Psychedelic Medicine and Interventional Psychiatry

Course #96790 - $60-


Study Points

  1. Outline factors that have contributed to the rise in interest in psychedelic and interventional psychiatry.
  2. Define terms related to the discussion of psychedelic and interventional psychiatry.
  3. Discuss the history of psychedelics in medical care.
  4. Evaluate factors that may impact the provision of psychedelic or interventional psychiatry techniques, including stigma, setting, and culture.
  5. Outline the role of psilocybin and ketamine in psychiatric care.
  6. Describe how MDMA and ibogaine may impact mental health.
  7. Review the clinical effects of kratom, LSD, and mescaline.
  8. Discuss the potential clinical role of nitrous oxide, ayahuasca, and dimethyltryptamine (DMT).
  9. Describe how psychedelics may be incorporated into the treatment of mental health disorders, including treatment-resistant depression, post-traumatic stress disorder, and substance use disorders.
  10. Identify interventional approaches that may be used in the treatment of mental health disorders.

    1 . Which of the following is a category of psychedelic drugs?
    A) Classic
    B) Natural
    C) Prescription
    D) Hallucinogenic

    INTRODUCTION

    Psychedelic drugs are often divided into two categories: classic and non-classic or dissociative. The classic psychedelics are usually derived from naturally occurring compounds and include such drugs as psilocybin, LSD, and DMT, an active component of ayahuasca, an increasingly popular sacramental drink originating from South America. The dissociative psychedelics are typically newer analogs and include ketamine, phencyclidine (PCP), MDMA, mescaline, Salvia divinorum, and dextromethorphan (DXM). While considered drugs of abuse, most agents being tested in psychedelic medicine clinical trials are not self-administered by laboratory animals, the usual test for abuse and dependence liability. If anything, hallucinogens tend to lose their ability to produce changes in the person over time and with regular use. These drugs are all variations on tryptamine, and while they may increase dopamine, they tend to do this through an indirect mechanism.

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    2 . Psilocybin has been legalized for consumer use in
    A) Oregon.
    B) California.
    C) New York.
    D) New Mexico.

    THE IMPORTANCE OF PSYCHEDELIC AND INTERVENTIONAL MEDICINE

    This movement may already be advancing with psychedelic drugs. This began with the decriminalization of psilocybin in Denver, Colorado, in 2019, followed by Oakland and Santa Cruz, California. In 2021, the city of Cambridge, Massachusetts, passed a law decriminalizing all "entheogenic plants," which includes the drugs ayahuasca, ibogaine, and psilocybin [19]. As of 2022, the largest city to decriminalize psilocybin is Seattle, Washington [19]. In 2020, the state of Oregon approved the use of psilocybin by consumers [20]. Also in 2020, the District of Columbia decriminalized the use of psilocybin mushrooms as well as other substances found in peyote and ayahuasca [20]. Other states are considering taking similar actions. In 2021, Health Canada, the premier health agency in Canada, approved trials of MDMA-assisted therapy for the treatment of PTSD [15]. It is important to note that it can be dangerous for psilocybin and other psychedelic drugs to be used by individuals who do not understand its risks. As popularity and interest in the medical use of these agents increases, clinicians have a responsibility to educate themselves and their patients about the safe and appropriate use of psychedelics.

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    3 . A hallucinogen is
    A) an illicit drug of abuse in all cases.
    B) any substance that allows for intensified experiences.
    C) a drug that is used to facilitate guided imagery exercises.
    D) any drug that may cause the user to experience visual, auditory, or other types of hallucinations.

    DEFINITIONS

    Hallucinogen: Drug that may cause the user to experience visual, auditory, or other types of hallucinations.

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    4 . In the context of psychedelic medicine, set refers to
    A) the patient's mindset.
    B) the process of providing effective therapy.
    C) the environment in which therapy is provided.
    D) the manual of best practices established for therapy.

    DEFINITIONS

    Set: Refers to the patient's mindset. For example, a person who is anxious and fearful is less likely to have a positive experience with psychedelic medicine than a person who has an open and positive outlook.

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    5 . Ketamine is considered a
    A) Schedule I drug.
    B) Schedule II drug.
    C) Schedule III drug.
    D) non-scheduled drug.

