Ghaemi told me that he is concerned that a regulated psychedelics program in Massachusetts could cause harms. The more widespread use of psychedelics could, in his view, cause “hallucinations and delusions”, which he believes would be “especially common and harmful in thousands of persons with mood conditions, bipolar and unipolar.”
Increased use of psychedelics would also “lead to more overcrowding of emergency rooms and hospitals with psychotic crises,” Ghaemi fears, “leading to harm to those with medical crises who will not be seen and treated effectively.”
“They also will lead to car accidents by those who are psychotic while driving,” he added, “which will cause death and disability to innocent civilians.”
Ghaemi’s dim view of Massachusetts’ potential regulated psychedelics program extends to his view of psychedelic research, too. The psychiatrist told me that he feels psychedelics may have promise in treating the symptoms of mental health disorders, like electroconvulsive therapy (ECT), but “they likely do not have any long-term benefit”.
He acknowledged that short-term symptom benefit can be useful, but that these uses should be “limited in scope and appreciated as emergency limited use scenario”.
“An exception could be in PTSD,” Ghaemi continued, “where long-term benefits could exist if proven.”. “In that case, benefits of short-term treatment with long-term improvement in the course of the illness, as currently proven only with EMDR therapy, would be an important contribution”, he said.
Why did Ghaemi single PTSD out? He told me that disease-modification “means improvement in the long-term course of a bona fide disease, like bipolar illness, schizophrenia or PTSD”, which he contrasted to some DSM diagnoses which he says “are not diseases, like ‘major depressive disorder’ or ‘generalised anxiety disorder’.” Rather, those are “constellations of conditions with similar symptoms”, he explained, meaning that even long-term improvement in those conditions “would still be only symptomatic.”
But, in the case of PTSD, he says that disease modification could be demonstrated, in theory, via a long-term double-blind two-arm study that follows-up for at least one year.
It’s worth noting that this whole ‘disease-modifying’ vs. ‘symptomatic’ treatments dichotomy has featured prominently in Ghaemi’s work (see, for example, Ghaemi, 2022), and isn’t necessarily reflective of other psychiatrists’ potential concerns around psychedelics’ role in the field.
Given Ghaemi’s strong conviction that psychedelics would not prove to be transformative for mental health issues, but rather deal with the symptoms, I asked him what would or could be transformative.
“There are many good mechanisms and drugs that have been developed”, he told me, but added that these are “ignored by many companies.” “The idea that we only have psychedelics”, he continued, “shows the intellectual bankruptcy of our field and of psychiatric drug development in general.”
I asked Ghaemi to be more specific, to which he provided a few examples of mechanisms “either associated with known drugs with disease modifying effects or scientific evidence that could support disease modification”. Those included “second messenger mechanisms”, “calcium channel activation”, and “epigenetic modification of certain genes”.
The problem, according to Ghaemi, is that no one is looking for disease modification. “The studies would need to look at the course of illness over years, as in cardiology and oncology, not current symptoms over days, weeks, months, as in psychiatry”, he said. “Companies don’t show interest in such mechanisms, and they don’t look for such approaches, because of the pervasive ideology that improving immediate symptoms is all we need to do”, he added.
He believes that this motivation can be traced back to psychedelic policy reforms, too, saying that “the public clamours for it, as with these ballot questions, without realising that their desires remain purely symptomatic.”
Ghaemi was focusing here on much larger topics like the incentive structure of drug discovery and development. I wanted to bring things back to psychedelic drug development and policy, so I asked him about concerns with psychedelics ‘subject matter experts’ (SMEs) that he raised in a recent Substack article.
“As with many things,” he said, “the SMEs follow the money… Wherever there is funding, they’ll study it.”
“I speak from experience, having been an expert in psychopharmacology of mood illnesses for three decades”, he told me. “I often found that certain medications, like antidepressants, were not effective”, he said, “[but] it was very difficult to get funding to show that such agents did not work, even from non-pharma sources such as NIMH.” “In contrast, colleagues who claim that something works, like ketamine, are able to get funded very easily from many sources, including government”, he added.
While the political economy of pharmaceutical research and development is certainly fair game for debate, and something that’s increasingly salient in American political discourse, so too is the public’s mistrust of healthcare professionals, including psychiatrists. I asked Ghaemi how he thinks psychiatrists can regain that trust.
“One way is by not going along with public fads, like hallucinogens”, he started, before drawing an analogy with cannabis.
“On the cannabis claims for medical benefits followed by legalization, the psychiatric profession was silent, even though we knew and know even more now that cannabis is addictive and harmful for many people”, he said. “This does not argue against legalization for social reasons, like decriminalization, but we need to be honest with the public about real medical harms”, he clarified.
“Now, with other hallucinogens, we have a chance to be honest in that way, and I find that my colleagues in Massachusetts are more aware and willing to be public about their concerns”, he said, but added that he is concerned that pro-psychedelics initiatives are being pushed by “the same Political Action Committees and right-wing billionaires” that promoted cannabis legalisation.
“We’ve learned from cannabis,” Ghaemi said, “and we are trying to engage the public in more thoughtful discussion now with psychedelics.”
“These days younger generations, millennials and Gen Z, are very attached to hallucinogens, and they may not be happy with us now when we point out flaws in their assumptions”, he said. But, in the long term, Ghaemi hopes that his ilk will gain their trust and “realize we tried to be honest with them.”