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Episode 31

  • What is Psychedelic PTSD Treatment?

  • What is MDMA?

  • What about Ketamine and Psilocybin as treatment options?

MDMA or Ecstasy is a unique kind of hallucinogen. It’s known as a party drug but also as a psychedelic PTSD treatment. We’ll explore this and two other hallucinogens that are currently being tested and used for treatment of PTSD and depression. 

Helpful Links

What is the history of MDMA? | National Institute on Drug Abuse (NIDA)

Who is using MDMA? | National Institute on Drug Abuse (NIDA)

What are the effects of MDMA? | National Institute on Drug Abuse (NIDA)

MDMA | Ecstasy | Effects of MDMA | FRANK

What are MDMA’s effects on the brain? | National Institute on Drug Abuse (NIDA)

Can MDMA use during pregnancy harm the baby? | National Institute on Drug Abuse (NIDA)

Fact Sheet: Breakthrough Therapies | FDA

Facts About the Psychoactive Drug Ecstasy (MDMA)

Is MDMA Addictive? | National Institute on Drug Abuse (NIDA)

FDA Grants Breakthrough Therapy Designation for MDMA-Assisted Psychotherapy for PTSD, Agrees on Special Protocol Assessment for Phase 3 Trials – MAPS

MDMA (Ecstasy/Molly): Effects, Hazards & Extent of Use – Drugs.com

MDMA-assisted psychotherapy for people diagnosed with treatment-resistant PTSD: what it is and what it isn’t

MDMA, Used In Therapy, May Help People Heal From PTSD : Shots – Health News : NPR

Five Things to Know About MDMA-Assisted Psychotherapy for PTSD – Physician’s Channel – Mount Sinai New York

Does recreational ecstasy use cause long-term cognitive problems?

Hallucinogen Use Disorders Among Adult Users of MDMA and Other Hallucinogens

10 Facts About MDMA | Drug Policy Alliance

From ecstasy to molly – what’s in a name when it comes to drug use?

Neurotoxicity of drugs of abuse – the case of methylenedioxy amphetamines (MDMA, ecstasy ), and amphetamines

“Ecstasy” to Addiction: Mechanisms and Reinforcing Effects of Three Synthetic Cathinone Analogs of MDMA

Club Drugs: MDMA, Gamma-Hydroxybutyrate (GHB), Rohypnol, and Ketamine – American Family Physician

Club Drugs | National Institute on Drug Abuse (NIDA)

A Look Inside MDMA-Assisted Therapy

The Psychedelic Therapy Podcast | Bessel van der Kolk (The Body Keeps the Score): A Revolutionary Treatment for Trauma

How ecstasy and psilocybin are shaking up psychiatry

Magic Mushrooms: Myths, Effects, Risks, and How to Get Help

Psychedelic Treatment with Psilocybin Relieves Major Depression, Study Shows

Psilocybin Treatment for Mental Health Gets Legal Framework – Scientific American

Psychedelic medicine: A mental health game changer? | Pursuit by The University of Melbourne

‘Magic mushroom’ ingredient could work as mental health treatment – CNN

Psilocybin for Depression: What You Need to Know

Effects of Psilocybin-Assisted Therapy on Major Depressive Disorder: A Randomized Clinical Trial | Complementary and Alternative Medicine | JAMA Psychiatry | JAMA Network

Johns Hopkins Center for Psychedelic and Consciousness Research

Publications — Center for Psychedelic & Consciousness Research

Psilocybin for Depression Study | The Beckley Foundation

Revisiting the Hallucinogenic Potential of Ketamine

Ketamine for major depression: New tool, new questions – Harvard Health Blog – Harvard Health Publishing

Ketamine abuse potential and use disorder – ScienceDirect

Revisiting the Hallucinogenic Potential of Ketamine

Ketamine: Uses, effects, risks, and warnings

What Is Ketamine? | Dual Diagnosis

Patterns of Ketamine Use Among Young Injection Drug Users

How Long Does a Ketamine Treatment Last? – Principium Psychiatry

Ketamine | Effects of Ketamine | FRANK

Everything You Need to Know About Using Ketamine

Stories of Special K patients

How ketamine combats depression — ScienceDaily

How New Ketamine Drug Helps with Depression > News > Yale Medicine

Long-Term Heavy Ketamine Use is Associated with Spatial Memory Impairment and Altered Hippocampal Activation

