For decades I have dreamed of giving MDMA (the recreational form is known as ecstasy or molly) to patients legally. In the early 1980s I prescribed MDMA legally. At the time, the power of this simple molecule to relieve emotional suffering and heal relationships deeply moved and inspired me as a psychiatrist. Then in 1985 the DEA chose to place MDMA in the most restrictive Schedule I category. Now, almost thirty years later, I will again dose a patient with MDMA legally as a member of the upcoming Phase III study sponsored by MAPS as a Site Principle Investigator in Fort Collins, Colorado. My motivations are larger than just helping a handful of folks overcome longstanding PTSD in this international trial.
While MDMA is a wonderful and needed tool that the practice of psychiatry cries out for, I think that MDMA is much more than a tool. We have many reasons to call MDMA a transformational agent. Recently, the FDA awarded the MDMA Assisted Psychotherapy for Severe PTSD Phase III Study with the “Breakthrough Therapy” moniker reserved for those agents with early evidence of substantial improvement over all existing therapies. As such the FDA does all they can to expedite review and analysis.
MDMA also represents a breakthrough in a number of other ways:
- It represents the possible movement of a Schedule I substance into an approved medical application.
- A donor sponsored Public Benefit Corporation funding the FDA trials.
- An episodically administered agent to enhance psychotherapy.
- A psychiatric medication that triggers improvement that continues over time without daily ingestion.
Yet in spite of all of the breakthroughs mentioned in the recent flurry of media and press releases, this medication has the potential to do much more. It truly is a transformational agent that will change the face of mental health care as we know it.
Psychiatry and the medical model have dictated mental health care policy and direction in this country for the last 50 years. From the lines of authority in psychiatric hospitals, community mental health centers and NIMH to the pay scales and practice models dictated by insurance companies to non-federal research funding, psychiatry drives the bus. Over the last 35 years as part of this shift to a medication-focused mental health, we have witnessed a remarkable shift in the spending for mental health care. We now spend more for medication and insurance administration than we do for all outpatient therapy (and much more than inpatient therapy). Sadly, the money we spend on psychotherapy per capita falls each year while the dollars spent on things like Abilify and Seroquel increases every year. For example, over 50% of children receiving mental health care now get medication management only. Like it or not, psychiatric philosophy and the practice of medicating symptoms dominates the field of mental health.
Psychiatry sits at an uncomfortable juncture. We are witnessing the fading end of a failing paradigm. Just as Kuhn told us in his landmark book, The Structure of Scientific Revolutions, scientific paradigms or belief systems do not fail step by step as the data reveals itself. Rather, they crash down when the weight of conflicting data shifts the perspective of the scientific community. Kuhn helped many of us to see that scientific paradigms are also socio-cultural phenomena driven and sustained by the inertia of individuals and institutions. So, often this shift to a new paradigm may occur one funeral at a time as the Nobel Prize winner Max Planck famously quipped.
When the theoretical structure that medical or psychiatric practice is built upon clearly outlives its value and validity it creates a time of turmoil, conflict and challenge for a profession. We are witnessing this phenomenon in psychiatry now as therapists, parents, patients and the news media question the prevailing practices. Research has eroded the belief in the safety and efficacy of the core treatments in depression, anxiety and schizophrenia. The number of practicing psychiatrists in the US actually fell over the last 15 years as recruitment and retirement erode those willing to do the work. The reputation of psychiatry both within medicine and by the public has soured.
Psychiatry is always vulnerable to distorted science as the complexity of the human brain and behavior exists orders of magnitude beyond our coherent grasp. As such, my profession can get caught up in harmful ideas that seem at first to be sound and medically based. Witness the frenzy around lobotomies and insulin shock therapy just seventy years ago. Today, these things seem horrific and unsound when viewed through the perspective of time, but if key thought leaders and a few studies point the way we can often lose our bearings in the rush to participate in the next advance of science.
