Can psychedelic drugs together with talk therapy enhance/improve treatment for PTSD? Much of what has been published in the last five years has been particularly promising. But the overall picture could best be described as developing.
Key issue for vets
This question is of prime interest to military veterans, especially those with combat experience. Much of the existing research addresses alcohol and opioid disorders. Both PTSD and alcohol & opioid disorders have direct bearing on the incidence of suicide. Suicide prevention is of course a prime veteran health concern, given the alarming rate at which it has occurred in recent decades (and to Vietnam war veterans.)
Research history
The potential for psychedelic (consciousness altering) drugs to be therapeutic has a 70+ year history of research and personal use. It’s an accelerating picture. It’s worth noting that this area of research experienced a significant hiatus from 2000-2020 due to social, political and legal barriers.
Studied drugs
Historically, LSD and psilocybin are probably the two most studied, with mescaline/peyote a distant third. The latter three drugs, which originate from natural sources, have long traditions of religious and ritual use by indigenous peoples. Only recently have there been pharmaceutical versions. As such, their non-pharmaceutical potency varies, but generally they do not present medical or mental health risks to risk-aware users.
Ayahuasca and ibogaine have historically been used by a few South American tribes for religious purposes, similar to the use of peyote (which contains mescaline) by numerous First Nation tribes in the Southwest U.S. and elsewhere. Ayahuasca research and personal use has been increasing over the last five years.
Two other pharmaceutical drugs, MDMA and ketamine, both of which have lengthy histories of recreational use, have achieved intensive, serious attention by researchers in the last ten years. Pharmaceutical psilocybin production has increased greatly, due to decreased legal restrictions and significant interest in researching low dose (non-hallucinogenic) therapeuticeffects
Targeted disorders and barriers
A range of psychiatric and substance use disorders have been targeted by researchers in the last decade. Depression, alcohol abuse, PTSD, acute anxiety and insomnia have received the most attention.
One factor that has limited the amount of research is social and political stigma. LSD, mescaline/peyote, MDMA and ketamine in particular are strongly associated with recreational drug use that accelerated in the early 60s and continues into today. These drugs are still illegal practically everywhere.
Cannabis
Psychoactive cannabis must be mentioned in this context. It continues to be researched, especially as it has become legal in many U.S. states and several countries. However, there is currently conflicting evidence that psychoactive cannabis will become a useful drug in the treatment of mental disorders, and there is little established when it comes to cannabis-assisted psychotherapy. The non-consciousness altering extract CBD(cannabidiol) has shown some initial though not validated promise.
Risks
It should be noted that some of the drugs have been implicated as risks for triggering psychotic episodes, mood and anxiety disorders.
MDMA
MDMA (best known by its street drug names, “ecstasy” or “molly”) may be the drug considered most promising in trauma treatment today.
Currently there are 31 completed, active or recruiting stage research projects on record. In research studies, MDMA is typically administered in conjunction with a talk therapy model that “integrates” more positive experiences that subjects experience under the drug’s influence
In a recent and widely cited research project, it showed the potential to accelerate the development of two psychological shifts in people suffering from PTSD.
a. establishing self-compassion, which recognized as an important dimension because PTSD symptoms can produce very high levels of fear, shame and self-loathing.
b. re-positioning memories of traumatic events firmly into the past; “flashback” symptoms are seen less as a present, continuing threat and more as resolved past incidents.
Promising study
This study’s prominence was due in part to the participation of Bessel van der Kolk, M.D., widely recognized as a pre-eminent leader in the study of PTSD.
“Results showed that compared to therapy with placebo, MDMA-assisted therapy participants had a statistically significant greater improvement in all self-experience measures.
“People who have histories of having been traumatized as children within their caregiving systems are particularly prone to developing major deficits in emotion regulation and often develop a self-identity of being worthless and defective,” said Bessel van der Kolk, M.D., Phase 3 investigator, president of the Trauma Research Foundation and author of The Body Keeps the Score.1“When these people are being treated for their PTSD, their lack of a sense of safety and difficulties with trust can be major obstacles to successful completion of treatment; these deficits often prevent treatment from being successful. In this study, we observed that MDMA-assisted therapy was more effective than psychotherapy alone in improving a range of problems with self-experience that are associated with treatment failure.”
FDA setback
However, in June 2024 these results were deemed insufficient for FDA (the U.S. federal Food & Drug Administration, which regulates the medical use of drugs) approval due to several research methodological deficiencies.
There is a new research project launched which aims to overcome the FDA’s objections to that research project’s reported deficiencies in methodology. Dr. van der Kolk is again an investigator.
“Compared with therapy with placebo, MDMA-assisted therapy had significant positive effects on transdiagnostic mental processes of self-experience which are often associated with poor treatment outcome. This provides a possible window into understanding the psychological capacities facilitated by psychedelic agents that may result in significant improvements in PTSD symptomatology.”
Integrated psychotherapy
MDMA research is conducted with what is termed as “integrated psychotherapy”. This means that research subjects receive a highly specialized form of psychotherapy which aims to consolidate therapeutic effects achieved while subjects are under the influence of the drug. Here is a detailed explanation of what this type of psychotherapy entails.
Focus on veterans
There are two non-profit organizations currently trying to assist veterans, Healing Breakthrough and Heroic Hearts Project, specifically with developing psychedelic-assisted psychotherapy for the treatment of military & combat level PTSD.
Psilocybin
Currently there are 119 active or recruiting studies, making psilocybin the leader in the number of active studies. Depression and end-of-life palliative care seem to be the most promising. While there are now “clinics” in Oregon that administer fully psychedelic dosages (with therapist support), most of the studies use so-called “microdoses” that do not induce hallucinatory effects. Rather, it’s been found that these microdoses have in some studies produced an anti-depressant effect, and more.
Uncertain psilocybin promise
After a promising beginning in 2018-20, psilocybin microdosing’s prospects have diminished somewhat, as further studies were not able to replicate some of the early studies’ results. The number of studies with proper controls and small sample sizes has hindered research progress.
Psychotherapy seems to show promise in conjunction with psilocybin, rather than the use of the drug on its own. This integration is now the treatment standard.
The research with psilocybin to date fits the longstanding practice of combining medication with psychotherapy as the most effective treatment mode.