Fragile promise of psychedelics in psychiatry

The authors of this recent BMJ paper write: "The US clinical market for ketamine, estimated at $3.1bn in 2022 and expected to expand at 10.6% a year until 2030, is just one of many signs of renewed interest in the use of psychedelics to treat psychiatric conditions. Various mind altering drugs have already entered the market, including esketamine nasal spray, which the US Food and Drug Administration approved in 2019. And in 2022 the Australian Therapeutic Goods Administration (TGA) allowed psilocybin and 3,4-methylenedioxymethamphetamine (MDMA) to be prescribed by authorised physicians for psychiatric conditions such as depression and post-traumatic stress disorder. The decision was taken despite an independent scientific report commissioned by the TGA advising against authorisation because the certainty of evidence for benefits was low or very low.  Psychedelics, the lay term for substances classified as hallucinogens, have various targets and distinct purported mechanisms of action. For instance, psilocybin is a serotoninergic agonist, whereas esketamine is a N-methyl-D-aspartate (NMDA) glutamate receptor antagonist, although its effect is also attributed to synaptic plasticity. Mystical experiences have also been reported as a mechanism of action. Nevertheless, hallucinogens as a group are often understood as “a new paradigm of care for mental health.”  While many countries, including the UK, Japan, Indonesia, Saudi Arabia, Singapore, Russia, and China, have maintained relatively strict regulatory standards for hallucinogens, more relaxed approaches in the US, Australia, and Europe are hindering repeated calls for a critical evaluation of the evidence."

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