Ketamine abuse potential and use disorder – PubMed

Ketamine Abuse Signs, Symptoms, and Addiction Treatment

Ketamine is revolutionizing antidepressant research, but we still don’t know how it works

6 Things to Know About Ketamine for Depression – MedShadow

The Real Pros and Cons of Ketamine Infusions – TMS & Brain Health

Ketamine May Relieve Symptoms of Treatment-Resistant Depression

Free Treatment Tool https://betsybyler.com/treatment-tool/

Transcript

You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 31.This is the last part in a series about hallucinogens. In the first series we covered classic hallucinogens like LSD and mushrooms. In the second part of the series, we covered dissociative hallucinogens, like ketamine and PCP. For this episode, we’re going to be talking about MDMA or ecstasy which I haven’t covered in the other sections. This is mainly because ecstasy is sort of unique. It is a hallucinogen, but it’s also an amphetamine derivative and therefore part stimulant.

Psychedelic PTSD Treatment: Ecstasy or MDMA

Ecstasy has gotten a lot of press. Part of that is because of the use in trauma therapy and the stage three trials that are going on right now.  Ecstasy has been making waves for many years. I remember it when I was in high school and people talking about using it at raves. I don’t hear a ton about raves anymore. I’m not sure if that’s because they’re not happening or if they’re just not a big deal anymore. When people are using ecstasy they don’t really need to be at a party and so the idea that these are quote club drugs, as they were referred to in the late nineties, isn’t really how people think of them anymore.

Ecstasy is often abbreviated MDMA because the scientific name methylenedioxymethamphetamine is a little hard to say. MDMA or ecstasy is a synthetic drug that acts like a stimulant and a hallucinogen. It produces an energizing effect, it distorts time and perception and gives you enhanced enjoyment from sensory experiences. It’s often described as an entactogen, a drug that can increase self-awareness and empathy. 

Ecstasy can also be called Molly. Molly is slang for molecular. It refers to the crystalline powder form of MDMA that’s usually sold as powder or in capsules. Some people believe that Molly does not contain contaminants and they call it pure ecstasy, but that’s not actually the case. So ecstasy in general is sold as tablets, the powder that’s in powder form or in capsules is what people refer to as Molly,

For our purposes ecstasy, and Molly are the same thing. The DEA has seized tons of ecstasy over the years and their chemical analysis of the drugs has found that most of them have a ton of contaminants in them. This could be fillers or it could be other drugs. For example, around 2015  epidemiologists from Florida and Washington state reported that the main ingredient in a lot of the ecstasy found that year was from bath salts, which is supposed to be synthetic methamphetamine. The chemical that makes up bath salts is really different than what we’re talking about with MDMA. While it does produce distortions and does produce an amphetamine like effect it is not the same thing as MDMA at all. Because MDMA is illegal it is really hard to find a pure sample of ecstasy

MDMA was developed by a German pharmaceutical company in 1912. It was intended as a parent compound to synthesize medications that control bleeding . Sometimes people say that it was found as a way to control appetite, but that’s not actually the case. 

MDMA gained a small following in the seventies and eighties, despite the fact that it had not  undergone formal clinical trials. Some psychiatrists believed that it enhanced communication in patient sessions and allowed patients to achieve insights about their problems. It was also during that time that ecstasy became more widely available on the street. 

In ‘85, the DEA declared an emergency ban on MDMA. It was placed as a schedule one drug defined as a substance with no currently accepted medical use and a high potential for abuse. It has been a schedule one substance ever since, except for a brief period of time between 1987 and 1988.

In the early nineties, the FDA approved the first human trial exploring whether MDMA could help relieve pain  in terminally ill patients, as well as serve as an adjunct to therapy. While  the results from these studies weren’t formally published, It did help create some safety guidelines for administering MDMA to patients in a controlled setting.

It’s important to note that on the street MDMA, ecstasy and Molly are the same thing.  But the researchers would definitely beg to differ. Ecstasy on the street is not pure MDMA the way they would have in research trials.

