Back to the Future: Psychedelics and a Return to the Concept of Recovery in Psychiatry

Modern psychiatry plays an under- discussed role in the observed epidemic of mental and brain health disorders. The prevailing model of psychopharmacology, and in medicine generally, suggests that a disease happens to reside inside of a person, and thus the disease should be the central focus of attention. That approach has its value, but it implies that treating the disease with better medicine is a sufficient objective. In CNS disorders, that has rarely proven to be the case.

To be sure, today's medicines are lacking.
Scientists have called the brain the "final frontier" of medical innovation. Most drugs presently in development are either reformulations of existing drugs or show only a marginal benefit over generics. SSRIs and their modern peers are as infamous for their side effects as they are for their inscrutable pathways to efficacy.

Thankfully, this decade has brought a resurgence of scientific and capital market attention to the deep, yet stimagized, body of research around psychedelic com- pounds as brain health medicines. And, while it is certainly simpler to treat the set of psychotropics that have recently excited the public imagination as if they are a single drug class, doing so papers over critical differences between them.

Dissociative anesthetics (ketamine, esketamine), empathogens (MDMA), and psychedelics (LSD, psilocybin, DMT, etc.) share qualities of rapid effects, a recent surge in attention, and most notably of acute, consciousness-altering effects. The similarities, however, end there. The contrasts between these treatments become most evident when considering the relationship between drug administration and concurrent psychotherapy. The dissociative state induced by ketamine, on one end of the spectrum, is not conducive to acute psychotherapeutic intervention. MDMA, on the other end, has not shown a sustained drug benefit without repeated sessions of psychotherapy soon after drug administrations. In contrast, classical psychedelics, with their notably experiential effects, have been shown to work independently of psychotherapy and to benefit from therapy.

Yet a clear relationship between subsequent sessions of psychotherapy and outcomes has not been fully explored. Although nearly everyone can benefit greatly from good psychotherapy, it is, to society's detriment, a scarce resource. Largely responsible is the financial pressure from government and private insurance providers whose low reimbursement rates for psychotherapy do not reflect its value.

Why does this matter?
These relationships between drug classes and psycho- therapy will have a profound impact on regulatory approval pathways and, critically, on insurers' willingness to pay. This, in turn, will determine if we continue to promote a two-tiered system of psychiatry that provides the highest quality treatments and resulting relief only to those who can pay, rather than to all who suffer.

The advancement of pharmacology is necessary but not sufficient for advancing the psychiatric paradigm. Psychedelic-assisted therapy is just the latest example of a provider model featuring unique treatment duration and labor-intensive delivery.

This model appears optimal for testing and implementing digital medicine solutions that improve patient outcomes and streamline the provider experience. Pre-treatment, digital medicine tools can facilitate patient education and engagement for the experience participants are about to undergo. During treatment, digital tools can support provider decision-making and reduce guesswork in environments where patients may struggle to describe their own experience. Post-treatment, these tools help providers to engage patients and monitor lagging biomarkers and side effects. All of these data points help to facilitate payer adoption of emerging therapeutic models.

Technology will also keep us honest about the differences between diagnosing a disease, managing symptoms, and effectively treating the patient. In a world where our best psychiatric practitioners spend their days dispensing and managing medications, psychotherapeutic support has been left by the wayside.

This context is critical to the resurgence of interest in psychedelic-assisted therapy. As a profession, we should welcome and support further research into a new generation of medicines, built on decades of clinical data from human trials. But we should pursue just as adamantly a return to a psychiatric model aimed at recovery, one which requires building the digital scaffolding for a new generation of treatment.