Psychedelic Drugs in Psychiatry — Guy Goodwin / Serious Science
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Psychedelic Drugs in Psychiatry — Guy Goodwin / Serious Science

I want to talk a little bit about the possible
future for the use of psychedelic drugs in psychiatry. The history of the use of psychedelics in
western medicine is pretty short and pretty disastrous. It started in 1943 when the properties of
LSD, lysergic acid diethylamide, were discovered by Albert Hofmann who worked for the Sandoz
drug company in Switzerland. He was investigating the effects of the plant
extracts called ergots and he synthesized this compound which he managed to get to his
fingers during the process of synthesis. He noticed strange subjective sensations and
he was smart enough to realise that it was pretty unusual. He was curious about what it was, so he got
a synthesis of this compound and he deliberately administered 250 micrograms to himself. So he was the first person in Western society
to take LSD as pure LSD. He then attempted to cycle home for lunch
and it was an interesting ride: it’s sometimes called ‘the bicycle day’. Along that day he experienced all the extraordinary
visual subjective sensations associated with an LDS trip as it came to be called. He was immediately amazed by the implications
of this, and others who read about it were also incredibly interested by what he discovered
because what he was showing was that you could profoundly change the perception and the mind
with a dose of the drug in the microgram range. Prior to this, drugs that acted on the brain
have really been thought as of depressants, drugs that essentially would be present in
milligram amounts at least and their mechanism of actions was not at all understood. In fact, at the time we didn’t really understand
that brain cells communicate with each other through chemistry. So this finding was way ahead of its time
in some way, it was the major stimulus to most basic neuroscience. People then went on to discover compounds
called the monoamines which are analogous to LSD: LSD works on the receptors that are
naturally occurring for these neurotransmitters, particularly serotonin. In addition, there was an interest for clinical
application. This is we’re talking about 1947, as early
as that. Sandoz made LSD available for the psychiatrist
to use in psychiatric patients. In those days there was very little regulation,
so the doctors were pretty free to try things out and report back. They did that in a very remarkable scale in
the 1950s: it was mainly with LSD and then with the other drugs that came along. It was realized that there was a big tradition
in the use of these sorts of drugs, plant extracts, in a number of indigenous societies
across the world, particularly in South America. That led to the discovery of other drugs like
mescaline which has come from the peyote cactus and also psilocybin from mushrooms, ‘the magic
mushrooms’ as they are sometimes called. Magic mushrooms grow all over temperate climates,
for example, in Europe so they’re present, there with us all the time. These compounds all have in common that they
bind to this group of receptors called 5-HT2A receptors in the brain and therefore they
work on serotonin pathways. This was established relatively recently but
nevertheless it was the stimulus to basic neuroscience that got us going. What happened to the clinical application
it was so widespread? About 40,000 patients were probably treated
and it was regarded as a way of facilitating psychotherapy at the time. The problem was that this was before the time
when psychiatrists really thought carefully about the objective properties of the illnesses
they were looking at. It didn’t really start until the 1980s. So the psychiatrists used very vague descriptions
and they used in order to understand the effects the terms that derived from psychoanalysis
which we now find a little confusing and ambiguous. That for us is a limitation of understanding
what was actually happening in the 1950s and reading the literature of the time. If we’d simply continued to use the drug they
would have been the possibility to understand better which patients it was best for, how
good it was for them, what the long-term outcomes were. But unfortunately other things happened: the
widespread use, particularly of LSD but also of other drugs, in what was called counterculture
in the United States in the 1960s. That resulted in a kind of moral panic around
the use of these drugs by young people. In fact, this was resulting in a tremendous
social schism and it also fed very much into issues around the Vietnam War which were tremendously
divisive in the United States. It pitted the younger generation against older
people and the use of drugs became a symbolic way of rubbing in the difference and it became
a political worry. So the politicians, as they usually do, resort
to law to try to prevent things and they made the drugs illegal. And when the United States makes drugs illegal
other countries basically through treaties usually have to follow, and that’s effectively
what happened. So in 1970 LSD and the similar compounds were
classified as highly dangerous drugs that were illegal. And an illegal drug is something that a person
could use illegally but it’s not something a doctor can use legally by definition. So, doctors, researchers could really no longer
