What to consider as we embrace medicinal psychedelics

After decades of little innovation with new treatment options, Australia’s mental health sector is experiencing a major paradigm shift, with the introduction of medicinal psychedelics.

From the first of July this year, people experiencing treatment-resistant depression or post-traumatic stress disorder (PTSD) have been allowed access to psilocybin or MDMA through an authorised psychiatrist, as part of their therapy.

For many clinicians and their patients, the introduction of psychedelic medicine is a welcome move, with remission rates for common mental health conditions having remained stubbornly low for decades.

Of the one in eight Australians who take traditional pharmacotherapies for depression, only 35% will experience remission; and for PTSD, the outlook is considerably worse, at less than 10%.

By comparison, around 60–70% of PTSD sufferers treated with medical-grade MDMA as part of their therapy went into remission in recent Phase 2 and 3 clinical trials.

Peter Hunt, Co-founder of mental health charity Mind Medicine Australia, said that with one in five Australian adults living with chronic mental illness, the move to new treatment options can’t come soon enough.

“We haven’t seen much innovation in the mental health space for decades and that explains why we have failed to improve remission rates over that time. Medicinal psychedelics will change that. They have proven to be safe and effective in clinical trials and are giving hope to people who are running out of options. That’s why we are putting so much effort into making them more known and accessible to the general population with appropriate controls in place,” he told Hospital+Healthcare.

Bad trips are possible, but could be beneficial

Not all clinicians support the use of medicinal psychedelics, with some concerned they could induce a psychosis-like state. Indeed, in an unregulated or recreational environment consumption of MDMA and psilocybin can be psychologically harmful for a small group of people, with lasting side effects, like flashbacks and anxiety.

However, Hunt believes comparing medicinal versus recreational usage is unfair.

“Unlike a number of other drugs that already exist in the market, there is a big difference between what is considered a ‘medicinal’ versus ‘toxic’ quantity of MDMA and psilocybin; and patients can’t overdose because these medicines will only be available in medically controlled environments,” he said.

“Of course, some people may have a challenging experience when taking MDMA or psilocybin in a medical context, but that’s actually part of the therapeutic process. Therapists will encourage their patients to move towards any negative emotions they experience during their sessions with the medicines and confront them. In doing so, patients may find that some of the negative feelings evaporate.”

Training and structural reform

To support this and other aspects of the psychedelic experience, Mind Medicine is currently training hundreds of clinicians throughout Australia.

“It is important that clinicians understand how to support a patient going through the psychedelic experience; and how to recognise which patients are suited to the therapy. If patients are already on antidepressants, the treating psychiatrist will need the knowledge and skills to take them off those medications safely,” Hunt said.

Alongside this fundamental training, the organisation is also taking steps to manage clinician burnout.

“The work is arduous and some therapists may experience compassion fatigue, which could affect the quality of the clinical guidance they give to patients during the medicinal session. The psychedelic process can last for up to seven hours, so that is a long time for a clinician to sit and be present with their patient. The training gives clinicians the tools to handle this and look after themselves.”

To further manage burnout, a rethink of the typical working week may also be required, Hunt said.

“Clinicians might only realistically undertake one or two medicinal dosing sessions a week, so the system needs to allow for this. Of course, this might initially create workforce challenges but, in the long run, this will ease, because the improved remission rates should mean that fewer people remain in the mental health system.”

Whatever the challenges of pursuing new treatment innovations like psychedelic medicine, Hunt believes the risks of not doing so should not be forgotten.

“In the world of physical health, we see this kind of balanced risk assessment regularly. If someone has cancer the doctor will immediately compare the risk of surgical intervention with the risk of not surgically dealing with the tumours.

“In the world of mental health, we don’t see these risk comparisons being made as often. We worry about the consequences of using a new treatment for a person with debilitating depression but we don’t measure this against the suffering of that person and the adverse impacts on their quality of life.

“It’s time we shifted the focus and put the patient’s needs first.”

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