Terry Gross on Fresh Air, June 22, 2020
A mind-altering drug called ketamine is changing the way some doctors treat depression.
People who have been taking antidepressants for several years sometimes hit a wall, a point when that treatment no longer seems to ease their symptoms. Psychiatrist Julie Holland says that’s where psychedelic drugs could help.
Holland was in charge of Bellevue Hospital’s psychiatric emergency room on the weekends from 1996 until 2005, and currently has a private psychotherapy practice in Manhattan. She’s a medical monitor on the MAPS studies, which involve, in part, developing psychedelics into prescription medication. Her new book, Good Chemistry, explores how she thinks psychedelic drugs, including LSD, psilocybin, MDMA and marijuana, might be used more widely in psychiatry to make treatment more efficient and effective.
“There are certain plant medicines in particular — things like psilocybin or ayahuasca — that really help people not only explore their personal trauma,” she says, but also “this feeling of unity and connection. People really come away from these experiences having a new perspective.”
Holland acknowledges that the use of psychedelic drugs in psychiatry is controversial — but she says the practice is slowly gaining acceptance.
“Good psychotherapy takes years and there are a lot of fits and starts,” she says, “and people run away when things get too heavy. But it’s changing more and more. … The data is so compelling that in my opinion, people in my profession have no excuse for not knowing what’s going on.”
On the limits of antidepressants
We haven’t had a lot of innovation in antidepressants in a long time. People got on these medicines and then they never got off. And a lot of people are taking antidepressants for decades and they really weren’t designed to be used that way. So that’s sort of a No. 1 issue. But things are absolutely changing where people are having a better understanding that it’s not as simple as just altered chemistry or altered genetics. That your childhood experiences and trauma and things like income inequality — there are all sorts of things that have an impact on what your mental health is going to be. And a big part of it is processing trauma. So the daily doses of antidepressants, anti-anxiety medicine, sleeping pills, antipsychotics, they are really not there to help the primary problem. They’re there to sort of seal up the cracks and act as Band-Aids, whereas psychedelic-assisted psychotherapy is really trying to get to the root cause of the symptoms instead of just sort of papering over the symptoms. …
I don’t mean to imply that everybody should throw their pills away at all. But I do think for people who have been on just antidepressants for decades, that it is worth exploring whether there are other ways that, maybe, you could treat some of the symptoms, and maybe get at some of the underlying causes of the symptoms.
My main job is that I prescribe antidepressants and anti-anxiety medicines and sleeping pills and sometimes mood stabilizers, antipsychotics. There are medicines that work very well. My patients are doing very well and they’re taking these medicines. So I don’t want to completely disparage it. It’s just, for some people, it’s not really what they need. It’s not appropriate.
But for other people, they need to stay on their meds. And it’s very dangerous to go off their medicines. So I don’t mean to imply that everybody should throw their pills away at all. But I do think for people who have been on just antidepressants for decades, that it is worth exploring whether there are other ways that maybe you could treat some of the symptoms, and maybe get at some of the underlying causes of the symptoms.
On treating post-traumatic stress disorder with cannabis
This is sort of a new paradigm, a revolutionary way to treat trauma. When people are traumatized, they get very anxious. They get sort of hyper-aroused. They can’t sleep well. They can’t eat well. You can give medicines to decrease anxiety or … to help with sleep. But you’re not really getting to the root cause, which is that they’ve been traumatized and they need to further process the trauma and work through the trauma. … And what CBD does and cannabis does and some psychedelics do and MDMA does is it puts you over into the other side of the nervous system, which is the parasympathetic nervous system, which is not about fight or flight — it is about staying and being open.
On treating PTSD with MDMA, or Ecstasy
MDMA is just an exquisitely perfect chemical for augmenting the process of psychotherapy, so that’s really why it has been chosen. MDMA helps people to feel more relaxed and more open and trusting and more trusting of the therapist, which is important. … It helps people be awake, alert, verbal, want to talk, want to explore. But also, because it increases serotonin, there is very little anxiety and also a feeling of satiety — like you don’t really need anything, like you have everything you need. So this high-dopamine, high-serotonin and also high-oxytocin state makes it really great for being open, being trusting, being able to explore traumas comfortably and trusting your therapist that they’re going to help you to explore these traumas safely. And this feeling of safety is actually very important. MDMA, because it increases oxytocin, there is a quieting of the amygdala — the fear response. Exploring trauma is scary, and often if people become afraid, they close down and they don’t want to talk and they don’t want to explore.
