Clinic founders tout the promise of psychedelics for mental illness; observers urge caution – MinnPost
Imagine that the conventional approach to treating mental illness was a snow globe. More than a century ago, Sigmund Freud gave the globe a vigorous shake when he developed his psychoanalytic theory. A flurry of theories about the treatment of people struggling with their mental health followed, some later to be proved harmful and dangerous, others found to be helpful.
Since the introduction of SSRI antidepressant medications in the mid-1980s, there has been little significant change in the treatment of mental illness, said Manoj Doss DO, co-founder of the Institute for Integrative Therapies (IIT), a Twin Cites-based clinic that offers psychedelics as a part of mental health treatment. To Doss and his colleagues at IIT, it seems like the contents of the snow globe have for too long been settled on the bottom â and need to be shaken up again.
âIf you compare psychiatry to every other field of medicine, there really havenât been many breakthroughs in the last several years,â said Doss, who is certified in occupational and general medicine. âWeâve hit a wall on whatâs been really effective for patients. Maybe we need to re-examine how we treat mental illness.â
Kyle Keller, LICSW, IIT co-founder, said that he and his colleagues try to approach mental health treatment from a different perspective. While mainstream treatments like talk therapy and psychotropic medications have helped millions of people worldwide, they also have their limitations, he believes.
Keller said that at IIT, an offshoot of Ellie Family Services, staff members see the use of psychedelic medication as a new and promising way to help patients move beyond blockages in their mental health and take further steps toward recovery.
âWe try to do things that are cutting edge and unconventional,â he said. âWe want to get to the next level of mental health care, and help people find progress where they havenât been able to before.â
When combined with psychotherapy, Keller said, psychedelics can help patients âtreat their mental health and process trauma. They tend to evoke something thatâs more spiritual or beyond the traditional therapeutic approach.â
For now, IIT offers ketamine treatment for patients. The drug, a commonly used anesthetic also known as the party drug Special K, has shown promise in treating severe depression and is being offered at clinics and infusion centers nationwide. Depending on FDA approval, Doss and Keller would like to expand IITâs treatment options to other psychedelics, including MDMA, popularly known as ecstasy or Molly, and psilocybin mushrooms. Both drugs have shown promise in the treatment of common mental illnesses, Keller said, including depression, anxiety, and PTSD.
âWeâre laying the foundation to provide additional psychedelic-assisted therapies as they become available,â Keller said.
In June 2020, IIT started accepting patients with a âsoft opening,â Keller said. As many as 40 patients have been treated since then; the instituteâs official opening is scheduled for May 1.
Keller said that patients well suited to psychedelic therapy include âsomeone who might feel a sense of meaninglessness or nihilism, like nothing matters. Many times, psychedelics help create a profound sense of meaning for individuals that lingers with them and that can carry forward in their lives.â
Another type of patient that has been shown to benefit from psychedelic therapy is, Keller said, âpeople with a terminal diagnosis. These kinds of patients report profound, transformative experiences where they come away no longer fearing their own mortality.â
Keller, who grew up in a strict religious background and struggled with the impact of this upbringing, tried psychedelic drugs when he was in college. âIt was the most significant experience of my transitioning-into-adulthood period that helped with the processing of the religious piece,â he said.
After learning more about the history of academic research into the use of psychedelics in the treatment of mental health disorders, he was inspired to learn more, completing a yearlong certification in psychedelic assisted therapy at the California Institute for Integral Studies.
Keller said that he has found that psychedelic drugs âwork on an unconscious level. They allow things to surface that may be repressed. A psychedelic experience is a disruptive thing. Of someone is caught in a pattern and they canât get out of it, a psychedelic can interrupt that reoccurring cycle that happens in someoneâs life.â
How psychedelic treatment works
Keller explained that staff at IIT take a multipronged approach to psychedelic treatment for mental illness, combining the use of psychedelic medications with traditional psychotherapy and medical monitoring. âWe follow a pretty standard structure,â he said. âItâs a model that is used by Johns Hopkins or NYU for doing psychedelic-assisted therapy.â
Keller said that IITâs treatment process has four parts: first, an evaluation session to assess if this form of therapy is suitable for the patient, followed by a medical exam (conducted by Doss) that determines if the patient has any preexisting conditions that would make this form of therapy unsafe; then a preparation session (or sessions) that prepare the client for the psychedelic experience.
Conditions that restrict a person from undergoing psychedelic treatment include a number of relatively common diagnoses, Doss said: âIâve turned people away for things like uncontrolled hypertension, uncontrolled or undiagnosed hyperthyroidism, uncontrolled diabetes or coronary heart disease or a history of stroke or cerebral tumor or glaucoma.â
The third step in the process, Keller explained, is a treatment session, which takes place in a specially designed room in IITâs St. Paul office.
