Can Psychedelic-Assisted Therapies Help Veterans with PTSD?

Evan Banks

You're listening to Policy Currents, a weekly podcast from the RAND Corporation. I'm Evan Banks. Millions of Americans experience debilitating symptoms associated with PTSD and depression, two conditions that are more prevalent among those who served in the military. There are existing treatments that are effective, but a lot of people, including many veterans, continue to struggle. RAND's Rajeev Ramchand, who's joining me in the studio today, is an epidemiologist whose research focuses on improving the mental health of service members and veterans, as well as their families and caregivers. He recently testified before Congress on the promise of psychedelic-assisted therapies for treating veterans' mental health conditions. Thanks for joining me in the studio.

Rajeev Ramchand

Thanks, Evan.

Evan Banks

So first off, when we say psychedelics, what kind of substances exactly are we talking about?

Rajeev Ramchand

There's a range of substances. The ones that are getting most traction right now in the United States are MDMA, also street name of ecstasy, and psilocybin, which has a street name is magic mushrooms. Things of that nature.

Evan Banks

Okay. What do these drugs do? Like, how do they affect the brain?

Rajeev Ramchand

They alter mood and in significant quantities they'll produce a hallucinogenic state that's been written about since the 60s when they kind of first came into it. Not first. I mean, they've been around for a long time. They have a history of use in American Indian, Alaskan native populations. They've been used in kind of religious and spiritual practices, but really kind of escalated during kind of the the 1960s. That's it's interesting because at the congressional hearing last week, somebody asked, do we know how these substances, the mechanism of action by which these substances create promise for people with mental health conditions. And that still is a big unknown.

Evan Banks

Okay. People don't tend to think of these substances as cutting edge therapies.

Rajeev Ramchand

They're not, I mean, they've been around for a long time. What's cutting edge about them is it's not necessarily--the ones that are really gaining traction. It's not just like you take a pill as if you would take an antidepressant and have elevated mood. Most of these treatments right now at the beginning stages at least, are they're being studied for PTSD, post traumatic stress disorder. And they the ones that are gaining traction that might become FDA approved is the combination of MDMA or ecstasy with a psychotherapy. And so what they're considering the package that's before the FDA has 15 sessions. So you get 15 treatment sessions. Three of those involve administering MDMA. So you're getting a lot of psychotherapy during it. And three of those sessions your under MDMA kind of treatment.

Evan Banks

I didn't realize that what they were considering was such a specific regimen of treatment.

Rajeev Ramchand

Well, so it's it's interesting. So that FDA is looking at that right now. Researchers are testing other compounds and their effects. But at the same time that this is happening, states and other jurisdictions are starting to make policy movement with these compounds that really range from everything from deprioritization, where the law doesn't change but they have decided to deprioritize kind of enforcement of that law to some laws, which is defelonization or reducing penalties associated with the law or with with breaking the law or, you know, possessing or distributing these substances. And in some cases we've even seen, you know, a form of legalization where consumption of certain types of these substances under certain conditions, as well as possession of certain quantities of these substances, is, you know, essentially at the state level or at least, legalized. That doesn't change federally that these substances, many of them are still considered illegal.

Evan Banks

Okay. I don't want to get too far ahead of ourselves, though, so maybe we can rewind and talk about, you had mentioned in the 60s there was the beginnings of research, like being done on psychedelics and their effect on PTSD in therapy. Can you can you talk about like that era and what was found and then why we stopped doing research?

Rajeev Ramchand

Well, I'm not that old, so this is based on historical historical record of the 60s. Although I did remember reading in graduate school, my graduate school work was funded by the National Institute on Drug Abuse. So I've been doing substance abuse research and substance use research for a long time, and so I've been interested in it for a while. So I do remember, you know, in high school of reading Ken Kesey's The Electric Kool-Aid Acid Test and things of that nature. But regardless, the 60s, this is getting a lot this these compounds were getting a lot of traction, but it was happening at the same time that there was a lot of concern about drugs. And and the Controlled Substances Act came around and hallucinogens got scheduled as a schedule one drug. The majority of these drugs got scheduled as schedule one drugs. And I mean, the belief is that that really put a pause on research. You can do research with schedule one drugs, NIDA funds a number of trials using marijuana using now MDMA. They've always had a history. It's not prohibited. It's just very difficult to do. They are controlled substances. There's a lot of regulations put on it. So the research has been going on since then, but a lot of researchers were not so enthusiastic about going through those steps. So it really stalled research on these compounds.