    PONDERING PSYCHEDELICS

    PSYCHEDELIC DRUG SCHEDULING

    Drug Schedule
    Ayahuasca/DMTI
    IbogaineI
    KetamineIII
    KratomNot scheduled
    LSDI
    MescalineI
    Nitrous oxideNot scheduled
    PsilocybinI
    MDMA ("Molly," "Ecstasy")I
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    6 . In the 1940s, LSD was marketed under the brand name Delysid for the treatment of
    A) neurosis.
    B) alcoholism.
    C) schizophrenia.
    D) All of the above

    PONDERING PSYCHEDELICS

    In 1947, Sandoz began marketing and distributing LSD, under the brand name Delysid, as a possible psychiatric drug to treat neurosis, alcoholism, criminal behavior, and schizophrenia. In addition, LSD-25 was also used to treat autism and verbal misbehavior [28,30]. In his book, Hofmann described how LSD helped provide relief to people who were dying of cancer and in severe pain for whom major analgesics were ineffective. He hypothesized that the analgesic effect was not inherent to the drug but was a result of patients dissociating from their bodies such that physical pain no longer affected them [29].

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    7 . Patients who receive psychedelic therapy experience better outcomes if the therapy is administered in settings in which
    A) they feel safe.
    B) they are completely alone.
    C) everything is new or unfamiliar.
    D) hallucinogenic effects are promoted by loud music and flashing colors.

    CONSIDERING PSYCHEDELIC-ASSISTED PSYCHOTHERAPY AS A TREATMENT OPTION

    Since the 1960s, therapists have noted that the response to psychedelic drugs is impacted by the patient's mindset as well as the setting where the psychedelic drug is administered. For example, if the person feels confident that the experience will be a positive one, then this "set" is considered more conducive to a good experience while under the influence of a psychedelic drug compared with when persons are extremely apprehensive and fearful beforehand. By extension, if patients are in an office setting with a therapist or other practitioner with whom they feel safe, the outcome is generally better than in those who feel unsafe. Research has shown a better outcome with patients receiving psychedelics in a therapeutic setting versus receiving the drug while undergoing a positron emission tomography (PET) scan [33]. These researchers stated [33]:

    The finding that the PET environment was strongly associated with anxious reactions could be partially explained by the perceived atmosphere. Whereas non-PET experiments were mostly conducted in laboratory rooms that were furnished in an aesthetically pleasing way, the environment at the PET center was much more clinical and "antiseptic" (i.e., lots of technical equipment, white walls, personnel in white lab coats). Our results are therefore in support of current safety guidelines, which recommend avoiding "cold" and overly clinical environments in human hallucinogen research in order to reduce the risk of anxious reactions.

    Another element of setting, and one that is also used to enhance set, is the use of music while the patient undergoes therapy with psychedelic medicine. Johns Hopkins has developed a "psilocybin playlist" lasting nearly eight hours that is used for patients who are undergoing treatment with psilocybin [34].

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    8 . Which of the following is an aspect of psychedelic medicine setting that can enhance set?
    A) Music
    B) Lighting
    C) Presence of a supportive healthcare professional
    D) All of the above

    CONSIDERING PSYCHEDELIC-ASSISTED PSYCHOTHERAPY AS A TREATMENT OPTION

    Since the 1960s, therapists have noted that the response to psychedelic drugs is impacted by the patient's mindset as well as the setting where the psychedelic drug is administered. For example, if the person feels confident that the experience will be a positive one, then this "set" is considered more conducive to a good experience while under the influence of a psychedelic drug compared with when persons are extremely apprehensive and fearful beforehand. By extension, if patients are in an office setting with a therapist or other practitioner with whom they feel safe, the outcome is generally better than in those who feel unsafe. Research has shown a better outcome with patients receiving psychedelics in a therapeutic setting versus receiving the drug while undergoing a positron emission tomography (PET) scan [33]. These researchers stated [33]:

    The finding that the PET environment was strongly associated with anxious reactions could be partially explained by the perceived atmosphere. Whereas non-PET experiments were mostly conducted in laboratory rooms that were furnished in an aesthetically pleasing way, the environment at the PET center was much more clinical and "antiseptic" (i.e., lots of technical equipment, white walls, personnel in white lab coats). Our results are therefore in support of current safety guidelines, which recommend avoiding "cold" and overly clinical environments in human hallucinogen research in order to reduce the risk of anxious reactions.

    Another element of setting, and one that is also used to enhance set, is the use of music while the patient undergoes therapy with psychedelic medicine. Johns Hopkins has developed a "psilocybin playlist" lasting nearly eight hours that is used for patients who are undergoing treatment with psilocybin [34].

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    9 . Which of the following statements regarding psilocybin is FALSE?
    A) The duration of action is four to six hours.
    B) It is active orally at doses of around 10 mg.
    C) Time to onset of effect is usually within 20 to 30 minutes of ingestion.
    D) It is about 20 times stronger than LSD but much less potent than mescaline.

