestion.

Psilocybin positive benefits, according to a psychedelic primer, include “increase(d) feelings of unity and transcendence of time and space…however it can also induce anxiety and distressing effects including a dread of ego dissolution … the loss of one’s sense of self.”

If research can help to better understand the psychobiological reasons for adverse experiences, and further elucidate the therapeutic dosage range, and prove superior in efficacy to other antidepressant treatments, then psychiatry will be dramatically changed to utilize these treatments as a formulary priority, over and above other treatments.

In 1979, a renowned nephrologist was admitted to Chestnut Hill, a Maryland psychiatric hospital, with a psychodynamically rich heritage of using talk therapies, to treat a severe episodes of depression. Although this physician was treated with outpatient therapy and medication treatment, and demonstrated improvement with this, his condition worsened when he stopped adhering to his medication prescription, and he required a psychiatric admission. At the time of his admission, Dr. Osheroff was treated for his anxiety and dysphoria with four times a week psychotherapy. A case conference was conducted about his lack of improvement and it was decided to continue psychotherapy alone and not to add medication to his treatment regimen. During his 7 months of hospitalization Osheroff lost 40 pounds, suffered with long term insomnia, and became severely agitated. The latter was so severe that he experienced foot trauma from constantly pacing. Osheroff’s family became upset and transferred him to Silver Hill Hospital, in affluent New Canaan, Connecticut.

At Silver Hill Osheroff was treated with antidepressant medication and will antipsychotic medication, and he improved within 3 weeks, and was discharged within 3 months. Dr. Osheroff resumed his medical practice and, on an outpatient treatment regimen of medications and psychotherapy, he was not hospitalized again and had no recurrence of his severe symptoms. Nonetheless, the lucrative medical practice that Osheroff had built never rebounded, and he lost his respect and standing in the medical community, as well as losing the custody of two of his children.

Dr. Osheroff filed a lawsuit in 1982 against Chestnut Lodge for negligence, citing the lack of psychopharmacological treatment, and the unnecessary psychiatric decline that this improper treatment engendered. A private settlement was reached.

As psychedelic treatment is further researched and employed clinically, this data may potentially reach a conclusion that such a treatment is superior in efficacy to other standard treatments, that less of a dose might be required than other medical interventions, and that longevity of response, to as little as a single dose, might potentially last for years based upon some current research. By comparison, standard antidepressant treatment requires a daily dose and missing that dose might result in side effects or in a relapse of the depression. More clinical research is needed, but if the promise of psychedelic treatment becomes a reality, treating eligible patients with any non-psychedelic treatment might be considered an affront to evidence based interventions, and might require the psychiatric clinician to recommend psychedelic treatment as a first priority. We aren’t there yet, but we might be in the future.