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Happy New Year! It is with great enthusiasm that CAMH continues working towards transforming mental health for all in 2023.In this month's brainbuzz™, we share research on the potential of psychedelics for mental health, and study findings on the feelings of psychiatrists upon losing patients to suicide.Questions and feedback are welcome at any time — feel free to get in touch.
Aristotle Voineskos VP Research, CAMH
Investigating the potential of psychedelics for mental health
CAMH scientist Dr. Ishrat Husain discusses groundbreaking work recently published in the New England Journal of Medicine
Despite promising results as far back as the 1960’s, the clinical study of all psychedelic drugs as a potential therapeutic for treatment-resistant depression and other major mental illnesses was banned for decades for largely political reasons. That freeze on research has lifted in recent years, with several small studies showing promising results.
Recently, one of the world’s most prestigious medical journals, the New England Journal of
Medicine (NEJM), published the largest clinical trial of its kind on the potential benefits of psilocybin, the active ingredient in “magic mushrooms”, for treatment-resistant depression.
The purpose of the clinical trial was to investigate the safety and efficacy of psilocybin at different doses. One group of participants was given a large dose, while others received a moderate dose, or a placebo-like dose. All participants received psychological support prior to, during, and after the psilocybin dosing sessions. The trial took place at 22 sites in 10 countries, and CAMH was the only Canadian site to participate.
In an accompanying editorial, the NEJM called the results of its clinical trial “intriguing and sobering.” Intriguing because the results
showed that one in three study participants with depression that had previously been treatment-resistant reported a complete absence of symptoms. The results were also sobering because psilocybin’s safety has not yet been established and there were serious adverse effects among participants in all three treatment arms, among these, self-harm and suicidal ideation. It remains unknown whether those adverse effects were because of the drug itself or a result of distress from participants who did not benefit from participation in the trial.
More clinical trials will be necessary to determine if psilocybin can be used safely in a clinical setting.
We asked him how he got involved in this area of mental health research and how he sees the future of clinical research into psychedelic drugs:
Tell us about your background and how you came to CAMH?
“I have been at CAMH for five years. I am Canadian but was born in Pakistan and completed my medical and research training in the U.K., so I consider myself a citizen of the world. My research involves assessing new ways of treating mood disorders, from novel trials including those involving psychedelic drugs, to assessment of low-cost scalable treatments in low-resource settings like Nigeria and Pakistan. My research program aims to improve outcomes for mood disorders across populations and settings.”
How much stigma is there regarding the study of psychedelics?
“There continues to be some stigma within the scientific community as well in the public with regards to therapeutic use of psychedelic drugs. I think that stigma has reduced substantially in the past 15 years because of growing preliminary data showing that these substances may be potentially safe and effective. Research methodologies have improved so much over the last few decades that now is the time to continue to build on these findings to truly assess whether psychedelic drugs can truly help those with mental illness and addictions.”
How would you describe the results of the study?
“Even though some might consider the results of the present study to be modest, a response rate of almost 40 per cent, and a remission rate of almost 35 per cent of participants showing a total absence of depressive symptoms so rapidly with a single-dose treatment is actually very rare. If you look at the results of this study and compare it to other medications currently used for treatment-resistant depression, I would say that they are very encouraging.”
What would you say to people who express an interest in using psilocybin for depression as a result of this study?
“I would warn the general public that although the findings from the studies being published are promising, they are being done in very controlled settings with very selected groups of individuals. For example, anybody who has a family or personal history of any type of psychotic illness was excluded from this study. Further studies are still needed to determine whether psilocybin is safe and effective for clinical use. CAMH is involved in these studies and we are building a program of research in psychedelic science that we hope will address some unanswered questions about the value of psilocybin in treating patients with mental health conditions like depression, but for now it remains very much an experimental treatment.”
Psychiatrists on losing patients to suicide
Clinician Scientist Dr. Juveria Zaheer is not unique among her fellow psychiatrists in, at times, feeling a sense of personal responsibility for the life and death of her patients. In fact, when a patient dies by suicide, some psychiatrists report becoming paralyzed by guilt and self-doubt that can negatively impact both themselves and their patients.
“We know that losing a patient to suicide is a common experience for many psychiatrists, but our knowledge of the impact of that is limited,” said study co-author Dr. Zainab Furqan, Clinician-Researcher at the University Health Network. “What we do know is that this event has a major impact on psychiatrists, with many calling it the most significant event of their careers.”
What the anonymous qualitative survey of 18 psychiatrists found was that
they can feel a unique burden of responsibility for their patients’ outcomes.
“We see it in the terminology we use,” says Dr. Furqan. “In hospitals we call the attending physician the ‘most responsible physician’. This was an important theme of the study. What does it mean to be responsible for a person’s care, and when a suicide happens, are you responsible for that outcome? It’s a question that the psychiatrists in this study really grappled with. I think feelings of self-doubt and second-guessing are universal in medicine, but there is something unique about suicide where it is hard to grapple with the sense as to whether it is a choice rather than part of the illness, so these questions start to come up in a unique way.”
found that while up to 80 per cent of psychiatrists will have a patient die by suicide at some point in their career, many said they had never received any kind of training in medical school or in professional practice about how to process the loss of a patient to suicide, including how to speak to grieving families. A majority of respondents also indicated being wracked by guilt and self-doubt in a way that compromised their ability to assess a patient’s risk of suicide. Many also expressed fears that they would be judged by their peers or supervisors for the death of a patient.
“I would divide my recommendations into three categories: pre-emptive training before the event, actions taken immediately after the event itself, and best practices after an event,” says Dr. Furqan. “During residency, we should teach future
psychiatrists about the common reactions clinicians have after a patient suicide. What are some practical strategies for supporting team members or the patient’s family after a patient suicide? And it is also important to have nuanced conversations about the ability to predict suicide. Some psychiatrists graduate with a belief that they can accurately predict suicide and therefore stop an outcome from happening. The reality of the matter is that our profession is not at that place right now- we simply do not have that ability. So having these complex discussions that can even get philosophical in nature during training could be really helpful and potentially alleviate some of the guilt and self-doubt that psychiatrists experience when this outcome happens. During and after the event, the most positive form of support can come from professional colleagues or mentors they have a
trusted relationship with. That can be highly therapeutic. It is also important for the institutions they work for to review the event using neutral language and a non-judgmental tone.”
For lead author Dr. Juveria Zaheer, a CAMH Emergency Department psychiatrist who has published many studies on suicide, this study was uniquely personal:
“The piece around change in practice really resonates with me. I remember, as someone who works in an emergency department, treating people with humanity and dignity is the most important thing. But then you hear this voice in the back of your head: ‘Am I missing something? Did I do something wrong? Should I be more cautious?’ Ultimately, you are sitting in a room alone with a patient and you have to figure it out together. One of the
reasons we proceeded with this study was just to feel less alone and to learn from each other.”