Given its roots in behavior, relationships and the ever-existing cultural milieu, psychiatric illness can best be viewed as a biologically based socio-cultural expression. Over time our prominent illnesses wax and wane in keeping with the changes in society. In Freud’s time it was neurasthenia, vapors and hysteria; in the 1950s we had hebephrenia and neurosis; the 1980s were littered with dissociative identity disorder, cult abuse and borderline personality. Today we have a pandemic of ADHD, bipolar disorder and depression. Psychiatry has always been a specialty that sits just outside of medicine and much closer to sociology and anthropology than any of us might like to admit. As such it reflects the fears and wishes of the culture it is based in.
For the last 60 years, modern psychiatry has gravitated around a medication model that mirrors our cultural zeitgeist that worships quick relief, flashy psychopharmacology and the avoidance of emotional depth. The chemical imbalance theory supplied all of that and a Jetson’s-like aura of science from the future. The marketing mania of SSRIs like Prozac (released in 1987) eroded the enlightened systems-oriented bio-psycho-social perspective of George Engels. By the time we reached the Decade of the Brain in 1990, all of us (myself included) could envision a day when a focused and advanced psychopharmacology would eliminate all psychiatric illness. The excitement was palpable and fueled by the whip-smart marketing of Lilly and the rest of Big Pharma (who now spend more on marketing than on research).
Here is the core of the chemical imbalance theory that was sold to the medical profession and the American people:
- Psychiatric illness represents an imbalance of key neurotransmitters.
- We are born with this imbalance and it does not change.
- Medications prescribed by physicians can correct this disorder.
The second tier implications of this paradigm are also critical but not as widely appreciated:
- Diet, lifestyle and to some degree relationships really don’t matter.
- Often the medication/chemical balance will shift and you must return to the psychiatrist for your medication management.
- These medications and thus the regular management of them are required indefinitely.
- Psychotherapy is nice, but not really indicated for serious problems.
- You can’t heal yourself.
Interestingly, this philosophy is unspoken and untaught in psychiatry residencies. Psychiatry as taught by all of the core textbooks is actually free of any unifying philosophy. Accordingly, there is no consideration of mental health in these textbooks. Psychiatry is a study of disease and the specific pharmacology that can manage them. Other treatment avenues are given lip service in residencies and academia, but out in the real world of private practice, community mental health centers, psychiatric hospitals and insurance companies, it is all about medication management of the chemical imbalance. We diagnose and then we prescribe. That is the role of psychiatrists in our mental health system. We re-balance the chemical imbalance.
While this overly simplistic and unrealistic theory became an urban myth that drove actual psychiatric practice, the science was never really there. We have no sound science to support the chemical imbalance theory of depression. Period. Never was, really. No reputable neuroscientist now supports the chemical imbalance theory of depression. All antidepressants have the same meager level of effectiveness over a placebo for treating depression (they do much better for anxiety). Researchers such as Irving Kirsch blame this slight advantage on an active placebo response generated by medications that create side effects that make us believe they are working and thus heighten our expectation and resultant healing. Many now doubt that these medications have any fundamental benefit for the depressed patient. We have no idea how these medications work, if they even do.
Now we are witnessing the deep erosion of this chemical imbalance paradigm in the treatment of depression. How do we reconcile the fact that selective serotonin reuptake inhibitors (SSRIs) are about as effective in randomized controlled trials as selective serotonin reuptake enhancers (SSREs)? They work in an opposing manner on neurotransmitters. They do the exact opposite of each other! One increases serotonin and one decreases it. The chemical imbalance theory is dead in the water.
Likewise, we have growing evidence that the long-term use of psychiatric medications offers no real benefit and may in many cases actually deteriorate outcomes for patients. For example, we have growing evidence that antipsychotic medication damages the frontal lobes of the brain and that schizophrenics in the US have better outcomes when they avoid these medications. In Robert Whitaker’s book Anatomy of an Epidemic, he explored the data surrounding the long-term use of psychiatric medications in schizophrenia, ADHD, depression and anxiety. Big Pharma studies typically highlight trials of only 6 to 12 weeks while the brain is still adjusting to the input of medication. The true response occurs over years when the brain begins to adapt to this input. Whitaker’s book documented what many observant and discouraged psychiatrists have seen for years: we don’t cure anybody with these medications and we harm way too many.
