Psychedelic perceptions: mental health service user attitudes to psilocybin therapy
Kate Corrigan · Maeve Haran · Conor McCandliss · Roisin McManus · Shannon Cleary · Rebecca Trant · Yazeed Kelly · Kathryn Ledden · Gavin Rush · Veronica O’Keane · John R. Kelly
Irish Journal of Medical Science (1971 -), 2021, 1-13.
Doi : 10.1007/s11845-021-02668-2
Introduction : Despite the rapid advance of psychedelic science and possible translation of psychedelic therapy into the psychiatric clinic, very little is known about mental health service user attitudes.
Objectives : To explore mental health service user attitudes to psychedelics and psilocybin therapy.
Methods : A questionnaire capturing demographics, diagnoses, previous psychedelic and other drug use, and attitudes to psychedelics and psilocybin therapy was distributed to mental health service users.
Results : Ninety-nine participants completed the survey (52% female, mean age 42 years). The majority (72%) supported further research, with 59% supporting psilocybin as a medical treatment. A total of 27% previously used recreational psilocy- bin, with a male preponderance (p = 0.01). Younger age groups, those with previous psychedelic experience, and those with non-religious beliefs were more likely to have favourable attitudes towards psilocybin. A total of 55% of the total sample would accept as a treatment if doctor recommended, whereas 20% would not. Fewer people with depression/anxiety had used recreational psychedelics (p = 0.03) but were more likely to support government funded studies (p = 0.02). A minority (5%) of people with conditions (psychosis and bipolar disorder) that could be exacerbated by psilocybin thought it would be useful for them. One fifth of the total sample viewed psychedelics as addictive and unsafe even under medical supervision. Concerns included fear of adverse effects, lack of knowledge, insufficient research, illegality, and relapse if medications were discontinued.
Conclusions : The majority supported further research into psilocybin therapy. Younger people, those with previous recrea- tional psychedelic experience, and those with non-religious beliefs were more likely to have favourable attitudes towards psilocybin therapy.
Keywords : Attitudes · Hallucinogens · Lysergic acid diethylamide · Psilocybin · Psilocybin therapy · Psychedelics · Psychiatry
Translational psychedelic science is evolving rapidly [1, 2]. Preliminary clinical evidence suggests that the synergistic combination of psychedelic compounds with psychological support may improve outcomes in major depressive disorder (MDD) [3, 4], treatment-resistant depression (TRD) [5, 6], and addiction disorders [7–10]. Exploratory studies suggest potential benefits of psilocybin therapy in OCD , eating disorders , and migraine suppression , with ongoing clinical trials of psychedelic therapy in MDD, TRD, bipolar disorder type II depression, anxiety, alcohol use disorder, smoking cessation, cocaine addiction, anorexia nervosa, depression with mild cognitive impairment, OCD, and various types of headaches . Results from ongoing well- powered double-blind randomized controlled trials (RCTs) will determine whether psychedelic therapy translates into clinical benefits for non-psychotic disorders in clinical psy- chiatry. More broadly, it has been proposed that psychedelic therapy may attenuate restricted and maladaptive habitual patterns of cognition and behaviour to facilitate the adoption of more healthy behavioural patterns .
The neurobiological mechanisms underlying psychedelic therapy are multi-modal, crossing molecular, cellular, and network systems. The primary initial pharmacological target appears to be activation of 5-HT2A receptors particularly in cortical layer 5 pyramidal cells [16–25], though 5-HT2A independent mechanisms may also be important . Psychedelics promote structural and functional neural plasticity [27–31] and both preclinical  and clinical neuroimaging data suggests that psychedelics lead to 5-HT2A receptor- mediated glutamate release in the medial prefrontal cortex . Psychedelics induce changes in global brain connectivity [33, 34], including default mode network (DMN) integrity  and amygdala reactivity [36, 37].