In 2012, the FDA had the Food and Drug Administration Safety  and Innovation Act was signed. This act section 902  provides for a new designation, of a breakthrough therapy designation. In order to qualify as a breakthrough therapy, the drug must be intended alone or in combination with one or more drugs to treat a serious life-threatening disease or condition. And that preliminary clinical evidence indicates that the drug may demonstrate substantial improvement over existing therapies on one or more clinically significant endpoints such as substantial treatment effects observed early in clinical development. If a drug is designated as a breakthrough therapy  the FDA will expedite the development and review of such drug.

Five years later in August of 2017, the FDA granted MDMA the status of breakthrough therapy. This opened the door for phase three clinical trials. It was a huge win for people who are working on MDMA research. That’s a bit about the history we’ll get to the treatment trials later in this episode.

In terms of prevalence MDMA first gained popularity among adolescents and young adults in the nightclub scene and at raves, like I mentioned before. The profile  of the typical person who uses MDMA has been changing. Beginning in ‘99 community level data from NIDA began to report that the use of MDMA had spread among populations outside of the nightclub scene.

According to NIDA, MDMA is predominantly used by males between the age of 18 and 25 with most use beginning around 21 years of age. Other NIDA funded research has suggested that sexual orientation influences MDMA usage rates. For instance, gay or bisexual men and women appeared more likely to have used MDMA recently than their heterosexual counterparts.

So on the street, ecstasy can come in tablet form or as a powder that’s either just the powder itself or contained in capsules.  When it’s taken in tablet or capsule form, a person begins feeling the effects 45 minutes later on average. The peak happens about 15 to 30 minutes after you first start feeling it to begin with and the effects can last from two to four hours. The after effects take a little while longer to subside, depending on what’s in the ecstasy, these times will vary depending on what kinds of other drugs are included in the tablet.

The difference here  from other hallucinogens is that there really aren’t a ton of reports of bad trips. You recall that when we talked about the other kinds of hallucinogens, that there was always this pretty high risk for a bad trip. That is possible that they could have a bad trip and the original advice stands: Don’t do it when you’re having a bad day, do it with people that you trust, that kind of thing.

Physical side effects are dilated pupils, tingling sensations, tightening, or moving of the jaw muscles, raised body temperature and a fast heartbeat or nausea. The feelings that people are after are happiness, feeling “loved up” where there’s an increase of feeling love and affection for the people they’re with and even strangers around them, feeling energized and alert and generally feeling more in tune with their surroundings like music being more intense, which is why MDMA became a party drug.

Ecstasy is also said to be an enhancement for sex. You can imagine that as a sensory experience, sex is pretty high up there . If ecstasy increases all those sensations doesn’t take a lot to figure out why someone might want to use that and then have sex. Makes sense.

So all this sounds pretty good, right? A hallucinogen that has somewhat of a stimulant effect. So you’re going to have a distortion, but also more energy. It enhances the sensations of things around you, both physical and mental and makes you happy.  What’s the downside? Well, there is a downside.

The potential downsides for MDMA are  two main things. One of them has to do with body temperature. And another has to do with the amount of water that’s consumed. So one of the main issues with MDMA when taken in a party atmosphere is the increased body temperature or hyperthermia. So we know that hypothermia has to do with cold weather and when your body temperature drops too low. Well, hyperthermia is just the opposite.

MDMA is often associated  with increased physical activity for extended periods of time and sometimes in overly warm environments, like concerts, parties, that kind of thing.  It’s a rare acute side effect, hyperthermia.  But research has shown that even moderate doses of MDMA can interfere with the body’s ability to regulate temperature.

Treatment of hyperthermia  requires prompt medical attention, as it can rapidly lead to muscle breakdown or electrolyte imbalance, which in turn can produce kidney failure or fatal swelling of the brain, especially in women.

MDMA use combined  with increased activity can cause dehydration leading some people to drink a large amount of liquids. . This could increase the risk of electrolyte imbalance or brain swelling because MDMA causes the body to retain water. One modest dose of MDMA can also reduce the pumping efficiency of the heart in people who use it regularly, which is of particular concern during periods of increased physical activity. 

