MDMA-assisted therapy for severe PTSD : a randomized, double-blind, placebo-controlled phase 3 study
Jennifer M. Mitchell, Michael Bogenschutz, Alia Lilienstein, Charlotte Harrison,
Sarah Kleiman6, Kelly Parker-Guilbert7, Marcela Ot’alora G., Wael Garas, Casey Paleos,
Ingmar Gorman 11, Christopher Nicholas12, Michael Mithoefer5,9,13, Shannon Carlin,
Bruce Poulter 8,9, Ann Mithoefer9, Sylvestre Quevedo2,14, Gregory Wells 14, Sukhpreet S. Klaire,
Bessel van der Kolk16, Keren Tzarfaty9, Revital Amiaz17, Ray Worthy18, Scott Shannon,
Joshua D. Woolley2, Cole Marta20, Yevgeniy Gelfand21, Emma Hapke, Simon Amar, Yair Wallach,
Randall Brown11, Scott Hamilton25, Julie B. Wang5, Allison Coker 1,5, Rebecca Matthews,
Alberdina de Boer5, Berra Yazar-Klosinski, Amy Emerson and Rick Doblin
Nature Medicine | www.nature.com/naturemedicine, 2021, 1-12.
doi : 10.1038/s41591-021-01336-3
Post-traumatic stress disorder (PTSD) presents a major public health problem for which currently available treatments are modestly effective. We report the findings of a randomized, double-blind, placebo-controlled, multi-site phase 3 clinical trial (NCT03537014) to test the efficacy and safety of 3,4 methylenedioxymethamphetamine (MDMA)-assisted therapy for the treatment of patients with severe PTSD, including those with common comorbidities such as dissociation, depression, a history of alcohol and substance use disorders, and childhood trauma. After psychiatric medication washout, participants (n = 90) were randomized 1:1 to receive manualized therapy with MDMA or with placebo, combined with three preparatory and nine integrative therapy sessions. PTSD symptoms, measured with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5, the primary endpoint), and functional impairment, measured with the Sheehan Disability Scale (SDS, the secondary endpoint) were assessed at baseline and at 2 months after the last experimental session. Adverse events and suicidality were tracked throughout the study. MDMA was found to induce significant and robust attenuation in CAPS-5 score compared with placebo (P < 0.0001, d = 0.91) and to significantly decrease the SDS total score (P = 0.0116, d = 0.43). The mean change in CAPS-5 scores in participants completing treatment was −24.4 (s.d. 11.6) in the MDMA group and −13.9 (s.d. 11.5) in the placebo group. MDMA did not induce adverse events of abuse potential, suicidality or QT prolongation. These data indicate that, compared with manualized therapy with inactive placebo, MDMA-assisted therapy is highly efficacious in individuals with severe PTSD, and treatment is safe and well-tolerated, even in those with comorbidities. We conclude that MDMA-assisted therapy represents a potential breakthrough treatment that merits expedited clinical evaluation.
PTSD is a common and debilitating condition with immeasurable social and economic costs that affects the lives of hundreds of millions of people annually. There are a number of environmental and biological risk factors that contribute to the development and maintenance of PTSD1, and poor PTSD treatment outcomes are associated with several comorbid conditions that include childhood trauma2, alcohol and substance use disorders3, depression4, suicidal ideation5 and dissociation6. It is therefore imperative to identify a therapeutic that is beneficial in those individuals with the comorbidities that typically confer treatment resistance.
The selective serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine are Food and Drug Administration (FDA)-approved first-line therapeutics for the treatment of PTSD. However, an estimated 40–60% of patients do not respond to these compounds7. Likewise, although evidenced-based trauma-focused psychotherapies such as prolonged exposure and cognitive behavioral therapy are considered to be the gold standard treatments for PTSD8, many participants fail to respond or continue to have significant symptoms, and dropout rates are high9,10. Novel cost-effective therapeutics are therefore desperately needed11.
The substituted amphetamine 3,4-methylenedioxymethamphetamine (MDMA) induces serotonin release by binding primarily to presynaptic serotonin transporters12. MDMA has been shown to enhance fear memory extinction, modulate fear memory reconsolidation (possibly through an oxytocin-dependent mechanism), and bolster social behavior in animal models13,14. Pooled analysis of six phase 2 trials of MDMA-assisted therapy for PTSD have now shown promising safety and efficacy findings15.
Here, we assess the efficacy and safety of MDMA-assisted therapy in individuals with severe PTSD. Participants were given three doses of MDMA or placebo in a controlled clinical environment and in the presence of a trained therapy team. Primary and secondary outcome measures (CAPS-5 and SDS, respectively) were assessed by a centralized pool of blinded, independent diagnostic assessors. MDMA-assisted therapy for PTSD was granted an FDA Breakthrough Therapy designation, and the protocol and statistical analysis plan (SAP) were developed in conjunction with the FDA16.