However, psychedelic compounds induce a wide range of complex subjective experiences with marked individual variation, even in the therapeutic setting and are contraindicated in psychosis spectrum disorders and mania [38, 39]. Furthermore, caution is required for those with a family history of psychosis. The individual variation and divergence between potential therapeutic utility for some disorders and contra-indication in others demands meticulous, high-quality research that incorporates a precise-personalized-psychedelic therapy paradigm [40, 41]
There are marked differences between recreational and therapeutic uses of psychedelics [42–44]. Psilocybin therapy data from John Hopkins University, over a 16-year period, encompassing 250 volunteers and 380 sessions, reported no major psychological issues, with 0.9% of volunteers experi- encing minor and transient psychological issues . This contrasts with a survey of 1993 recreational psilocybin users, of which 7.6% reported seeking treatment for psychological symptoms they attributed to their challenging psilocybin experience . This included three self-reported cases of incipient and enduring psychotic symptoms (at least one year) and three cases of attempted suicide .
In parallel to the “Psychedelic Revolution in Psychiatry” , recreational use appears to be increasing [46–51]. A recent survey conducted from March to May 2020 by the European Monitoring Centre for Drugs and Drug Addic- tion with 10,000 respondents from across Europe (average age 29 years, 58% male) showed that 10% used lysergic acid diethylamide (LSD) in the last 30 days . Nation- ally representative data from the Crime Survey for England and Wales (2018/2019) reported that 0.5% of 16–59 years used magic mushrooms in the last 12 months, whereas in young adults (16–24 years), the rate was 1.6% . A decade ago, Irish data from a representative number of people aged between 15 and 64 years (n = 7669 respondents) indicated that 7% had previously used magic mushrooms in their lifetime (6.5% of men and 4% of women) and 0.5% had used magic mushrooms in the previous year . A recent survey of American university students (n = 3525) showed that 11% had previously used psychedelics .
Notwithstanding the self-selection bias inherent in the Global Drugs Surveys (GDS), the most recent GDS of 26,000 people, of whom 72% were males and approxi- mately 1% were Irish, revealed some interesting trends . This survey demonstrated increasing psychedelic use and reported that 55% of respondents used magic mushrooms in the last 12 months, mostly for “well-being,” but also for “self-medication” . Worryingly, 40% of those who reported using psychedelics did not undergo any preparatory or integration sessions . In addition, almost a quarter of respondents self-reported psychedelic microdosing over the last 12 months . Furthermore, 4.2% of those using rec- reational psychedelics for emotional distress or psychiatric conditions sought emergency medical treatment over the last 12 months, including people with self-reported psychotic (0.2%) and bipolar (2.1%) disorders .
In terms of acceptability of psychedelic therapy, 35% of American college students (n = 124) agreed that psych- edelics can be a therapeutic tool for those with depression and 39% for anxiety , with a much higher proportion (84%) supporting further research . Interestingly, these attitudes were approximately in line with an online survey of American psychiatrists (n = 324), in which 42% reported that psychedelics show promise in treating some psychiatric dis- orders, with a quarter thinking psychedelics are unsafe even under medical supervision . Echoing the college stu- dents, approximately 80% agreed that psychedelics deserve further research, with males and early career stage trainees (< 40 years) having more favourable attitudes towards the therapeutic use of psychedelics .
Results from the previous GDS (2019) of 85,000 people showed that 59% of people who previously used psychedelics said they would accept it as treatment for depression or PTSD, compared to only 18% of those surveyed who had never used psychedelics . Of the respondents who would not accept PT, concerns related to “brain damage and bad trips” .
Society’s relationship and attitude towards psychedelics are complex, but if we are to consider using these com- pounds in clinical practice, it is essential to look beyond past mistakes of over-exuberance and non-scientific ideol- ogy, towards a shared transparent scientific understanding of the risks and benefits of psychedelic therapy . This is all the more important in the context of increasing rates of recreational psychedelic use, the potential of psychedelics to exacerbate underlying pre-dispositions to psychosis and mania, together with psilocybin therapy being on the verge of translating into the psychiatric clinic for a range of non- psychotic psychiatric disorders .
Clear communication between researchers, clinicians, service users, and the public is required for the shared scientific understanding of the risks and potential benefits of psychedelic therapy and is a vital component in “keeping the Renaissance From Going Off the Rails” [60, 61]. This study will investigate mental health service user attitudes to psychedelics and psilocybin therapy.