The issue here is that when someone is on ecstasy, they’re not thinking about things in an average, typical way. Their perception is distorted. Their feelings are magnified, and they’re really focused on the experience, and not necessarily paying attention to their body temperature and whether or not they’re safe. As with any stimulant, there’s going to be some issues with heart rate risk for cardiac arrhythmias and high blood pressure.

There are some other things that MDMA  abuse can produce like involuntary jaw clenching, lack of appetite mild detachment, like depersonalization illogical, or disorganized thoughts, restless legs, nausea, hot flashes and chills, headache sweating of course, and muscle or joint stiffness..

Once MDMA is metabolized or broken down its byproducts interfere with the body’s ability to metabolize MDMA. Because of that additional doses of MDMA can produce unexpectedly high blood levels, which could worsen the toxic effects of this drug. Combining MDMA with other substances like caffeine, amphetamines, marijuana, and alcohol can increase the risk of adverse health effects.

The way MDMA works is it affects the activity of at least three of our main neurotransmitters, serotonin, dopamine, and norepinephrine. Like other amphetamines MDMA enhances the release of these neuro-transmitters and blocks their reuptake. This results in increased neuro-transmitter levels.

MDMA causes a greater release of serotonin and norepinephrine than of dopamine, which is kind of interesting.  Usually when we’re talking about drugs, we’re talking a lot about dopamine , since that’s our feel good chemical.

We do know that serotonin plays an important role in regulation of mood, sleep, pain, appetite, and other behaviors. It’s suggested that the excess release of serotonin when you take MDMA is likely the cause for the mood elevating effects that people experience. Because of the big release in serotonin on the backend the supply of serotonin has been depleted  which can lead to low feelings. This could be for several days after taking MDMA.

One of the things about long-term or intense use of MDMA is that there’s a potential for  damaging changes in the brain. Remember that this is about abuse, not about the clinical trials.

Research has suggested that there’s damage to the nerve cells that contain serotonin, that there might be reduced numbers of serotonergic neurons even seven years later, indicating that some of the effects on the brain can be long lasting. Following binge dosing. So that’s taking it multiple days in a row or at high volumes for a few weeks. The low mood or lack of serotonin flowing in the system can last for several weeks after that period of bingeing. Some studies suggest that long-term use also creates some cognitive impairment in processes involving norepinephrine.

A lot of MDMA is being used during childbearing years. There’s some research to suggest that use of MDMA while pregnant could be associated with motor delays in children up to two years after birth. We need more research to determine if these delays persist in later life. A lot of the research is done on animals because as you can imagine, doing research on pregnant women and administering MDMA to them is not something they’re going to do.

Fatal overdoses from MDMA are rare, but have been recorded. The issue with ecstasy in terms of danger has to do with the long-term effects from binge use or long-term abuse of MDMA.  

In terms of whether MDMA can be addictive the research is inconclusive. There seems to be consensus that you could develop a tolerance and that there could be some semblance of dependence in terms of feeling like you want to get those feelings back. I haven’t known a very many people at all in my career who had ecstasy or MDMA as their primary drug of choice.

I believe it’s somewhat self-limiting due to the recovery time and the comedown from it. If you’re feeling low and that happens for a few days. Yeah. You could take more, but eventually you have to be able to return to whatever normal life looks like for you.

Plus you’re getting ecstasy from a number of different people and all of it’s going to have different ingredients. That makes it unpredictable. And if it’s mixed with things like say bath salts, that’s going to cause a really different experience than pure MDMA.  I have found in doing substance abuse assessments, that people have experimented with ecstasy,  but typically haven’t used it on a regular basis.

We’ve covered the first part of our episode, talking about ecstasy and the abuse of ecstasy. Now we’re going to move into the second half of our episode, where we’re talking about the use of some psychedelics in mental health treatment. MDMA is one of the ones that is most commonly talked about when we’re talking about mental health treatment and illicit drugs.

