“As psychedelic therapies gain increasing prominence, it is vital that psychiatrists remain mindful of unique ethical and practical challenges surrounding their use in clinical settings,” wrote Gregory Barber, M.D., a psychiatrist in private practice in Bethesda, Md., and Charles Dike, M.D., M.P.H., chair of the APA Ethics Committee, in a review article appearing in Psychiatric Services in Advance. Dike is also an associate professor of psychiatry at Yale University School of Medicine.
Contemporary research on psychedelics for the treatment of mental illness is focused primarily on psilocybin, found in a type of mushroom, and MDMA, a synthetic amphetamine derivative in the subgroup of psychedelics called empathogens. Barber and Dike underscored several ethical issues that psychiatrists may face regarding psychedelic therapies in clinical practice:
- Research equipoise amid high enthusiasm for psychedelics: Psychedelic therapies are in a relatively early stage of research. Research equipoise requires that researchers and clinicians must not decide what is true before the science informs their decision.
- Informed consent: Distinctive features of psychedelic psychotherapies may require what some have called “enhanced consent.” The goal of “enhanced consent” is to ensure that patients have a thorough understanding of psychedelic therapies. “These principles of consent apply in current research settings but would also be relevant in general clinical practice if psychedelics were to be approved for broader use,” they wrote.
- Patient vulnerability: Psychedelic psychotherapy involves profound and acute changes in consciousness, and some unique risks and possible adverse effects, which place patients in a vulnerable position. “Psychedelics are not effective or desirable for everyone, and psychiatrists should attempt to identify patients who are particularly vulnerable to negative outcomes before suggesting that [they] undergo a psychedelic experience,” they wrote.
- Off-label use of psychedelics: “If psychedelics are approved for general psychiatric use, psychiatrists will likely encounter patients who seek psychedelic therapies,” they wrote. In that case, psychiatrists should be mindful that psychedelics should be prescribed only to treat diagnosable psychiatric disorders. Patients should be carefully screened for any underlying psychopathology. “If no clinical indication is found, psychiatrists should avoid prescribing psychedelics, just as they would any other medication.”
- Nonclinical uses of psychedelics: Psychiatrists may already be hearing from patients who are seeking their advice about the use of psychedelics outside clinical settings. Psychiatrists should be clear that although clinical trials are promising, these medications are still in the experimental stage. Such conversations may offer opportunities to educate patients on “the difference between psychedelic use in a clinical setting, where clear protocols are in place to ensure patient safety, and in a naturalistic setting [for example, for recreational use], where efficacy and safety are less assured,” they wrote.
- Equity and access: As research and clinical applications of psychedelics expand, efforts should be made to ensure that these interventions can be accessed by anyone who may benefit from them and are not reserved for a select few.
“As psychedelics become more prominent in psychiatry, psychiatrists should continue to emphasize their safe, effective, and ethical use,” Barber and Dike wrote.
For related information, see the Psychiatric News article “Psychedelics Legislation Gains Momentum.”
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