The Ecstasy and the Agony: Using MDMA to treat PTSD

My aunt alerted me to a recent New York Times article on the use of MDMA (known as the street drug Ecstasy) to treat posttraumatic stress disorder (PTSD). I’ve written about research on the use of another drug used recreationally, ketamine, in the treatment of depression and bipolar, so I decided to check out the article.

PTSD involves painful and chronic anxiety and fear following a traumatic experience. People with PTSD often feel like they are reliving the experience through nightmares and flashbacks, may have difficulty sleeping, and may feel detached from themselves and those around them. We’re not sure why some people develop PTSD, but the effects can be devastating. Although we have effective treatments for PTSD, not everyone benefits, so exploring additional options is a noble effort.

The NY Times article reports on an ongoing study of the use of MDMA to treatment people with PTSD. The research is spearheaded by a psychiatrist and nurse couple in South Carolina—Michael and Ann Mithoefer. The couple are aided in their research by the Medical University of South Carolina and funded by The Multidisciplinary Association for Psychedelic Studies.

Initial results from a pilot study were published in the Journal of Psychopharmacology in 2010. You can download the full article here. For the purposes of the blog, I decided to write about published data from this study. While I don’t have any philosophical objection to the rigorous study of recreational drugs, I’m also cautious about making too much of limited studies. Drugs must pass through a variety of rigorous studies and careful analyses before they‘re considered safe enough for the public, and it’s rare that any drug becomes the ‘miracle drug’ often hoped for by the public.

The details of the study

The researchers studied 20 people whom they randomly assigned to receive either MDM-assisted psychotherapy, or the same psychotherapy with an inert placebo. Everyone was assessed two months later to determine if improvements were maintained, and those in the placebo condition were later offered the MDMA-assisted therapy.

Why would a party drug help with PTSD?

The gold standard psychotherapy treatment for PTSD is what’s broadly called exposure therapy. Exposure therapy involves contacting and processing painful reminders of the trauma. However, not everyone benefits from exposure therapy: some people refuse treatment, some become too overwhelmed during treatment, and others are too shut down emotionally to effectively engage.

The authors suggest MDMA may help increase an individual’s willingness to engage painful thoughts and feelings, which may in turn help facilitate successful exposure therapy. While this is a reasonable assumption, theoretically, I do question whether taking a psychedelic drug AND participating in exposure therapy would be less threatening for the majority of people than exposure therapy alone. It might be a hard sell to many people.

What did they do?

The Mithoefers served as the therapists in the study. Participants met with the Mithoefers for a few 90-minute informational sessions. The participants then underwent two sessions lasting 8-10 hours each in which they were administered the MDMA (or placebo). Participants stayed overnight in the clinic after the experimental sessions and were monitored for any medical problems.

Two months after the second experimental session, the researchers followed up with each individual. At that time, they could offer a third MDMA session. Between experimental sessions, participants met for 11 90-minute non-MDMA sessions where they could talk about their experiences following the MDMA sessions.

One thing I was a little uncomfortable with was choice of psychotherapy. Although the authors showed they were familiar with gold standard exposure-based treatment such as prolonged exposure therapy by referencing them in their Introduction, they did not actually use an established treatment. Instead, they created a protocol based on the work of psychiatrist Stanislav Grof, MD, an early advocated of using LSD in psychotherapy. Grof is a controversial figure, regarded as a maverick genius by some and a crackpot by others. Although he continues promote his work, it’s never been tested in rigorous studies.

Referencing gold standard treatments in the intro but basing their treatment on Grof’s work strikes me as a bit of a bait-and-switch.

What did they find?

In brief, people who received MDMA and psychotherapy showed much greater improvement than those who received psychotherapy only. Although there were some side effects from the MDMA, they didn’t appear to be serious and long-lasting. Overall, people seemed to benefit from MDMA-assisted therapy without any major problems.

What I liked about the study

Every study is going to have strengths and weakness, but for a small pilot study, it seemed pretty well done. The measures they used were appropriate and thorough. It appeared they took a number of precautions to ensure the safety of those who participated.

In sum, I thought the design was pretty rigorous, the researchers drew reasonable conclusions about their results, and they acknowledged the problems and limitations with the study. I didn’t see anything sneaky or suspect from what I read.

A few concerns…

Here are some weaknesses of the study. Some are pretty normal and expected, and others are more concerning.

Can you really blind people to a placebo when using a psychedelic drug?

As the authors openly acknowledge, 19 of the 20 participants were able to guess whether they received MDMA or the placebo. This is a common problem in medical research when a drug has strong physical effects. What it means, though, is that it makes it harder to tease out the actual effects from people’s expectations.

For example, as people signed on knowing they might receive MDMA, some may have had greater expectations when they realized they probably received the MDMA; conversely, those in the placebo condition may have been disappointed when they realized they probably didn’t get the MDMA.

MDMA-assisted therapy ain’t cheap!

With 31 hours of contact with two therapists, medical monitoring, and overnight stays in a clinic, MDMA-assisted therapy is going to be much more expensive than basic exposure therapy, which typically involves 10-20 sessions with one therapist for 60-120 minutes.

For these reasons, MDMA-assisted therapy will never be a first line treatment if conducted in this fashion. That said, chronic PTSD is very expensive in the long-term (e.g., meds, inability to work, disability). For people who don’t respond to outpatient treatment, MDMA-assisted may be worth the expense if it helps people who don’t benefit from other approaches.

Why didn’t the researchers adapt a therapy with actual research support?

The authors predicted that MDMA may help individuals more effectively respond to exposure therapy for PTSD. Although the treatment protocol they used contains elements of exposure, it wasn’t based on any gold standard treatments for PTSD.

Instead, they used an invalidated protocol based on the work of Stanislav Grof. This makes me squeamish. Grof’s work has some wonky stuff in it. For example, although this wasn’t included in the protocol, Grof has written that psychological problems occur due to “trauma” during the one’s birth! In his Holotropic Breathwork, people are sometimes encouraged to contact “memories” associated with their births—despite the fact that all science suggests we’re incapable of forming these kinds of memories until around age 2.

This doesn’t mean that all Grof’s ideas are bad, but I have some concern in granting legitimacy to his work given some of the more questionable elements of it.

Concluding thoughts

Despite my concerns, I thought this study was reasonably well-designed and fairly transparent. I think the results are strong enough to warrant continued study of MDMA-assisted therapy for PTSD.

However, I think we’re a long way off from seeing it offered as a treatment to the public. And if it does make it that far, it will likely be a last resort for those who don’t respond to other treatments. If it helps people who don’t find relief for their suffering through other means, however, I’m open to it.