Remember earlier, when we were talking about the history of MDMA well, in the seventies and eighties, there was research happening and some discussion in the psychological and psychiatric community about the use of psychedelics for treatment. There was some great backlash though and you may recall that it was during that time that hallucinogens were getting banned kind of all over the place. A lot of the research stalled in the Nixon administration because of the ”war on drugs”.  The resurgence of psychedelic research has been around for many, many years.

The Multidisciplinary Association for Psychedelic Studies or MAPS has been around for over 35 years. They have been conducting research and continuing to push the government to allow this research to occur. It’s taken incredible perseverance for them  to get clearance, to be able to do these kinds of trials.

So some might wonder why is the government allowing researchers to use psychedelics in their studies? Well, I think it has to do with 2001. We had not been at war as a country for many, many years. Yes. We had a military conflict in the early nineties called Desert Storm, but it was really short lived and there was not a large loss of life.

In 2001, after 9/11 we went to war and we’d been at war for well over 10 years. There are still troops that are deployed that started out as part of that original conflict. We started that war in Afghanistan and extended it to Iraq. With war comes combat, and with combat comes loss and death and grief and PTSD. The VA has been overwhelmed with the number of veterans coming home with PTSD. And honestly, I don’t know that they’ve been equipped to deal with it.

I’m not blaming the therapists at the VA. The VA is a giant organization and moves slowly. It’s the government; that’s how that works. Some areas of the country the VA is amazing. My parents were both in the military and I have experience with the Veterans Administration because of it. I know that the VA in Sioux Falls, South Dakota took amazing care of my mom. I couldn’t have asked for better care for her. Now, the VA in other places that we lived like in certain places in Michigan, it was kind of a cluster.

I don’t think the VA was prepared structurally to deal with the influx of PTSD. We have a ton of vets all around the country who are suffering and have not been taken care of well. The need for really effective treatment for PTSD is huge. The VA has often felt that exposure therapy was the way to go.

Those of us who do trauma therapy know that exposure therapy can do some good. I also know that it’s not effective for every client that I work with. In addition to being a substance abuse counselor, I’m a trauma therapist and I was trained in the method that the VA had supported. Cognitive Processing Therapy did work for some of my clients. I also saw it go badly. 

I ended up training in EMDR, even though I was resistant to it. I initially thought it was some voodoo magic bullshit, but I found that I didn’t have enough skills to work with my traumatized clients. Some of them I could do good work with. Some of them were getting better, but there was a subset of them that weren’t getting better.

The commonality between them was that they had more severe trauma, the likes of what you’d see on Law and Order SVU, that kind of thing. So EMDR became it for me and I have found it to be incredibly effective. I don’t mind admitting that I was totally wrong about it.  It is this surge of PTSD cases that I think  is pushing the scientific community to find ways to treat PTSD.

When I first heard about them using MDMA I was a little shocked. It was Bessel van der Kolk that I heard it from first. I was at a conference in the fall of 2017 when I heard him speak about it. He had planned his MDMA experience for like three weeks  after I saw him there. The man was 70 or so at the time. I heard him talk about what it could do and he showed us portions of a video from some MDMA assisted sessions. Ever since then I’ve been watching it carefully.

The idea behind MDMA assisted therapy is not that people are going to be taking MDMA on the streets. The research is being done on guided trips in a controlled environment. Currently the trials require two psychotherapists to be present for the trip. This could be during an eight hour period where both therapists are there to help guide the individual through the experience from start to finish.

This makes sense to me because MDMA is a hallucinogen and during hallucinogenic trips, people are generally pretty suggestible. The way this works  from what I can tell as well as my own experience with hallucinogens when I was using, is that it separates you from your everyday self. You can look at things differently and view them in a new light. Those of us who do trauma therapy know that we’re trying to get our clients to step out of their own perspective and see their trauma from a different perspective so that they can see the whole picture.

In the video that I watched of a treatment, it was a vet who had been on a convoy in Afghanistan. There had been an IED on the side of the road and it blew up their convoy. Almost everyone died and he survived. He had tremendous survivor’s guilt and felt like he had done something cowardly that allowed him to survive.

During this experience, he was able to see it from a more distant view. And in very short order was able to come to his own conclusion that he did what he needed to do to survive and that there was no shame in that. Think about if we could help someone in one few hour session, come to those conclusions.