use the drug for human experimentation or human treatment studies. Essentially the whole thing went underground. People in America continued to use these drugs
to assist psychotherapy but it was essentially outside the law, it was outside formal reporting
procedures, it was unregistered. So in a sense, we lost these important compounds
for many many years. Two generations kill interest in anything. So that was a position we were in by the 2000s:
about that time people started to get interested again. In the last 10 years, people applied to do
clinical research studies, scientific studies on these drugs under controlled conditions
using modern measurements and we started to try and rediscovered them and also rediscover
their potential uses. To cut a very long story short, there have
now been at least two trials which have been reasonably well controlled: there has been
a kind of placebo condition which allows you to say what the effects of the active treatment
are, versus no treatment or minimal treatment. What seems to occur is that in patients particularly
with depressive symptoms there is a good long-term outcome over many months of treatment with
a single dose of particularly psilocybin. Psilocybin is emerging as the hallucinogen
of choice because it’s a probably gentler experience than LSD, it doesn’t last as long,
so it fits into a working day. It’s now relatively easy to synthesise, so
it’s available, you don’t have to get it from mushrooms, you can get it in a pure form. A great risk with the illegal drug is that
you don’t know what you’re taking. So what we’re moving to is an era where we
will look much more carefully (with psilocybin probably first) what their properties are
for treating patients particularly with mood disorders. The interesting part of the story is that
the initial studies we’ve done in people who were depressed or anxious because they had
terminal cancer. The idea was that their existential distress
about their life soon ending would be the thing that was influenced by the drug, so
the drug will give you this mystical experience, that mystical experience will make you reevaluate
your life and death and in a sense make it more bearable. That’s pretty much what people described but
it’s also very much what people expected. What was little less predictable was that
depressive symptoms were so clearly treated. So what has now happened is that we’ve gone
on to look in patients with treatment-resistant depression who don’t have an existential crisis,
so they’re not in a position where their life is going to end, but they are often in a position
where their life has become totally miserable and worthless. The question is, does this drug reestablish
some kind of function? In the first twenty patients that were treated
in London at Imperial College there was a surprisingly good response and in some of
those patients, a transformational response when taking a full dose of psilocybin and
then following up for at least a year. I met three of those patients, the three who
probably had the best responses and it’s most impressive to talk to them. They have very long and complicated histories;
they have got to the end of the line, they were really contemplating suicide, they thought
their lives were really worthless. They have been turned around by the experience
with this drug. That’s not game, set and match for any compound:
you have to do fair comparisons between an active treatment and perhaps the standard
treatment or no treatment at all. Those studies are now starting to be done. But we seem to be on the verge of the new
era when we take these important drugs seriously, use them under clinical settings and we may
be able to remedicalise them. The big risk we face is whether remedicalising
will reintroduce them into free-range where people use them for recreational purposes. The difficulty with that is that these drugs
are dangerous when people take them in the wrong setting, with the wrong people and in
the wrong circumstances. Really really bad things can happen. That was part of the original moral panic
as well as the political implications of drug use, and it remains a valid concern which
we’ve got to take very seriously. So the challenge for our society is, are we
know to simply reestablish this for medical implications and if we are going to do that
what are we going to do about recreational indication? Because all the experience with cannabis suggest
that you start with the medical indication but you end up with a much wider recreational
legality which is happening all over North America. We’re not sure that this is really a great
idea for the society at large. That’s where we sit at the moment, we sit
at an interesting point: we’re waiting for the results of definitive trials that show
the usefulness of psilocybin and other hallucinogens particularly with difficult to treat depression
but we’re unsure how we’re going to take this forward maintaining a medical cocoon of safety
but at the same time recognizing that people may claim the right to make these drugs a
recreational choice. It’s going to be an interesting social and
political challenge to get this right.

6 thoughts on “Psychedelic Drugs in Psychiatry — Guy Goodwin / Serious Science

  1. I wonder if Guy here has any anectodal insights he shares or is afraid to share with his students. I also wonder if drug use still carries stigma in such a profession or if everyone in the Oxford psychiatry department listens to the grateful dead.

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