    EMERGING PSYCHEDELIC TREATMENTS

    Psilocybin was first studied during the 1960s to establish its psychopharmacologic profile; it was found to be active orally at around 10 mg, with more potent effects at higher doses, with a four- to six-hour duration. Psilocybin is rapidly metabolized to psilocin, a full agonist at serotonin 5-HT1A/2A/2C receptors, with 5-HT2A receptor activation directly correlated with human hallucinogenic activity. Time to onset of effect is usually within 20 to 30 minutes of ingestion. As a drug, it is about 20 times stronger than mescaline but much less potent than LSD [37].

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    10 . Nasal spray esketamine is approved by the FDA for the treatment of
    A) schizophrenia.
    B) cluster headaches.
    C) opioid use disorder.
    D) treatment-resistant and/or suicidal depression.

    EMERGING PSYCHEDELIC TREATMENTS

    Ketamine is a Schedule III drug that is a combination of s-ketamine (esketamine) and r-ketamine (arketamine). In 2019, the use of esketamine as a nasal spray (brand name Spravato) was approved by the FDA for the treatment of treatment-resistant depression. Since then, it has also been approved to treat suicidal depression. However, it should be noted that this nasal spray formulation is not available at most pharmacies; instead, it is provided solely through a restricted distribution system. The FDA also requires that patients be overseen for a minimum of two hours after treatment, in order to allow sufficient time to identify and address and adverse reactions that develop in patients. (It is not clear if all ketamine clinics adhere to this provision.)

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    11 . Researchers have demonstrated the efficacy of combination psychotherapy and MDMA in the treatment of
    A) PTSD.
    B) depression.
    C) end-of-life anxiety.
    D) obsessive-compulsive disorder.

    EMERGING PSYCHEDELIC TREATMENTS

    Today, researchers have demonstrated the efficacy of combination psychotherapy and MDMA in treating PTSD. The FDA has granted "breakthrough therapy" permission for MDMA therapeutic treatment, largely as a result of the findings of several small studies. Clinicians who use MDMA-assisted psychotherapy to treat individuals with PTSD have access to a manual outlining best practices for this therapeutic use. In the 2017 revision of this manual, the following explanation is given [54]:

    The basic premise of this treatment approach is that the therapeutic effect is not due simply to the physiological effects of the medicine; rather, it is the result of an interaction between the effects of the medicine, the therapeutic setting, and the mindsets of the participant and the therapists. MDMA produces an experience that appears to temporarily reduce fear, increase the range of positive emotions toward self and others, and increase interpersonal trust without clouding the sensorium or inhibiting access to emotions. MDMA may catalyze therapeutic processing by allowing participants to stay emotionally engaged while revisiting traumatic experiences without being overwhelmed by anxiety or other painful emotions. Frequently, participants are able to experience and express fear, anger, and grief as part of the therapeutic process with less likelihood of either feeling overwhelmed by these emotions or of avoiding them by dissociation or emotional numbing. In addition, MDMA can enable a heightened state of empathic rapport that facilitates the therapeutic process and allows for a corrective experience of secure attachment and collaboration with the therapists.

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    12 . Which of the following statements regarding ibogaine is TRUE?
    A) It is a derivative of phencyclidine (PCP).
    B) It is FDA-approved for the treatment of opioid use disorder.
    C) Its metabolism is purportedly mediated by the p450 cytochrome enzyme CY2D6.
    D) It is easiest to obtain in the United States, and travel from other countries to obtain treatment is common.

    EMERGING PSYCHEDELIC TREATMENTS

    Largely derived from the Western African shrub Tabernanthe iboga, ibogaine has been explored as a possible treatment for opioid use disorder, although there are many caveats to be considered, including the fact that ibogaine is a Schedule I drug. Given the current climate surrounding opioid misuse and use disorder in the United States, possible treatment options are a major focus. According to the Centers for Disease Control and Prevention, more than 70% of drug overdoses in the United States in 2019 were related to opioid use [59]. Ibogaine apparently acts to eliminate craving for opioids and rapidly detoxifies individuals with opioid dependence, although much further study with larger populations is needed. Most people who seek treatment with ibogaine have opioid use disorder, but some have been dependent on stimulants such as cocaine.

    Metabolism of ibogaine is purportedly mediated by the p450 cytochrome enzyme CY2D6. Because of genetic differences, an estimated 10% of persons of European heritage (predominantly White Americans in the United States) lack the necessary gene to synthesize this enzyme. Among this group, including the many individuals who do not realize they lack this gene, administration of ibogaine can result in plasma levels as much as twice as high as those in persons with the gene. As a precaution, a test dose of the drug may be given to subjects to assess the response. Another option is genotype screening of subjects who seek treatment with ibogaine, to ensure safety and to aid in treatment decisions [62].

