As we head toward U.S. elections weâre dedicating a portion of our coverage to related issues.
Last week, for example, we published The Psychedelics Lobby, which tracks federal lobbying efforts among psychedelic drug developers and nonprofit advocacy groups.
Having looked at how the psychedelics field is exerting its influence at the federal level, in this Interview we look at how incumbent healthcare providers view psychedelic policy reform at the local level: namely, psychiatrists in Massachusetts.
To do so, I spoke with Nassir Ghaemi, psychiatrist, author, and professor of psychiatry at Tufts University School of Medicine (and a lecturer at Harvard Medical School to boot). Heâs also a distinguished life fellow of the American Psychiatric Association and the President of the Massachusetts Psychiatric Society.
That latter position is especially relevant because Bay Staters will vote on Question 4 in November, whichâif passedâwould create a regulated psychedelics program like that established in Oregon and Colorado. Itâs a ballot question that the Massachusetts Psychiatric Society, and Ghaemi himself, oppose.
It appears that the outcome of the ballot initiative is too close to call: one recent poll found support among 47% of respondents with 6% undecided, while another (slightly larger and earlier) poll reported 42% in support, 44% against, and 14% undecided. And, just today, the Boston Globe Editorial Board encouraged Bay Staters to vote no on the question.
My discussion with Ghaemi touched on the ballot initiative but also his views on psychedelic (or, âhallucinogenâ, in his lingo) research and psychiatric drug development more broadly. Of course, Ghaemi doesnât speak for all psychiatrists, and has a penchant for certain theories of mood disorders and their potential treatments, but his views do provide a chance to again look at perceptions of psychedelics beyond the bubbleâŠ
Ghaemi told me that he is concerned that a regulated psychedelics program in Massachusetts could cause harms. The more widespread use of psychedelics could, in his view, cause âhallucinations and delusionsâ, which he believes would be âespecially common and harmful in thousands of persons with mood conditions, bipolar and unipolar.â
Increased use of psychedelics would also âlead to more overcrowding of emergency rooms and hospitals with psychotic crises,â Ghaemi fears, âleading to harm to those with medical crises who will not be seen and treated effectively.â
âThey also will lead to car accidents by those who are psychotic while driving,â he added, âwhich will cause death and disability to innocent civilians.â
Ghaemiâs dim view of Massachusettsâ potential regulated psychedelics program extends to his view of psychedelic research, too. The psychiatrist told me that he feels psychedelics may have promise in treating the symptoms of mental health disorders, like electroconvulsive therapy (ECT), but âthey likely do not have any long-term benefitâ.
He acknowledged that short-term symptom benefit can be useful, but that these uses should be âlimited in scope and appreciated as emergency limited use scenarioâ.
âAn exception could be in PTSD,â Ghaemi continued, âwhere long-term benefits could exist if proven.â. âIn that case, benefits of short-term treatment with long-term improvement in the course of the illness, as currently proven only with EMDR therapy, would be an important contributionâ, he said.
Why did Ghaemi single PTSD out? He told me that disease-modification âmeans improvement in the long-term course of a bona fide disease, like bipolar illness, schizophrenia or PTSDâ, which he contrasted to some DSM diagnoses which he says âare not diseases, like âmajor depressive disorderâ or âgeneralised anxiety disorderâ.â Rather, those are âconstellations of conditions with similar symptomsâ, he explained, meaning that even long-term improvement in those conditions âwould still be only symptomatic.â
But, in the case of PTSD, he says that disease modification could be demonstrated, in theory, via a long-term double-blind two-arm study that follows-up for at least one year1.
Itâs worth noting that this whole âdisease-modifyingâ vs. âsymptomaticâ treatments dichotomy has featured prominently in Ghaemiâs work (see, for example, Ghaemi, 2022), and isnât necessarily reflective of other psychiatristsâ potential concerns around psychedelicsâ role in the field.
Given Ghaemiâs strong conviction that psychedelics would not prove to be transformative for mental health issues, but rather deal with the symptoms, I asked him what would or could be transformative.
âThere are many good mechanisms and drugs that have been developedâ, he told me, but added that these are âignored by many companies.â âThe idea that we only have psychedelicsâ, he continued, âshows the intellectual bankruptcy of our field and of psychiatric drug development in general.â
I asked Ghaemi to be more specific, to which he provided a few examples of mechanisms âeither associated with known drugs with disease modifying effects or scientific evidence that could support disease modificationâ. Those included âsecond messenger mechanismsâ, âcalcium channel activationâ, and âepigenetic modification of certain genesâ.
The problem, according to Ghaemi, is that no one is looking for disease modification. âThe studies would need to look at the course of illness over years, as in cardiology and oncology, not current symptoms over days, weeks, months, as in psychiatryâ, he said. âCompanies donât show interest in such mechanisms, and they donât look for such approaches, because of the pervasive ideology that improving immediate symptoms is all we need to doâ, he added.
He believes that this motivation can be traced back to psychedelic policy reforms, too, saying that âthe public clamours for it, as with these ballot questions, without realising that their desires remain purely symptomatic.â
Ghaemi was focusing here on much larger topics like the incentive structure of drug discovery and development. I wanted to bring things back to psychedelic drug development and policy, so I asked him about concerns with psychedelics âsubject matter expertsâ (SMEs) that he raised in a recent Substack article.
âAs with many things,â he said, âthe SMEs follow the money⊠Wherever there is funding, theyâll study it.â
âI speak from experience, having been an expert in psychopharmacology of mood illnesses for three decadesâ, he told me. âI often found that certain medications, like antidepressants, were not effectiveâ, he said, â[but] it was very difficult to get funding to show that such agents did not work, even from non-pharma sources such as NIMH.â âIn contrast, colleagues who claim that something works, like ketamine, are able to get funded very easily from many sources, including governmentâ, he added.
While the political economy of pharmaceutical research and development is certainly fair game for debate, and something thatâs increasingly salient in American political discourse, so too is the publicâs mistrust of healthcare professionals, including psychiatrists. I asked Ghaemi how he thinks psychiatrists can regain that trust.
âOne way is by not going along with public fads, like hallucinogensâ, he started, before drawing an analogy with cannabis.
âOn the cannabis claims for medical benefits followed by legalization, the psychiatric profession was silent, even though we knew and know even more now that cannabis is addictive and harmful for many peopleâ, he said. âThis does not argue against legalization for social reasons, like decriminalization, but we need to be honest with the public about real medical harmsâ, he clarified.
âNow, with other hallucinogens, we have a chance to be honest in that way, and I find that my colleagues in Massachusetts are more aware and willing to be public about their concernsâ, he said, but added that he is concerned that pro-psychedelics initiatives are being pushed by âthe same Political Action Committees and right-wing billionairesâ that promoted cannabis legalisation.
âWeâve learned from cannabis,â Ghaemi said, âand we are trying to engage the public in more thoughtful discussion now with psychedelics.â
âThese days younger generations, millennials and Gen Z, are very attached to hallucinogens, and they may not be happy with us now when we point out flaws in their assumptionsâ, he said. But, in the long term, Ghaemi hopes that his ilk will gain their trust and ârealize we tried to be honest with them.âÂ