That takes a ton of time in regular therapy. And even in EMDR, which I find to be way quicker than traditional therapies, it’s still not that fast. Because the feelings of empathy and love and compassion that are produced with MDMA , they’re often able to have compassion for themselves and less judgment.  What they found is that the effects are long lasting. A specific study showed the year later that the participants still maintain the gains that they made and did not meet criteria for PTSD anymore. That is so huge.

I’m walking a fine line here as an addict in recovery, a substance abuse counselor and a therapist specializing in trauma. I see the different sides. As a substance abuse counselor and an addict in recovery, I see some dangers with MDMA and I’m not as concerned about those becoming the drug of choice as I am about others. If someone gets sober from their drugs of choice, I don’t know that MDMA is going to be an issue for them.

As a trauma therapist I want to do whatever I can to bring healing into the lives of my clients. Healing that is long lasting where they actually recover from PTSD. When I first learned EMDR, it was like a miracle. I know that sounds like I’m exaggerating, but I have seen it work time and again, I have seen people process some really fucked up experiences and things that people should never have to experience. And I’ve seen them recover. That kind of hope is contagious. And so if MDMA supported  psychotherapy can do that. I think that it is our responsibility to support it and see what it can do.

MDMA assisted psychotherapy session typically involves taking 125 milligrams of MDMA. Remember this is synthetically created and produced for these trials and is pure MDMA without the contaminants from street drugs.

So they take the 125 milligrams and then there’s an optional half dose administered about two hours after to extend the therapeutic effects. The effects can last as long as eight hours in that way. During that time, the client has the opportunity to revisit important past events and emotions with two trained therapists. Preparation and integration sessions help the client consolidate the therapeutic gains. Generally clients will receive two or three sessions within a 12 week period.

Clients can apply to be part of the phase three clinical trials. If they go to the maps site, that’s the Multidisciplinary Association for Psychedelic Studies or maps.org

Before trauma therapists think  about taking MDMA as an experiment. You might want to hear what Bessel van der Kolk had to say about his experience. and he’s not the only therapist who’s talked about this happening when they were on a hallucinogen. During his experience, Bessel van der Kolk described that his patients’ traumas came to visit him. That he began processing through the traumas that his patients had described to him over the years.

I don’t know about you, but I am not thrilled at the idea that that could happen. While I think it is an honor for us to be able to hold those traumas. Keeping them from interfering with our daily lives is something that those of us who treat trauma know that we just have to do. Voluntarily sitting in a four to eight hour trip with those things, moving through my brain. I don’t think so.

Psychedelic PTSD Treatment: Mushrooms or Psilocybin

Next, we’re going to move on to talking about psilocybin or magic mushrooms. Now I know that pronunciation varies and it could be a psilocybin, but I tend to say psilocybin so I’m sorry if it drives you nuts. Psilocybin is the main chemical that’s in shrooms and taken for hallucinogenic effect.

Now, the interesting thing about psilocybin is that it was approved long before MDMA for research as early as 2006. Now there’s been psilocybin studies and research ongoing, but those results haven’t necessarily been published.

Psilocybin is being considered for use with trauma, but also with depression. My guess is that they’ll figure out whether psilocybin is better for working with PTSD, or MDMA. Remember that our goal here is to find things that work better than what we currently have and to find the most effective treatments for our clients.

Psilocybin is a classic hallucinogen, meaning that it creates distortion of time and space along with hallucinations. People are suggestive when they’re on that kind of a drug and so those sessions are guided by a therapist. It works pretty much the same way as MDMA,  but one of the components that seems to be missing is the sense of compassion or increased love for others. I wonder what impact that will have on trauma research. 

Psilocybin  is also being considered for depression treatment, which kind of is weird to me. I had a little trouble understanding how the mechanisms work. The research has been ongoing and generally the John Hopkins University team is at the forefront. They are to psychedelic research like the trauma center in Boston is to trauma.

Dr. Roland Griffiths is the man at the head at the Psychedelic Research Center at John Hopkins. He has Ted Talks online and a number of papers if you’re interested. He talks about psilocybin for a couple different things. One is the hallucinogenic effect  and that participants have reported meaningful experiences where they have come to new conclusions or seeing things in a different light. Post experience these participants reported that the feelings and experiences that they had continued to be some of the most important that they’ve had in their lives. He also did research, looking at psilocybin for terminally ill cancer patients and it was found to reduce their feelings of stress and anxiety.

