The False Promise of Psychedelics in Psychiatry

Mental illness, or rather, what is called mental illness, is a serious matter. But what is it?

To find the answer, or an answer, we can turn to the 1,000-page tome published by – who else? – the American Psychiatric Association. It’s called the Diagnostic and Statistical Manual of Mental Disorders. The last (fifth) edition was published in 2013 and is known as DSM-5. It’s sometimes reverentially referred to, not entirely tongue-in-cheek, as the bible of psychiatry. Therein you can find diagnostic criteria for some 300 mental ‘disorders’.

To talk of mental disorders, however, implies these diagnoses are due to abnormalities in the brain. Unfortunately, or rather I should say, fortunately, no objective evidence has been found for the existence of any such state.

New paradigm
What, then, are mental illnesses or disorders? These words refer to mental symptoms, that is, feelings or states of mind. In contradistinction to the hundreds of disorders listed in DSM-5, I would propose there are only three symptoms: depression (unhappiness, sadness, or melancholy); anxiety or nervousness; and hallucinations or delusions where the person has ideas or beliefs at variance with reality.

We can add to this, certain behaviours that other people find upsetting or frightening. For example, it can happen that someone appears out of control who could conventionally be described as ‘mad’. I have been involved in one or two cases where a man was running around in public shouting and screaming, with no clothes on. People in this situation are obviously in a very distressed state and may believe aliens are controlling their thoughts and ordering them to harm themselves or others; they may need short-term custodial care and be given sedative drugs until they’ve calmed down.

At the opposite end of the spectrum of disturbed behaviour, someone may be so depressed as to be unable to get out of bed; they may need institutional care until they’ve returned to the point where they can live independently.

This simple classification is not in any way intended to minimise or downplay the suffering that people with severe degrees of these symptoms may experience. But in both these kinds of cases there is no objective reason for labelling them as suffering from a mental illness, that is, a brain disorder. On the contrary, such symptoms and behaviours can be regarded as meaningful, if misguided, reactions to real life problems; they don’t arise in a vacuum.

The DSM-5 classification, however, is largely based on symptom count and duration of mental symptoms and is used to fit patients into pre-defined pigeonholes. Utility for this approach has been claimed in that it allows patients with similar symptom groupings to be compared in different locations, and in particular, for investigating drug efficacy. For example, if a patient is diagnosed with major depressive disorder, drugs A, B, and C can be compared. Unfortunately, such an approach is entirely arbitrary and assumes patients with a given diagnosis will be amenable to treatment with drugs (‘antidepressants’) which are claimed to work in this situation.

On the contrary, these drugs create a drug-induced state in the brain; they do not correct any underlying abnormality, if such exists. Some people, nonetheless, may prefer these effects to being undrugged.

The use of psychoactive drugs in what are called mental illnesses, therefore, is empirical (trial and error). It may have some value for symptomatic relief, but this needs to be set against the risk of harms, euphemistically called side effects. The potential harms, for example of drugs called SSRIs used to treat depression, include, but as the lawyers like to say, are not limited to, worsening of depression and inducing suicidal thoughts, movement disorders such as tardive dyskinesia, and sexual dysfunction which may be irreversible.

Biologico-mechanical approach
Being fixated on the biologico-mechanical approach, those advocating drugs for what is called treatment resistant depression, have come up with another approach: the mind-altering drug ketamine, which is given intravenously; esketamine, in the form of a nasal spray; and now, hallucinogens, also known as psychedelics, such as psilocybin (magic mushrooms).

We should note that the market for ketamine in the US was estimated at $3.1 billion on 2022 and is expected to increase at 10.6 per cent a year until 2030. We should also note that ketamine is potentially addictive, can cause high blood pressure, and result in severe inflammation of the bladder.

There is no doubt that marketing psychoactive drugs is a hugely profitable for the manufacturers, but for patients it’s a blind alley. This is because of the false assumption that distressing feelings, emotions, and behaviours are due to abnormalities in the brain which can be cured by drugs.

This disease-centred approach to mental problems should be abandoned. Drugs would still have a place for relief of symptoms or as a last resort, but they should be used sparingly and for the minimum time.

Text © Gabriel Symonds

Photo credit: Christian Schwarz on Creative Commoms