Will psilocybin lose its magic in the clinical setting?
In a new article published this week, in the journal Therapeutic Advances in Psychopharmacology, authors explore the difficulties that may be encountered as psilocybin emerges from research toward a licensed medicine.
Abstract
Psilocybin as a novel treatment for depression is garnering a lot of attention from both the mainstream media and the academic community. Although phase 3 trials are only just beginning, we feel that it is important for clinicians to consider what psilocybin-assisted psychotherapy might look like in the clinical setting. In this narrative review article we have considered the difficulties that may arise as psilocybin emerges from the research setting, which may hamper its progress towards becoming a licenced medication. Psilocybin has its own unique challenges: the expectation patients come to dosing with having read overwhelmingly positive media; patient suggestibility under the influence of psilocybin and requirement for specialised therapists to name a few. We have also made some recommendations for measures that should be taken in both the phase 3 trials and with clinicians to try and minimise some of the issues raised. In doing so our hope is that psilocybin will continue towards becoming a licenced medication that suitable patients are able to access with relative ease. Practicing psychiatrists need to have an awareness of the potential pitfalls of psilocybin as they will be responsible for prescribing it in the future.
Over the past few years, psilocybin therapy has shown promise in preliminary studies investigating its safety and efficacy in substance misuse, Obsessive Compulsive Disorder, Major Depressive Disorder and Treatment-Resistant Depression, and end of life anxiety associated with cancer and AIDS. This suggests that psilocybin may be a versatile tool that can be used to alleviate transdiagnostic psychological distress.
However, this review highlights the bias of the research - A significant number of those who volunteer to take part in trials have previous experience with psychedelics, and they often come with a high expectation of a positive experience. In the vast majority (70.6%) of psilocybin studies, 75% of all participants were white. This is important because, as Michaels et al. point out, we are currently testing a highly specific therapy under narrow conditions on an exclusive group. This is reiterated by Sellers et al, who describe the study population as ‘Often mainly Caucasian, highly educated living in major urban centers with access to tertiary medical care.’ As Hayes et al. delineates in this article - 'clinicians should be mindful that the reality of clinical psilocybin on a broader population may not match the promising picture painted by the research. This is a particular concern when psilocybin is being researched as a treatment for depression as its prevalence is greater in those of a lower socioeconomic status'
The paper concludes that whilst psilocybin is a 'valuable and versatile tool in the treatment of several mental disorders when utilised with the appropriate therapeutic support' that 'ideally future phase 3 trials should recruit study populations that better represent the full population for whom this treatment is intended'. that there is a need for 'more information about long-term effects before psilocybin can be used in psychiatric practice'. they finalise with a word of caution regarding expectancy bias and that 'it is paramount that strict standards around therapist training, chaperone provision, and course of therapy are maintained in clinical settings to maximise benefits and minimise risks'.
Hayes C, Wahba M, Watson S. Will psilocybin lose its magic in the clinical setting? Therapeutic Advances in Psychopharmacology. January 2022. doi:10.1177/20451253221090822
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