    Ibogaine is difficult to obtain in the United States, and travel to other countries to obtain treatment has been reported, which can be very costly. Assuming that ibogaine were to be equal in efficacy to clonidine or lofexidine for detoxification from opioids or acute discontinuation, it is still unclear what long-term effects or level of continued abstinence can be expected. Naltrexone (Vivitrol) following detoxification might be facilitated. But, data supporting the use of suboxone and methadone in reducing overdoses, deaths, and emergency department visits are clear, including both short- and long-term outcomes. It is important to compare ibogaine to buprenorphine or methadone treatment, just as psilocybin was compared to SSRI therapy [64].

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    13 . Which of the following statements regarding kratom products in the United States is TRUE?
    A) All kratom products are considered Schedule I drugs.
    B) The products are typically freeze-dried leaves, concentrated extracts, or liquid "energy shots."
    C) Products marketed in the United States have been tested for purity and uniform concentration.
    D) While kratom products are available locally in smoke and "head" shops, they cannot be legally purchased over the Internet.

    EMERGING PSYCHEDELIC TREATMENTS

    Kratom is a drug derived from Mitragyna speciosa, an evergreen tree native to Southeast Asia, where it has been used for generations, largely by locals who chew on the leaves or brew it into a tea and reportedly use the drug for an energizing purpose (e.g., to facilitate longer work periods), much as Americans use caffeine. Kratom is used by consumers in the United States as a drug of abuse and, less commonly, to manage depression. As of 2022, the drug is not scheduled by the U.S. Drug Enforcement Administration (DEA), although the DEA did consider categorizing kratom constituents mitragynine and 7-hydroxymitragynine under Schedule I in 2016. This effort was met with considerable resistance and was abandoned. As such, the product remains available locally in smoke and "head" shops, although many purchase the drug over the Internet. Kratom is banned in six states, including Arkansas, Indiana, Tennessee, Vermont, Wisconsin, and most recently in Alabama [65].

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    14 . Mescaline toxicity can result in
    A) bradycardia.
    B) hypotension.
    C) hypothermia.
    D) respiratory depression.

    EMERGING PSYCHEDELIC TREATMENTS

    The average dose of mescaline ranges from 20–500 mg, and the duration of action is about 10 to 12 hours. Individuals suffering from mescaline toxicity (typically seen with doses of 20 mg/kg or greater) may experience tachycardia, hypertension, seizures, hyperthermia, respiratory depression, and rarely death [73]. Concomitant use of mescaline with stimulant drugs (e.g., nicotine, cocaine, ephedrine, amphetamines) may increase the risk of adverse central nervous system effects.

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    15 . Nitrous oxide has been demonstrated to improve the condition of individuals with
    A) PTSD.
    B) psychosis.
    C) treatment-resistant depression.
    D) attention deficit hyperactivity disorder.

    EMERGING PSYCHEDELIC TREATMENTS

    Nitrous oxide has been demonstrated to improve the condition of individuals with treatment-resistant depression. A study of 20 subjects with treatment-resistant depression were randomly placed in either a nitrous oxide treatment group (10 subjects) or placebo group (10 subjects). The nitrous oxide group inhaled 50% nitrous oxide/50% oxygen, and the placebo group received 50% nitrogen/50% oxygen. There were two sessions one week apart. At the end of the study, four patients (40%) had a decrease in symptoms of depression and three patients (30%) experienced full remission. In contrast, one patient improved after receiving the placebo (10%) and none of the placebo patients remitted from their depression. The improvements in the nitrous oxide group were rapid, occurring in some cases within as little as two hours of receiving the drug [80]. Adverse events were mild and included nausea and vomiting, headache, and dizziness/lightheadedness. At the time of the second session, some patients in the treatment group experienced a carryover effect from the first week's treatment, as evidenced by sustained improvements in their scores on the Hamilton Depression Rating Scale (HDRS-21).

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    16 . The most common adverse effect of ayahuasca is
    A) flashbacks.
    B) severe headache.
    C) nausea and vomiting.
    D) respiratory depression.

    EMERGING PSYCHEDELIC TREATMENTS

    In a Brazilian study involving 29 subjects with treatment-resistant depression, patients were randomized to receive a dose of either ayahuasca or placebo. Subjects were evaluated on the MADRS at the following points: baseline, day 1, day 2, and day 7 after dosing. They found MADRS scores were significantly lower in the ayahuasca group at all points and all individuals in this group experienced improvements. In contrast, 27% of patients in the placebo group developed worse depression symptoms. However, ayahuasca sickens many people, and most of the subjects who were given this substance felt nauseous and 57% vomited [83].