âOur focus is on optimizing the setting,â he said. âIt is important that the environment is in all ways conducive to the process, including music.â Once settled in the treatment room, the patient puts on eye shades and headphones and rests in a lounge chair.
Music is projected through the headphones, Keller explained: âWe curate playlists for them that evoke relevant emotional content and follow the trajectory of the ketamine.â
During treatment â which can last, depending on the method of ketamine delivery, anywhere from an hour and a half to three hours â the patient is closely monitored by a therapist and a physician.
Beyond tracking physical reactions to the drug, the observation is mostly hands-off. âWe follow their lead and let them tell us what they need,â Keller said.
The institute administers ketamine orally or through intramuscular (IM) injection. âThe oral route is more gentle and takes more time to take effect,â Keller said. âThe IM is a more psychedelic experience. People tell us they go on journeys, feeling like theyâre leaving the room.â
Doss administers the medications. During IM treatments, he stays in the room with the therapist, monitoring the patientâs condition. âIâm there to witness that they are tolerating it well,â he explained. For sublingual treatments, he said heâs usually in and out of the room every 15 minutes: âBut Iâm just down the hall if they need me.â
The fourth part of psychedelic treatment at IIT is called integration and generally takes place on the day after treatment. âItâs the most important part of the therapy,â Keller said. âWeâre watering the seeds that were planted during the therapy itself.â This part can take place in person or by a video conferencing call.
Further follow-up sessions are scheduled as needed, he added: âWe can also do a few sessions afterward focusing on taking the lessons and insights and putting them into practice in the experience.â
Doss said that for most patients, ketamine isnât a once-and-done treatment.
âThe effects of ketamine can be short-lived, on average two to four weeks,â he said. But he said that he and Keller believe that carefully targeted therapy can extend the drugâs impact: âI think that the best approach would be if someone needs to do it every three to six months. As the effects wear off, you might need a âreset.â Thatâs what the therapy session would add to it.â
Psychedelic treatment sessions are not covered by insurance and can cost as much as $850 for a single treatment. Most patientsâ insurance covers the assessment and follow-up therapy sessions, Keller said. He explained that the clinic is working to address financial barriers to treatment.
âAccessibility is the No. 1 obstacle. Weâre always looking at creative ways to bring costs down.â
Promise and potential
Because they see such potential in the ability of psychedelics to take mental health treatment to the next level, Doss and Keller are committed to building a practice that can quickly expand treatment options to patients as new options are approved for use.Â
âWeâre excited to someday offer MDMA (Molly) and psilocybin mushrooms,â Keller said. âWeâre at the inflection point where things are going to happen very rapidly in the next year.â
Doss said he sees IIT as it is structured now as a template for future expansion. âEssentially, what weâre doing is setting up the infrastructure,â he said. âKetamine is a great drug for depression, but there are limits on what it can do. We want to be able to offer other options for our patients.â
Well publicized research on the positive impact of psychedelics in the treatment of a range of mental illnesses combined with significant progress toward FDA approval for their use makes Doss feel confident that he and Keller are on the right track.
âItâs coming,â Doss said of eventual FDA approval for MDMA and mushrooms. Because of this eventuality, he said, âWe need to have good actors out there. There are going to be some bad actors that show up, but if we start this clinic and we become the standard of care, hopefully, anybody else that comes into this field will use us a model of how things should be done.â
Rory Remmel, professor in the department of medicinal chemistry at the University of Minnesotaâs College Pharmacy, said that he sees the potential of psychedelics for treating a range of mental illnesses. âI think itâs really quite promising,â he said. âMDMA especially has been really successful in treating post-traumatic stress disorders. It just seems to work with one or two doses typically. It allows people to access their memories in a non-threatening atmosphere.â
Have any of IITâs patients ever had negative experiences with psychedelic treatment? Their websiteâs FAQ section addresses the issue in this manner: âItâs our belief that âbad tripsâ can be avoided, with attention to set and setting and through trusting relationships with your therapist. For some people, the ketamine therapy experience can still be challenging ⊠but, itâs often the challenging experiences that are the most rewarding.â
Doss recalled a patient who had a âpretty difficult emotional experienceâ during a treatment session. In the end, he said, processing the negative experience added to the long-term impact of her follow-up therapy sessions: âShe came out of it describing more openness. She described a decrease in rumination, which was not something sheâd expected with how she was feeling immediately after the session.â The impact of psychedelic therapy goes far beyond the actual time in the treatment room, he explained: âItâs not just the medicine. It is the work afterward.â
As for potentially dangerous physical side effects of psychedelic treatment, Doss said, all drugs IIT proposes to one day offer to patients are safe when administered by a medical professional.
