Magic Mushrooms Is Not Risk Free

The psychedelic drug psilocybin shows promise as a new treatment for mental health conditions such as severe depression, substance abuse and post-traumatic stress disorder (PTSD), but that does not mean it is risk-free.

The hallucinogenic properties of psilocybin, the active compound in “magic mushrooms”, carry substantial risks of harmful side-effects and its safety and efficacy as a medical treatment has not yet been proven, the South African Society of Psychiatrists (SASOP) warns.

Psychiatrist and member of SASOP, Dr Melané van Zyl said: “We know from emerging, but limited, scientific evidence that psychedelics like psilocybin may have therapeutic benefit in the treatment of a range of mental illnesses, when combined with psychotherapy (‘talk therapy’).

“However, we don’t yet have enough robust, conclusive scientific evidence on the safety and efficacy of psychedelic therapy and how to mitigate the risk of harmful physical and mental side-effects, for it to be considered for widespread use.”

The caution advised by SASOP, as the professional body for psychiatry in SA, comes amid growing calls from public activists for de-criminalisation of psychedelics, court challenges to their status as illegal substances, and limited legalisation in a few countries for controlled medical purposes.

The hallucinogenic or “mind-altering” effects of psilocybin are said to “reset” brain connections related to mood, memory and cognition – thereby expanding self-awareness, breaking the cycle of depressive mindsets and unearthing past trauma in order to process it.^[i]

However, Dr Van Zyl said, the small number of studies conducted to date involve small population sizes which are not representative or generalisable to the wider population, are often based on anecdotal evidence or self-reported positive or negative effects, and lack robust research methods and long-term follow-ups.

“The gold standard for drug research is randomised controlled trials, and we do not have those yet.

“Without credible, controlled trials, we do not yet know enough about recommended doses and frequency of treatment, side-effects, interactions with other drugs, or what is the appropriate training for clinicians,” she said.

The potential harm of unsupervised or recreational psilocybin use stems from the “distorted sense of reality” and diminished sense of control that the drug induces, that can lead some people into erratic or potentially dangerous behaviour, or to accidentally harm themselves or others.

A “bad trip” of re-experiencing past trauma or experiencing frightening visions and thoughts can cause anxiety, fear and panic, impaired judgment, paranoia and even suicidality, and there is a risk of long-term side-effects of distressing and debilitating hallucinogenic “flashbacks”.

“Although these risks are deemed to be low and such negative consequences are uncommon, the current information is based on small numbers of users and self-disclosed information. With increasing recreational use, where the user may be unprepared for the experience, not guided or supervised, or guided by an unqualified person, we are likely to see more incidences of people needing treatment for negative side-effects and possible harm,” Dr Van Zyl said.

A recent study in California in the USA, for example, found that hallucinogen-related emergency department visits had risen by 54%, albeit off a low base, from 2016 to 2022, and hospitalisation by 55%, compared to just a 1% increase in hospitalisations related to alcohol or cannabis.^[ii]

Rising social acceptance of psychedelic use, albeit illegal, is indicated in the same study – usage of non-LSD hallucinogenics by young adults, aged 18 to 30, in the USA, doubled between 2018 and 2021 to 8%, the highest prevalence in three decades.

Australia last year became the first country in the world^[iii] to allow psychiatrists to prescribe psilocybin for treatment-resistant major depression, with strict regulations. Only authorised psychiatrists with the required training can prescribe psychedelic therapy, which must be administered under medically-controlled conditions and only when conventional treatments have proved ineffective.

Similar regulations exist in New Zealand, Canada and Switzerland where controlled use of psilocybin is permitted in limited cases for clinical trials or therapeutic purposes.

Dr Van Zyl said that the limited amount of research on psychedelic-assisted therapy had consistently shown that psychological support, such as psychotherapy/talk therapy, is an essential component of the treatment.

“Treatment would entail the therapist discussing the risks, benefits and possible impacts with the client in advance; administering the drug in a calm, safe, supervised therapeutic setting; providing aftercare and then integrating the experience into further therapy sessions to explore and understand the experience and insights gained.

“The therapist must also be equipped to support the patient through a ‘bad trip’ or negative experience and manage any physical side-effects such as vomiting, fever or increased blood pressure,” she said.

SASOP also notes that “increasing public awareness and enthusiasm” for psychedelic therapy, along with the lack of a clear legal and medical pathway to accessing such treatment, contributes to unregulated use of psychedelics, with associated risks.

“Until there is sufficient compelling clinical evidence, and systematic research to overcome the current limitations, SASOP does not, at this stage, endorse the widespread use of psychedelic-assisted therapy.  We encourage active research to build on the current evidence-base.

• “In addition, before any movement beyond clinical trials and consideration of regulatory approval, there is need for appropriate treatment methodologies, adequate training by those delivering the treatment, and an ethical and legal framework that provides appropriate safeguards to ensure harm reduction,” Dr Van Zyl said.

More information:

SASOP Position Statement on the use of psychedelic and empathogenic agents for mental health conditions. 2022.

https://www.sasop.co.za/_files/ugd/cc5d8c_c374aef5e8f3415590b14b0d7825d8c8.pdf

REFERENCES

^[i] Dr Leana S. Wen. 6 September 2023. “Opinion. Psychedelics have great medical promise. That doesn’t make them safe.” The Washington Post. https://www.washingtonpost.com/opinions/2023/09/06/psychedelic-mushrooms-drugs-recreational-legalization/

^[ii] Garel N, Tate S, et al. 2024. “Trends in hallucinogen-associated emergency department visits and hospitalizations in California, USA, from 2016 to 2022”. Addiction, Vol 119, Issue 5. https://onlinelibrary.wiley.com/doi/full/10.1111/add.16432

^[iii] BBC. 30 June 2023. “Australia legalises psychedelics for mental health”. https://www.bbc.com/news/world-australia-66072427