Big Pharma and our professional guilds remain unrepentant and surprisingly non curious about these devastating insights. However, more and more psychiatrists have begun to question the model and the paradigm that our modern practice of psychiatry is built upon. The chemical imbalance paradigm dictates a life of medically managed misery that is increasingly unpalatable to patients and doctors alike. As the conflicting evidence and opinion build, the profession is beginning to flee the sinking ship. What other options do we have? Usually in Kuhn’s perspective models don’t crumble as much as they fail from lack of support as interest flows to something more scientifically compelling. Where is it going next? How does the MDMA trial relate to this process?
In line with all these changes, the big research dollars in psychiatry have moved away from neurotransmitter manipulation and toward other models of understanding and intervention such as the connectome. This model postulates that we have networks of activity in the brain that drive behavior and illness. While this is much more reflective of modern science, it has the potential to be just another three-decade-long rabbit hole that we jump into with the hope that salvation is just around the technological corner.
Besides the connectome, a number of other possible successors exist to become the next predominant model in mental health. Epigenetics has overpowered genetics and the genome. It brings nutrition, supplements, health and lifestyle into the conversation, but most suffering Americans are not ready for this level of personal change. Neuroplasticity and neurofeedback tell us that we can retrain any brain, even an aging brain. This has a wow factor and appears to work for ADHD, but a comprehensive approach to a range of psychiatric issues is still decades off. Whole person medicine (often inspired by integrative/functional medicine) with facets like the microbiome, inflammation and autoimmunity offers a more systems-oriented view of mental health, but the indications are mainly for the chronic illness subset of our patients. Psychedelic science has exploded in the last ten years and offers broad hope for transformational interventions, but these interventions still struggle with predictability and narrow indications. Oh, there is that whole ‘illegal’ thing too. Thus, we have some contenders, but nothing that can form a unifying umbrella for mental health.
If MDMA can effectively treat and perhaps even cure PTSD it will create clear documentation that the core premises of the chemical imbalance theory are dead wrong. We can heal ourselves when barriers are removed. Recovery is possible. We can get better. We move from a pessimistic model that denies the responsiveness of the human being to their environment to one that acknowledges that change and improvement can be dramatic even from a serious and longstanding mental disorder.
Holistic/integrative medicine shares this core premise about the inner healer. MDMA can become the entry point to foster a vibrant integrative psychiatry that becomes more than just the supplementation of medication management. The concept of catalyzing personal transformation begins to open the realm of spiritual medicine and pulls us back to our roots in shamanism. Here the power of psychedelics can gain much needed appreciation and cautious application for a range of chronic, often existential maladies.
Once we embrace the power of a living system to heal and adapt, a range of other implications also emerge. The idea of chronic symptom suppression becomes more obviously repellent. Psychiatric medications will become short-term tools to enhance catalytic change but will be avoided as long-term interventions. Psychotherapy will become more focused on providing support and enhancing expectation. The arguments over technique will fall away to a focus on creating a safe container, trust and an open heart. Ignored tools like breath work, somatic therapies and art will gain traction.
In short, this MDMA study has the far-reaching implications that will transform mental health care and our view of the human psyche. The inner healer will become the new paradigm for mental health. Psychiatrists will move from being managers of medication to healers. Psychotherapists will become more valued and we will focus more on the inner development of the practitioner than merely valuing of specific techniques. We will witness a much-needed expansion of our theories about the healing that underlies mental health that have sat dormant since the time of Jung and Maslow. True, this is only one study, but it stands as a crucial test with massive implications. It can become a nidus around which a new paradigm can form. It is ironic and only fitting that a chemical molecule will finally bury the chemical imbalance theory and allow us to move on. Patients, practitioners, professions and the public as a whole will reap the benefit.