Almost any drug can be dangerous if used in the wrong setting, Doss said: âFentanyl has a horrible rap, but it has also done wonders in the operating room. In a controlled setting, it is completely safe. The same can be said about psychedelics. If you are using the drug in a safe setting, then youâre using it in the right setting.â
But people are being addicted to ketamine, Remmel said. It isnât as large of an issue in the United States, but in the UK and some European countries, there is, he explained, a subculture of people  âwho use ketamine all the time. They get tolerant of it, just like an opiate. They keep having to use higher doses.â
Keller said that when administered safely, the deeper benefits of psychedelics far outweigh the risks.
âA term used in psychedelics is an âinner feelingâ or an âinner intelligence,ââ he said. âMany people believe that the higher self is always striving toward wholeness and healing.â Psychedelic drugs can help user access the higher self, he believes: âWherever it goes is where youâre meant to be. Trusting that there is a part of yourself that knows what you need to experience is part of the journey they are on.â
C. Sophia Albott, M.D., assistant professor in the University of Minnesotaâs Department of Psychiatry and Behavioral Sciences, said she doesnât endorse the theory that a psychedelic journey can cure severe mental illness. âClinically Iâm not entirely certain what a mystical experience can do in terms of vegetative depression,â she said. âI have to wonder how this type of experience is relative to being so depressed that you arenât able to get out of bed. To me, it feels like youâre not actually treating the depression at its core â even if people are having meaningful experiences.â
âFollow the scienceâ
While key medical advances can come from experimentation, itâs important to not jump too quickly on the psychedelics-for-mental-illness bandwagon, said Joseph Lee M.D., president and CEO designate of the Hazelden Betty Ford Foundation.
âIn todayâs age of hype,â Lee said, âwe have to be careful. While there is some promising data about hallucinogens and depression, sometimes we can be a little premature and jump the gun. When you are a hammer everything is a nail.â
With this hammer-nail comparison, Lee cautions that practitioners should take a measured approach to the use of psychedelics in the treatment of mental illness. He is concerned by what he sees as an emerging overenthusiasm for this treatment approach.
Hallucinogens, Lee said, may have efficacy in the treatment of some conditions, but he cautions that they may not work equally for all. âI think we want to follow the science. What we mean by that is, âFollow the science fully.ââ
Following the science means waiting for more robust research that proves psychedelicsâ effectiveness in the treatment of mental illness, Albott said. âI have a lot of ambivalence about it, to be honest,â she said. âI think the research is still very much its infancy. There arenât even any randomized controlled trials of the combination of ketamine with psychotherapy. There isnât evidence supporting that.â
While Lee said that he understands that even the most addictive substances can be helpful to patients in controlled settings and he resists the impulse to âgrant moral properties to substances,â he still remains concerned about the potential negative impact of psychedelics in the treatment of mental illness.
âWeâve seen the downsides of psychedelics,â he said, âeverything from psychosis to people bypassing the rapid tolerance they get and using levels that arenât safe.â In his experience as a child and adolescent psychiatrist, he said, âI have not had a number of young people come up to me and say, âBecause of my experience with hallucinogens, Iâve thought differently about x, y, z.â Maybe a handful â but not a significant amount.â
The same goes for patients addicted to other substances, Lee added: âThe only people who came into my office talking about the benefits of alcohol for their health were people who drank too much.â
Regarding potential addiction, Doss said, âPeople who arenât aware of the process and the medication automatically go toward addiction or abuse. Any drug can be abused. I donât prescribe these drugs [directly to patients]. They are administered in a controlled setting in the correct manner. Patients donât have access to them after they leave the facility.â
Albott also takes objection to the idea that there have been no significant effective treatments for mental illness introduced in the last several years.
âI think there has been substantial development in the treatment of depression,â Albott said, listing what she sees as significant advances in psychotherapy and other hands-on approaches. And new, non-pharmaceutical tools are being developed, she added: âI am part of a group that does interventional psychiatry using transcranial magnetic stimulation (TMS), which has very few side effects and can be very effective for people. I wouldnât say that we havenât made any progress.â
Keller argues that at IIT he and Doss are focused on progress. Their goal is to help patients take the next step in the healing process: They see psychedelics as a key tool that can break patterns that have been blocking people from recovery.
To illustrate what he sees as the power of psychedelics in the treatment of mental illness, Keller describes a passage in Michael Pollanâs best-selling book, âHow to Change Your Mindâ: âHe compares using psychedelics to going snow skiing: If youâre always heading downhill in the same tracks, eventually youâre going to create deep grooves in the snow. By the 500th time down, youâre stuck in the tracks youâve established.â
All too often, Keller said, traditional mental health treatment follows the same well-worn grooves. He wants to help his patients forge a new path: âA psychedelic creates a new snowfall,â he continued. With the hill covered in fresh snow, âThe tracks grab you less.â