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    17 . Research indicates that a modest dose of psilocybin given to patients with terminal cancer under the supervision of trained therapists can improve
    A) prognosis.
    B) life expectancy.
    C) mood and quality of life.
    D) tumor size and associated pain.

    DIAGNOSES AND PSYCHEDELIC MEDICINE

    As discussed, research has demonstrated that psilocybin can be effective in improving mood and quality of life of patients with terminal cancer diagnoses. This aspect of cancer care has been largely overlooked and undertreated. Agrawal notes that, "Oncologists are well-equipped to fight the physical threats of cancer with powerful, yet sometimes imperfect tools including chemotherapy, radiation, and surgery, but they often feel helpless when it comes to treating the intense psychological agony many patients experience" [94]. A seminal study published in 2016 explored the use of a modest dose of psilocybin given to patients with terminal cancer under the supervision of trained therapists. The findings demonstrated that more than 80% of 51 patients who had received life-threatening cancer diagnoses and who subsequently developed depression or anxiety experienced significant and sustained improvements in mood and quality of life six months after taking psilocybin. In addition to feeling calmer and happier, the participants reported forging a closer connection with their friends and family [95]. This study demonstrated the careful and controlled use of psilocybin might be a safe and effective treatment for existential anxiety and despair that often accompany advanced-stage cancers. In addition, in limited studies, LSD has been found to significantly decrease anxiety levels in patients with life-threatening diseases.

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    18 . Which of the following psychedelics has been studied for the treatment of social anxiety in persons with autism?
    A) MDMA
    B) Ibogaine
    C) Mescaline
    D) Psilocybin

    DIAGNOSES AND PSYCHEDELIC MEDICINE

    In a study of 12 adults with autism and issues with severe social anxiety, subjects were randomized to receive either MDMA (75 mg or 125 mg) or placebo during the course of two 8-hour psychotherapy sessions. The MDMA was administered after a guided progressive muscle relaxation exercise. The experimental sessions were held one month apart and separated by three nondrug sessions of psychotherapy. The patients were provided with as few sensory interruptions as possible, such as soft lights, noise abatement, and fidget objects to help them with self-regulation through repeated actions (i.e., "stimming") [100]. On the Leibowitz Social Anxiety Scale, the MDMA group experienced a significantly greater improvement in social anxiety scores compared with the placebo group. Improvements persisted at six-month follow-up. The researchers said of the follow-up, "social anxiety remained the same or continued to improve slightly for most participants in the MDMA group after completing the active treatment phase" [100].

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    19 . The goal of electroconvulsive therapy (ECT) is to
    A) stimulate the prefrontal cortex.
    B) provide a competing traumatic experience.
    C) induce a seizure through applied electric shocks.
    D) induce the creation of new dendrites in the brain.

    INTERVENTIONAL PSYCHIATRY: BRAIN STIMULATION THERAPIES

    ECT has been used to treat depression, bipolar disorder, schizophrenia, and other psychiatric diagnoses for many years, starting in the first half of the 20th century. The goal of ECT is to induce a seizure through applied electric shocks. The procedure was initially introduced in the late 1930s in Italy, and in the 1940s through the 1960s, ECT became popular in the United States as a mainstream treatment [109]. However, early treatments did not provide anesthesia and sometimes led to physical and psychological trauma [110]. Physicians later learned that significantly milder shocks could achieve the same goals.

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    20 . Deep brain stimulation
    A) is dangerous and potentially painful.
    B) is the subject of intense research for the treatment of eating disorders.
    C) has been proven effective in amelioration of severe depression in large randomized controlled trials.
    D) involves the permanent implantation of electrodes that send regular and continuous electrical impulses to stimulate a specific part of the brain.

    INTERVENTIONAL PSYCHIATRY: BRAIN STIMULATION THERAPIES

    The first documented use of DBS occurred in 1948, when neurosurgeon J. Lawrence Pool implanted an electrode into the brain of a women with anorexia and depression. Results were initially positive, until the wire broke several weeks later [130]. Today, DBS involves the permanent implantation of electrodes that send regular and continuous electrical impulses to stimulate a specific part of the brain. Some describe DBS as a sort of brain pacemaker to correct imbalances, comparable to a heart pacemaker that corrects cardiac abnormalities. It should be noted that DBS is an invasive and expensive procedure that is only available to very few individuals, and it is not approved for the treatment of depression by the FDA as of 2022.

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