Third, he has been doing research on using psilocybin with depression. The treatment was described as two psilocybin doses given by two clinical monitors who provided guidance and reassurance. The doses were given two weeks apart at the John Hopkins Medical Center. Each treatment session lasted approximately five hours with the participant lying on a couch, wearing eye shades and headphones that played music in the presence of the monitors.

All participants were given a depression rating scale. In this case, not the PHQ-9 but instead the Grid Hamilton Depression Rating Scale, it seems pretty similar to the PHQ-9 where a score of 24 more  indicates severe depression, 17 to 23 moderate depression, eight to 16, mild and seven or less, no depression.

The participants in this particular study had an average depression rating of 23. So we’re definitely in the major depressive category. But one week and four weeks after treatment, the average score on the depression scale dropped to eight. That is incredible. And honestly, I was really stunned. Now this is a small study, it’s 24 participants, that is still significant to me. Even more surprising to me is that almost half were in remission from depression at follow-up.

Dr. Griffiths explains it as reprogramming the operating system of a computer and that makes sense to me. What it seems like it’s doing is going underneath all of the thoughts and all of the preconceived notions and changing things at a base level.

That’s part of what we’re trying to do in EMDR. But if it could happen over two sessions in a couple weeks, man, that would be huge. I know I’ve talked about treatment resistant depression before, and it continues to be something that I want us to be able to find answers to. If you have had people in your practice that have treatment resistant depression, you know how awful it is for them and as therapists for us to not really know what to do to help them. Having people go into remission from depression who have had long-term depression and haven’t had any success with traditional anti-depression medications, this is a really big deal. 

There are some risks for increase in psychosis for people who have previous psychotic disorders like schizophrenia or psychotic features and for those who have experienced mania. So people who have been diagnosed with schizophrenia or bipolar disorder are not eligible to participate in these trials. The same goes for MDMA.

Psychedelic PTSD Treatment: Ketamine

The last one we’ll talk about today is ketamine. Ketamine is a little bit different. It is a hallucinogen and it’s classified as a dissociative drug.  It was once used mainly as an anesthetic on battlefields and in operating rooms. More recent history it’s been used a lot in veterinary clinics for surgery on animals.

Ketamine was one of the later hallucinogens to get banned in 1999. Research studies between 2000 and 2006 showed promising results for using ketamine to treat depression. Ketamine isn’t really in early stages at the moment. Ketamine infusion clinics have popped up all over the United States.

It’s interesting that a drug that can be used on the streets in this case, it’s called special. K, can also be used to treat depression. The president of the American Society of Anesthesiologists is quoted as saying “outside of the clinic, ketamine can cause tragedies, but in the right hands, it’s a miracle”.

The FDA hasn’t necessarily approved it  for use in depression, but it’s being used off label at the moment to treat depression anyway.  We do this a lot. We use prazosin for nightmares, even though it’s a blood pressure medication, same with propranolol we use for social anxiety, it too is a blood pressure medication. We use Trazodone for sleep when it was created as an antidepressant. We use things off label all the time. 

Here’s how it works. Ketamine for depression is done by I V drip. The person goes into the clinic and they’re there for a couple of hours. The ketamine is administered through this IV drip and experiences vary. There are a lot of accounts of people having ketamine infusions and they’ll talk about feeling disconnected some bit of euphoria, a little bit, just odd. Like they’re kind of in that place between a sleep and awake during that time.  Those effects fade though and then the person leaves and moves on with their day.

Ketamine infusions work really quickly, often within hours. Imagine easing depressive symptoms in hours. That is so bizarre to me. Researchers are still trying to pinpoint the mechanisms behind the effects, but they do know that it stimulates a rapid increase in glutamate. Glutamate helps strengthen and restore vital neural connections and pathways in the regions of our brain that are most impaired by depression. These new connections help bring about beneficial changes in brain circuit function.

