My mother took her life in 2003 after suffering for months with psychotic depression. This particular type of depression occurs in up to 15% of patients with severe depression and causes symptoms such as hallucinations and paranoia. It is a disease with a high mortality rate for which no FDA approved treatment exists. My mother received the typical treatment: hospitalization, a combination of SSRI’s (Lexapro, then Zoloft) and antipsychotics, and several rounds of electroconvulsive therapy (ECT).
The hospitalization was helpful in that they were able to keep her safe when she was at her worst. The SSRI’s weren’t so effective, even after eight months of taking them. The antipsychotics worked short-term and helped her relax enough to get something in her stomach. ECT, although scary at first, was downright miraculous. She would wake up bright-eyed like her old self wondering why she was in a hospital. However, the effects of ECT would wear off within two to three weeks and she’d be right back where she started, but with the extra added bonus of memory loss which caused her even more stress.
I nearly drove myself crazy after my mother’s death thinking there was more we could have done for her. I remember reading about a study being done at Stanford using the abortion pill mifepristone (RU-486) and thinking she would have been a good candidate. If only I had been doing my homework while she was alive. If only…
Continued research over the last 17 years has revealed that cortisol, a hormone released during times of significant stress, is extremely elevated in psychotically depressed patients. It seems their sustained levels of cortisol create a chronic stress reaction that can lead to psychosis. Because mifepristone can rapidly bring down elevated cortisol levels, it has shown promise in treating additional conditions caused by elevated levels of cortisol including alcoholism and substance abuse, anorexia nervosa, ulcers, diabetes, Parkinson’s, multiple sclerosis, and Alzheimer’s. However, doctors cannot provide this drug to their patients in an off-label manner without special approval on a case by case basis through the Compassionate Use Program because of the restrictive use the FDA agreed to in order to appease the anti-abortion opponents who threatened its approval.
For decades, psychedelics such as psilocybin (magic mushrooms) and LSD were used in clinical studies, but were never able to gain any traction after they were classified as Schedule I drugs in the 70’s. They were all but abandoned for medical use in the 80’s with the advent of SSRI’s like Prozac, but psychedelics are making a comeback.
In two phases of an FDA-approved trial, patients with post-traumatic stress disorder responded better to MDMA (Ecstasy/Molly) assisted psychotherapy than to talk therapy alone. In fact, MDMA assisted psychotherapy is expected to be approved by the FDA by 2021. Researchers have also experimented with LSD and psilocybin to treat anxiety in terminally ill patients.
I’m especially excited by the news that ketamine (Special K), known as surgical anesthetic and party drug, has shown fast acting results for treatment resistant depression. While SSRI medications can take weeks to start working, patients treated with ketamine report relief in as little as one to two hours. Johnson & Johnson plans to file for FDA approval of a nasal spray version within a year.
Psychedelic drug therapy is going to be the biggest story in psychiatry in over 30 years. If you want to learn more, I recommend Lauren Slater’s Blue Dreams: The Science and the Story of the Drugs that Changed Our Minds (Little, Brown, 2018).
I’m downright giddy that Michael Pollan (The Omnivore’s Dilemma) has written a new book called How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression, and Transcendence that is due out on May 15, 2018, but is already a bestseller on Amazon. The book grew out of the reporting he did for a 2015 article about psychedelic psychotherapy in the New Yorker, called “The Trip Treatment.” Given the popularity of Pollan’s books, I’m hopeful his insights will help psychedelic drug therapy gain mainstream acceptance and fast track them for FDA-approved medical use.