As I’m pre-charting for my primary care clinic, I see Ms. C on the schedule, whom I know well through our nearly monthly follow-up visits over the past two and a half years of residency. We talk in Spanish as it’s her preferred language. She shares her escalating distress over being an immigrant, a full-time caregiver for her dad with advancing dementia and three kids, and current marital issues while managing her anxiety, depression, fibromyalgia, IBS, and pelvic pain syndrome. She has seen multiple specialists, used virtually all the common psychotropic medications, and tried transcranial magnetic stimulation therapy, yet she still reports suffering greatly. It has gotten so bad that she is now going to the ER regularly, seeking relief, putting her at increased risk of opiate exposure.
Sadly, her situation is not rare. Many of my patients have demonstrated the limits of current biomedical models to alleviate or truly “cure” complex problems that touch the emotional, spiritual, and social domains. As a soon-to-graduate primary care resident, I find myself wondering how well-prepared I am to help her and what other forms of support would be most beneficial.
Psychedelic therapies have recently been in the headlines, and with the trends toward decriminalization in some states, some patients are seeking them out. Like other complementary and integrative related approaches, many patients do not share their interest in these therapies with their doctors because of fear of criticism, among others. Yet, even if our patients said to us, “Hey, what do you think about psilocybin psychedelic therapy for what I have, doc?” Are we, as primary care and specialist doctors, really ready to talk about it with them in a balanced and well-informed way?
The business world has clearly paid lots of attention to the emerging promising results of psychedelics research, especially in mental health and trauma, and an explosion of wellness-focused retreats, therapy centers, and expensive out-of-pocket treatments are increasingly becoming available worldwide. Users-led advocacy groups are also expanding rapidly, and it seems the trend is growing exponentially.
Meanwhile, a quick search of the keywords “psychedelics,” “psilocybin,” and “hallucinogens” on the American College of Physicians website led to zero results. At the American Medical Association, the first result is a report of the Council on Science and Public Health named “Emerging Drugs of Abuse are a Public Health Threat.” Even the NIH’s NCCIH has no key documents discussing this topic.
There has been a growing body of research on the therapeutic potential of psychedelic substances, particularly in the treatment of mental health conditions such as depression, anxiety, existential distress, and PTSD. Several clinical trials have found that psilocybin, the active ingredient in “magic mushrooms,” can significantly sustain improvements in depression, anxiety, and existential distress in patients with life-threatening illnesses, such as cancer. For example, a randomized, double-blind study published in JAMA Psychiatry found that a single dose of psilocybin produced significant reductions in depression and anxiety in patients with cancer-related psychological distress. These effects persisted for up to six times months. Another study involving patients with treatment-resistant depression who received two doses of psilocybin along with psychological support, showed significant improvements in depressive and anxiety symptoms that lasted for up to 12 months. No serious adverse events were reported, and the treatment was well-tolerated by the participants.
For thousands of years, traditional indigenous groups have used psychedelics as sacred medicines, seeing them not as drugs to treat an illness but as guides or teachers to facilitate deeply spiritual healing that unites the body, mind, and spirit. In contrast to the biomedical model of treating symptoms as isolated from the whole person, traditional medical systems view individuals as interconnected beings whose well-being requires restoring balance and harmony to all aspects of their being.
Psychedelics are known to produce profound alterations in consciousness, including changes in perception, thought, and emotion. The exact mechanism of action of these substances is not fully understood, but one prominent theory is that they work by binding to and activating serotonin receptors in the brain, causing changes in the activity of neural circuits.
Another theory suggests that psychedelics may work by increasing the plasticity of neural networks in the brain, enhancing the ability to form new connections between neurons and to break down existing patterns of thought and behavior, allowing for novel insights and experiences.
In addition to the theories mentioned above, scientific research is trying to grasp the essence of the “mystical experiences” described as potential mechanisms through which psychedelics work. These mystical experiences are often described as a sense of unity, interconnectedness, and transcendence of time and space, and may be a key component of the therapeutic potential of psychedelics. These topics that relate to consciousness and “otherworldly” experiences are not part of common medical speak or understanding at this time.
The lack of information on psychedelics in the mainstream medical community can lead to patients seeking these therapies without the guidance or co-management of their health care professionals, potentially putting them at increased risk. It is crucial for us as doctors to be informed, as well as to honor and respect the origins of these traditional medicines and be up to date with the emerging research supporting their safe and equitable use for specific patient populations.
I believe a starting point to grow awareness of psychedelics would be through medical education, starting with medical students and residents. That would look like having a session or workshop that would support students to reflect on their own biases and perceptions of these therapies, and potentially opening up to the possibility of other ways of knowing and healing that traditional medicines may teach us. Health systems could also apply this to provide carved-in time for in-service training for primary care doctors. By doing so, we can provide our patients like Ms. C with the best possible care, addressing their physical, emotional, and spiritual needs.
Thaís Salles Araujo is an internal medicine resident.