‘You can bring up all sorts of things in people’

Hardly anyone was interested when Joost Breeksema set up a foundation sixteen years ago with a few other enthusiasts to get more scientific research into psychedelics off the ground. It took him great effort to get psychology study associations alone to give a lecture on the subject, let alone convince scientists to do research.

In the meantime, social and scientific enthusiasm about the therapeutic application of psychedelics is so great that Breeksema tries to temper expectations. ‘Until a few years ago I had to make it clear in conversations with journalists or politicians why this was a topic in the first place, now I emphasize that we don’t know a lot yet and what the risks are.’

In addition to his work as director of the Open foundation, Breeksema (40) is also doing a PhD on patient experiences with psychedelics at the UMCG. This makes him one of the rapidly growing group of scientists who are studying the role that mind-altering drugs can play in mental health care.

The results are promising. Substances such as MDMA (the active ingredient in ‘cuddly drug’ ecstasy) and anesthetic ketamine appear to be effective in treating psychiatric disorders such as post-traumatic stress disorder (PTSD) or major depression. Last summer, the Groningen professor of psychiatry Robert Schoevers was awarded more than 3 million euros in public money for his research to esketamine (a variant of ketamine) in the treatment of major depression.

Minister of Health Kuipers (D66) sees a pioneering role for the Netherlands to use these types of products in practice, once they have been approved by the medicines authority EMA. That is not a distant vision: MDMA is expected to be approved by the American regulator FDA at the end of next year for the treatment of ptsd in the US. Europe would follow about two years later. Esketamine in the form of a nasal spray has already been approved for the European market.

Why might resources that we mainly associate with going out and festivals help people with a mental illness?

‘During an experience with psychedelics, people become more flexible in their thinking. They gain new perspectives, are confronted with parts of themselves that they did not know and gain more access to emotions. That can have therapeutic value, for example if people do not progress in their regular treatment.’

Are the expectations of that therapeutic value too high?

‘There are reasons to be enthusiastic, but it is good to realize that there is still relatively little strong scientific evidence. Public interest does not match what we know about safety and effectiveness. That worries me.’

Patients are already queuing for psychedelic therapy while a lot is still uncertain?

‘Yes, and that’s understandable. Patients who are completely stuck see a documentary series about psychedelics on Netflix and thinking: I want that too. I am regularly approached by desperate patients or their relatives, everyone in this field of research has. The difficult thing is: if you have tried everything as a patient and there is no one in the official circuit who is willing to offer such a treatment with psychedelics, you may end up in a circle of people who claim that they can offer that therapy, but no be professionals. Then you take huge risks with people’s mental health. If you are not a mental health professional, you cannot provide the necessary guidance. You can bring up all sorts of things in people and make their problems worse.’

What is the alternative?

‘I refer people who knock on my door to the studies that are ongoing at UMCs, in which they might be able to participate. That chance is small, because there are few places and the selection criteria are very specific. I am not a practitioner myself, but I know that psychiatrists who work with this also find this a dilemma. It is your responsibility as a practitioner to cause as little damage as possible, but how do you do that? By offering nothing to someone who has been treated, while there may be a remedy that helps?

‘At the UMCG we are thinking about whether we can offer this group something. For example through a compassionate use program, whereby a drug that is still under development may already be prescribed in specific cases. This is already happening in Canada. D66 recently filed a motion submitted to see if something like this is possible here. It was adopted this week in the House of Representatives.’

On the one hand you want to dampen the enthusiasm, at the same time you are trying to get psychedelics to patients as quickly as possible. Doesn’t that bite each other?

‘It has to be both. You have to believe in the potential to keep working for it. I think psychedelics have something to offer for some of the patients who are now stuck in conventional treatments. If there is an opportunity to help these people right now, why not do it?

‘At the same time, we are not there yet. The good research results available are the result of small studies with carefully selected patients. If you start doing larger studies, or if some psychedelics are soon registered as medicines, you will have patients with multiple disorders and a very different socio-cultural status.

‘It is generally highly educated, white people who participate in this type of research, many of them already have experience with psychedelics and know somewhat what to expect from them. This group is not representative of the average person with depression. That is also why expectations may be tempered: the research results do not always remain so good.’

What is solid evidence? What are we sure of?

‘The evidence for MDMA-supportive psychotherapy for people with severe PTSD is clearly. This remedy is undeniably a huge benefit for people for whom other forms of therapy do not help. MDMA makes people milder, more empathetic, that makes it eminently suitable. It helps patients go back to trauma without feeling that intense fear.’

What will psychedelic therapy look like in the future? Do people take LSD home with them?

‘No, psychedelics are emphatically aids in psychotherapy, they help where people experience blockages, for example. Patients are first prepared, they get to know their therapists and discuss what they are struggling with. They get the psychedelics themselves in a living room-like setting. Patients lie on a bed or on a couch during such a session. There is music on and there are always two therapists on hand to reassure them if things get scary or uncomfortable. Afterwards, a number of conversations follow to process the experience. That is very important: people sometimes gain important insights, but they then have to give them a place.’

You conduct research into patient experiences with psychedelics. What does that show?

‘I interview patients a few weeks after they have taken a substance. Most of the research is still ongoing, but I’ve completed my research on ketamine in persistent depression. This involved patients receiving ketamine in psychiatric clinics. They were not always well prepared for this and sometimes experienced anxious moments, I heard during the interviews. That fear can have therapeutic value, but there must be someone who guides you, who, for example, helps to investigate where that feeling comes from. We have improved the care for this group.’

This summer also a striking research from you to other psychedelic studies. Researchers appear to be careless about reporting side effects. For example, one study on the drug ayahuasca stated that four participants were hospitalized for a week, missing details about their condition or how it related to the ayahuasca therapy.

‘It also didn’t say whether it was about people who had used ayahuasca at all, or whether they came from the control group. I think that’s sloppy and I think it’s bad for the legitimacy of this research. Research into psychedelics has long been taboo. Much research was done in the last century with promising results, but that stopped completely when these types of substances were banned in the late 1960s.

‘I think there may still be researchers, and I understand that somehow, who think: let’s not emphasize the negative sides of psychedelics, the research will soon come to a halt for years. Ultimately, I think it’s wiser to be as open as possible, you can only learn from that.’

If MDMA is approved in the US, it is expected to be approved in Europe a few years later. Are we ready for that?

‘There are already therapists who are gaining experience with this treatment because a study is underway in ARQ Centrum ’45, a specialized clinic for the most severe PTSD cases. But by that time other centers will also be needed that want to offer this form of therapy. That’s going to be a bottleneck, there aren’t enough people yet to train and supervise all those therapists. This is really a totally different kind of treatment, patients can react very unexpectedly.

‘Partly for this reason, we as the Open Foundation are now setting up a consortium together with the UMCG and ARQ Centrum ’45, among others. For example, we want to ensure that therapists are trained and health insurers are informed. We also want to immediately set up a large-scale study with which we can follow all patients. It’s an ambitious plan, but I think it’s our best option to give psychedelics a safe place in our healthcare system in the coming years.’