Several studies have indicated that over half of people with treatment resistant depression have significant symptom relief after a single infusion and many more find relief after two or three infusions. From what I’ve read from personal accounts, it isn’t necessarily quite as fast, but it’s not very much longer either. One woman stated that it was five sessions before she really started feeling better.

Ketamine therapy isn’t a one and done.  This isn’t the same as using psilocybin or MDMA where you do a couple of sessions for PTSD and then that’s it. This is something that has to be  given on a regular basis. For an average patient the first part of treatment calls for a series of six infusions spaced out over the course of two to three weeks. And then treatment is followed by long-term maintenance that includes booster infusions as needed. From what I’ve read, it seems like these happen monthly, but I’m certain that that varies depending on patient needs.

At the moment, ketamine is reserved for the worst cases of depression. The ones that are truly treatment resistant and have tried numerous other medications without effect. It’s estimated that a third of people with depression fall into that category.

Ketamine isn’t perfect though. There is the risk of addiction and dependence. At this point, we don’t have enough long-term research to determine when that addiction potential begins. It’s going to vary for the person based on their genetics, addictive properties in the medication, the amount they’re taking, all sorts of different things are going to influence that. But it is a long-term concern and with use of ketamine long-term and at certain higher doses, there are some pretty significant issues that start to come up physically.

Another drawback is that while it’s used at a sub anesthetic level, it can still cause temporary side effects like mild hallucinations, floating sensations, fuzzy vision, and dizziness. A lot of this subsides fairly quickly, but it is something that can happen as this is an anesthetic dissociative drug.

The last issue with ketamine right now is that, of course it’s not covered by insurance and so it can be pretty expensive. For some people they go in and they’re able to get some relief, but the high cost of going back for maintenance therapy can be prohibitive. As I’ve thought about that treatment resistant depression is almost always accompanied by ever present suicidal ideation. While the effects might not be permanent and need maintenance therapy, keeping the person alive long enough to be able to experience life and build something new. That’s a huge deal.

I don’t know if my listeners are surprised or not, that I’m in support of the research behind these drugs and their uses. For myself I don’t really see it being contradictory, but I can see why some might think that I am primarily a mental health therapist. I am a substance abuse counselor second and yes, in my personal life an addict  in recovery.

But my calling was to bring people more hope, healing and freedom in their lives. And PTSD is one of the main things I treat. I don’t know how it would work to do an eight hour long session with another therapist and who’s going to pay for that. But I would love to be able to see it happen. I know during my EMDR sessions, that when I see my clients making a new connection, or I see that each processing experience they’re getting better. It is the most motivating thing I have experienced. It rivals the experience of seeing someone find recovery from alcohol or drugs.

It’s like they finally can stand back and see what the rest of us see. And it is a miracle. 

Hallucinogens have their downsides and it seems like some of them might have their place in our medical community. The only thing that frustrates me when I hear about this in regular conversation is that a lot of people will use it to say, see, drugs are good. We should legalize everything. The researchers are constantly saying that this is not for use by people without trained therapists around.  You can have a bad trip and have a terribly traumatic experience. Totally opposite of what you would have when doing a guided therapy session.

I want to be cautious about anything that suggests  that all use of drugs is going to be fine and that everyone’s just being conservative and we should just take all these “natural routes”, lots of these drugs aren’t natural and being natural, of course, doesn’t mean  that it’s not dangerous.

I  hope you’ve enjoyed listening to the information about hallucinogens. When you talk with your clients about substance use, I think it’s good to understand their experiences with these drugs if they’ve had them.  If not, then you move on, but it definitely is something that you can ask. And instead of asking, “have you ever had hallucinogens” asking specifically about, have you ever tried LSD, shrooms, peyote or ketamine? Asking those questions rather than asking just about hallucinogens.

Next week  we’re going to have a bit of a different episode. I’ll be interviewing a woman who is a therapist, an addict in recovery, a substance abuse counselor, and happens to be a childhood friend of mine. I wanted to hear her recovery story and also talk with her about what it’s like to be a therapist and a substance abuse counselor. She has a lot of insight regarding recovery and treatment.  I hope you’ll join me for that interview. Until then have a great week. 

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know.  Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.