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Ian enjoyed several months of relief from his depression as well as a new perspective on his life—something no antidepressant had ever given him. “Like Google Earth, I had zoomed out,” he told Watts in his six-month interview. For several weeks after his session, “I was absolutely connected to myself, to every living thing, to the universe.” Eventually, Ian’s overview effect faded, however, and he ended up back on Zoloft.
“The sheen and shine that life and existence had regained immediately after the trial and for several weeks after gradually faded,” he wrote one year later. “The insights I gained during the trial have never left and will never leave me. But they now feel more like ideas,” he says. He says he’s doing better than before and has been able to hold down a job, but his depression has returned. He told me he wishes he could have another psilocybin session at Imperial. Because that’s currently not an option, he’ll sometimes meditate and listen to the playlist from his session. “That really does help put me back in that place.”
More than half of the Imperial volunteers saw the clouds of their depression eventually return, so it seems likely that psychedelic therapy for depression, should it prove useful and be approved, will not be a onetime intervention. But even the temporary respite the volunteers regarded as precious, because it reminded them there was another way to be that was worth working to recapture. Like electroconvulsive therapy for depression, which it in some ways resembles, psychedelic therapy is a shock to the system—a “reboot” or “defragging”—that may need to be repeated every so often. (Assuming the treatment works as well when repeated.) But the potential of the therapy has regulators and researchers and much of the mental health community feeling hopeful.
“I believe this could revolutionize mental health care,” Watts told me. Her conviction is shared by every other psychedelic researcher I interviewed.
• • • “IF MANY REMEDIES are prescribed for an illness,” wrote Anton Chekhov, who was a physician as well as a writer, “you may be certain that the illness has no cure.” But what about the reverse of Chekhov’s statement? What are we to make of a single remedy being prescribed for a great many illnesses? How could it be that psychedelic therapy might be helpful for disorders as different as depression, addiction, the anxiety of the cancer patient, not to mention obsessive-compulsive disorder (about which there has been one encouraging study) and eating disorders (which Hopkins now plans to study)?
We shouldn’t forget that irrational exuberance has afflicted psychedelic research since the beginning, and the belief that these molecules are a panacea for whatever ails us is at least as old as Timothy Leary. It could well be that the current enthusiasm will eventually give way to a more modest assessment of their potential. New treatments always look shiniest and most promising at the beginning. In early studies with small samples, the researchers, who are usually biased in favor of finding an effect, have the luxury of selecting the volunteers most likely to respond. Because their number is so small, these volunteers benefit from the care and attention of exceptionally well-trained and dedicated therapists, who are also biased in favor of success. Also, the placebo effect is usually strongest in a new medicine and tends to fade over time, as observed in the case of antidepressants; they don’t work nearly as well today as they did upon their introduction in the 1980s. None of these psychedelic therapies have yet proven themselves to work in large populations; what successes have been reported should be taken as promising signals standing out from the noise of data, rather than as definitive proofs of cure.
Yet the fact that psychedelics have produced such a signal across a range of indications can be interpreted in a more positive light. When a single remedy is prescribed for a great many illnesses, to paraphrase Chekhov, it could mean those illnesses are more alike than we’re accustomed to think. If a therapy contains an implicit theory of the disorder it purports to remedy, what might the fact that psychedelic therapy seems to address so many indications have to tell us about what those disorders might have in common? And about mental illness in general?
I put this question to Tom Insel, the former head of the National Institute of Mental Health. “It doesn’t surprise me at all” that the same treatment should show promise for so many indications. He points out that the DSM—the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition—draws somewhat arbitrary lines between mental disorders, lines that shift with each new edition.
“The DSM categories we have don’t reflect reality,” Insel said; they exist for the convenience of the insurance industry as much as anything else. “There’s much more of a continuum between these disorders than the DSM recognizes.” He points to the fact that SSRIs, when they work, are useful for treating a range of conditions besides depression, including anxiety and obsessive-compulsive disorder, suggesting the existence of some common underlying mechanism.
Andrew Solomon, in his book The Noonday Demon: An Atlas of Depression, traces the links between addiction and depression, which frequently co-occur, as well as the intimate relationship between depression and anxiety. He quotes an expert on anxiety who suggests we should think of the two disorders as “fraternal twins”: “Depression is a response to past loss, and anxiety is a response to future loss.” Both reflect a mind mired in rumination, one dwelling on the past, the other worrying about the future. What mainly distinguishes the two disorders is their tense.
A handful of researchers in the mental health field seem to be groping toward a grand unified theory of mental illness, though they would not be so arrogant as to call it that. David Kessler, the physician and former head of the FDA, recently published a book called Capture: Unraveling the Mystery of Mental Suffering that makes the case for such an approach. “Capture” is his term for the common mechanism underlying addiction, depression, anxiety, mania, and obsession; in his view, all these disorders involve learned habits of negative thinking and behavior that hijack our attention and trap us in loops of self-reflection. “What started as a pleasure becomes a need; what was once a bad mood becomes continuous self-indictment; what was once an annoyance becomes persecution,” in a process he describes as a form of “inverse learning.” “Every time we respond [to a stimulus], we strengthen the neural circuitry that prompts us to repeat” the same destructive thoughts or behaviors.
Could it be that the science of psychedelics has a contribution to make to the development of a grand unified theory of mental illness—or at least of some mental illnesses? Most of the researchers in the field—from Robin Carhart-Harris to Roland Griffiths, Matthew Johnson, and Jeffrey Guss—have become convinced that psychedelics operate on some higher-order mechanisms in the brain and mind, mechanisms that may underlie, and help explain, a wide variety of mental and behavioral disorders, as well as, perhaps, garden-variety unhappiness.
It could be as straightforward as the notion of a “mental reboot”—Matt Johnson’s biological control-alt-delete key—that jolts the brain out of destructive patterns (such as Kessler’s “capture”), affording an opportunity for new patterns to take root. It could be that, as Franz Vollenweider has hypothesized, psychedelics enhance neuroplasticity. The myriad new connections that spring up in the brain during the psychedelic experience, as mapped by the neuroimaging done at Imperial College, and the disintegration of well-traveled old connections, may serve simply to “shake the snow globe,” in Robin Carhart-Harris’s phrase, a predicate for establishing new pathways.
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