Psychedelics as a therapy against depression

Turning point in the treatment of depression? Psychedelics are experiencing a revival. What most know in connection with hippie culture could become a game-changer in the treatment of depression be. PQ author Margit Hiebl spoke with Prof. Dr. Andreas Menke about possibilities and risks. Prof. Dr. Andreas Menke . He is a specialist in psychiatry and psychotherapy and the medical director of the Medical Park Chiemseeblick, a specialist clinic for psychosomatic medicine and psychotherapy.

What is depression?

Depression is a mental illness - characterized by a depressed mood, reduced drive and reduced interest. This illness can also be so severe because it significantly affects all areas of life. In private life, because you withdraw, hardly maintain contact with friends and family. You also can't really work anymore - depression spreads like a black carpet over everything.

What are the first signs?

It often begins with concentration and memory problems or trouble falling asleep and staying asleep. Appetite can also change, either increasing or decreasing. Restlessness and tension can also occur. Feelings of guilt can arise. The most severe form leads to suicidality, where a person develops the thought or even takes the first steps to end their life.

Everyone has a low point sometimes... is that already depression?

Basically, a distinction is made between just being in a bad mood and having depression - even if people sometimes say "I'm depressed today" in everyday language. By definition, the depressed mood and reduced drive must persist for at least two weeks, with a certain number and severity of symptoms, otherwise I cannot diagnose it. If you're just sad and there's a reason for it, that's not yet depression.

How do you get depression?

On the one hand, there is a genetic predisposition of about 40 percent. However, there is no single depression gene, it's like a mosaic and each piece of the mosaic has, taken by itself, always a small effect. 60 percent are due to environmental factors.

Our conventional medications like antidepressants and antipsychotics also have psychoactive effects.

The main factor here is chronic, toxic stress: for example, at work, when you feel like you're in a hamster wheel. But also constant relationship conflicts, lack of sleep, financial problems, fear of losing your job. All this can lead to depression.

Recently, there have been reports of psychoactive substances or psychedelics like psilocybin, which promise a new approach to treatment.

It's important to differentiate. Even our conventional medications like antidepressants and antipsychotics are psychoactive.However, classic psychedelics are not approved for treatment unless within a study design. For psilocybin, for instance, there are now good studies showing very good efficacy. And very quickly – even after one dose, the depression can be gone.

Prof. Dr. Andreas Menke, specialist in psychiatry and psychotherapy and medical director of Medical Park Chiemseeblick The new book by Prof. Dr. Andreas Menke: Depression – Know What Helps: Latest Findings and Effective Therapies to Overcome the Illness | A Scientifically Based Guide for Affected Individuals and Relatives, Piper Publishing House

That sounds very promising...

Yes, it's assumed that such entrenched structures in the brain, which have solidified over a long time, are broken up so that new experiences are possible again, almost like a child, you can learn new things again. This is also why combining with psychotherapy makes sense, as it creates a prerequisite for new experiences.

And the risks?

They truly act psychoactively, meaning they can trigger not only dissociative but even psychotic symptoms, which can be very distressing. Like hallucinations, paranoia, or similar. This can last up to two hours. Outside a therapeutic framework, I would not recommend it. Within a setting, it lasts about six to eight hours. LSD has a similar effect, but with a longer half-life.

If the study results are so convincing, then it could be approved soon.

It is expected that it will be approved by the FDA in the coming years, and then the EMA in Europe would soon follow.

In emergency medicine and anesthesia, ketamine has been known for a long time

Would you use it in your clinic?

If it is approved, I will also use it in our clinic. Here the setting is ideal, as we can combine psychiatric expertise with good psychotherapy options. It is a turning point, so to speak, because the substances work immediately. Not much has happened in the development of antidepressants since the 1950s – while tolerability has improved, efficacy has not. It takes about six weeks for them to work.

How is it with ketamine?

Ketamine is not quite a true psychedelic yet – but it works somewhat like one. This substance is also considered a rapid-acting antidepressant and is used in studies at university hospitals to treat depression as an infusion. It has been known in emergency medicine and anesthesia for a long time.

Some time ago, it made less than honorable headlines because actor Matthew Perry died from it.

The danger lies in the misuse. Because it is an anesthetic and is otherwise used for anesthesia. With an incorrect, too high dosage, there is a risk of falling asleep and not waking up again because it eventually blocks the respiratory center.

But there is a further development…

Yes, the esketamine – a nasal spray. A clear advantage is the form of application, no infusion is needed anymore. And the dosage is adjusted. It is already approved, but only for treatment-resistant depression or in a suicidal crisis. According to guidelines: At least two antidepressants have been tried that have not helped. Esketamine can work after one or two doses, but it is usually used over four to eight weeks.

What condition are you in when you have taken that?

You become tired, but do not sleep. It could also lead to dissociations, but not as often as with psychedelics.

And afterwards, would you also happily leave the clinic?

At first maybe yes. Antidepressants and psychedelics work but do not lead to a change in behavior. That means, if you have problems interacting with other people, partners, and in professional life, or difficulties with values ​​or schemas from childhood and adolescence that keep recurring in adult life, they will not be changed by medication.

Antidepressants and psychedelics work but do not lead to a change in behavior.

It only treats the depression. If the medication is discontinued, there is a risk that depression will be triggered again by these stresses. However, if there is a change in behavior, such as through psychotherapy, the chance of not getting sick again is significantly higher.

But psychotherapy alone is not enough either?

Some are so sick that they first need to be brought to a certain level in terms of concentration, memory, or drive with antidepressants in order to benefit from psychotherapy. Because it only works if you can really participate.

Last but not least: One more word about cannabis and depression?

Cannabis is not a medication for treating depression or improving any psychological symptoms. This is clearly demonstrated in studies. It rather has the disadvantage that it can cause damage to the brain, especially in people under 25 years of age.

It can even trigger depression more easily, as well as psychosis or schizophrenia. Also common is the so-called 'California Surfer Syndrome', which manifests itself in not feeling like doing anything anymore. Although you feel fine, you won't achieve much in life anymore. And that is not treatable.