On the effectiveness of MDMA-assisted psychotherapy
Pretty much everybody that I’ve spoken to who has had an MDMA-assisted psychotherapy session has come away from it feeling like they have processed a good deal of their trauma — maybe not all of their trauma, but they certainly have a better, sort of, lay of the land of what it looks like. … I have a patient who, her spouse committed suicide. And she had a very hard time sort of forgiving him or processing that and [with MDMA] she was able to do that in one session and to just leave some of that weight and heaviness there in the therapy room.
I’ve had patients who have stopped self-harming or picking at themselves. I have had patients who are no longer feeling compulsively suicidal. Lots of patients who have changed their behaviors around alcohol or eating compulsively or drug abuse.
On why MDMA doesn’t work if a patient is on antidepressants
Eighty percent of these antidepressants are prescribed by people who aren’t psychiatrists and they just get renewed over and over. Antidepressants that work on serotonin are called the SSRIs — where they sit is exactly where MDMA needs to go to do the work. So they absolutely block the site. So if you’re taking an SSRI, you basically won’t feel MDMA if you take it. And then you have something like ayahuasca, which is very popular — a psychedelic tea — and there are a bunch of medicines that you cannot take if you’re going to have an ayahuasca experience.
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There needs to be some sort of medical monitoring sometimes in these situations, because I don’t want people to do things that are potentially deadly when they could have a positive growth experience if they just weren’t taking certain medicines.
On how these psychoactive medicines might facilitate brain rewiring
A lot of these medicines we’re talking about, like ayahuasca and psilocybin, MDMA, cannabis, they all facilitate what’s called neuroplasticity, which is the brain sort of growing and changing and rewiring. And there are things called synaptogenesis, which is like new synapses forming. And then there’s neurogenesis, which is new brain cells forming.
Anyone who grew up in the ’80s has this idea that these drugs kill brain cells, but it’s actually the exact opposite — that a lot of these plant medicines and psychedelic medicines, they engender brain cell growth and what’s called neuroplasticity, which is sort of new connections being formed and potentially the brain being somewhat rewired, which really helps. That’s what’s fostering the growth and the change in behavior. And you don’t necessarily see a lot of growth and change in behavior when people are taking antidepressants or even maybe going to therapy for years. With really good therapy [that] you go [to] for years, you do have behavioral changes. But to see them after one session is really remarkable. And it’s hard to just go back to the daily dose after you see this kind of tremendous behavioral change.
On how the pandemic has made many people more anxious
Even before the pandemic and the sort of political unrest, I had patients who were extremely anxious just by the current political situation or some people are upset about the environment and what’s happening. So our anxiety levels were already pretty high before all of this happened in the spring. Basically since the ’90s, the numbers have just been going up and up on prescription anti-anxiety medicines being used. And we saw a big spike around 9/11, and we’re going to see a big spike now as well. So it’s pervasive. It’s an ongoing problem. Anxiety has sort of overtaken depression as the No. 1 complaint, not only with psychiatrists, but just sort of general medical practitioners. …
At the beginning of the pandemic, there was anxiety about contracting the virus. But what’s happened over the last several months is, besides the sort of a pervading sense of anxiety and doom, is that the people who have been isolated, the people who are living alone, my patients haven’t had any human touch for three months. And being that isolated and that disconnected will make you more anxious. It will make it harder to sleep. … So it feeds on itself. That’s the thing I’m really worried about now, is that the isolation and the disconnection affects the physiology, makes people more anxious, and then they don’t sleep well, they don’t eat well. They’re trying to soothe themselves with all these unhealthy behaviors, and it all cycles on itself.
Sam Briger and Seth Kelley produced and edited this interview for broadcast. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for the Web.