Evan Banks

Okay. I think the the history for me that I read that really helped me kind of understand where that world came from was Michael Pollan's book, How to Change Your Mind. And then I'm currently reading The Body Keeps the Score by Bessel van der Kolk and that's also a fantastic kind of history of not necessarily psychedelic assisted therapy, but just therapies for PTSD in general and trauma and what the mind goes through when we're experienced to trauma and kind of what different therapies do to help a person regain, I guess, a sense of of normalcy.

Rajeev Ramchand

People don't necessarily use the word cure, but it helps you manage your symptoms. I think about it, you know, psychotherapy is very similar to physical therapy or speech therapy or any of these other therapies. You're not curing the problem, but you're necessarily creating an environment that's conducive for the body mind voice to manage these symptoms.

Evan Banks

So we have several types of therapies available now for symptoms of PTSD, and they've been proven to be effective and they're therapies that the VA currently uses. Why should the VA look into psychedelic-assisted therapies at all?

Rajeev Ramchand

These treatments work, but they don't work for everyone. And so we need more. We need to keep researching and keep pushing the needle to figure out how we can continue to improve the lives of veterans and others. You know, a lot of research the VA does will affect other traumatized populations or peoples or populations or individuals with a history of trauma. So I think, you know, the research is needed more broadly, but for veterans in particular. There's the current treatments have a relatively high dropout rate, so people don't complete the first full course of treatment and drop out after the first session in the second session of treatment is quite high. So people start it and that's really brave to to go in and start treatment and then just realize, whoa, this isn't for me. This isn't what I signed up for, for whatever reason. So it's trying to come up with new treatments to keep veterans and others engaged in the treatment process. And then ultimately when they complete treatment so that we can they can manage their symptoms so that they wouldn't necessarily meet criteria for PTSD, that they'd be able to, again, manage those symptoms so that they can live, you know, fulfilling lives.

Evan Banks

So just to be clear that that dropout rate being high is for the treatments that we have now.

Rajeev Ramchand

Exactly. Treatments like prolonged exposure therapy, cognitive behavioral therapy, cognitive processing therapy, those are the treatments that are most frequently used and the ones that are highly recommended by the VA in their clinical practice guidelines.

Evan Banks

Okay. Do we have numbers on how many veterans are looking for psychedelic assisted therapy?

Rajeev Ramchand

No, we don't have that those numbers now. I think we could get them. It would be hard to. It would be hard to get, really. I'm just thinking epidemiologically what we need to do to kind of understand that we have rough estimates of the number of veterans with PTSD, the number that have access to treatment. It's definitely not 100% of those with PTSD who have access to treatment. The proportion for whom treatment hasn't worked, who might be interested in this. But then there's also people who maybe never, haven't yet engaged in treatment and if this were available, they might be more likely to try it out.

Evan Banks

Okay. And you think that as states change their laws, these sorts of treatments will be in more and more demand?

Rajeev Ramchand

So that's an interesting question. So it's going to be really interesting to see what happens. Kind of if you think about the medical marijuana experience. We can kind of project what might happen with hallucinogens. So what the FDA is, is considering is a very specific protocol for MDMA-assisted psychotherapy, for PTSD. So if that gets approved, then there will be a whole bunch of things that will happen and that treatment might become available. But there's no governing body that governs psychotherapy. There's you know, it's kind of we hope that that that's how it's administered. But as that becomes available, will people start using it, what we call off label? So without psychotherapy, how will we have those guardrails set up? Or right now in Oregon, for example, they have supervised consumption sites for psilocybin, which is mushrooms, and there's two, the law, I think, dictates that there's two sessions before you initiate the trip experience, then one with the trip and then one integration session afterwards. But that's not an evidence-based protocol that there's no science behind it. So that's just kind of what they came up with, given kind of the laws in Oregon, how they've handled it. So as more cities, states, municipalities, deprioritize or make these treatments more available kind of before the science or in tandem with the science, at the very least, they'll be really interesting to see how these get rolled out and what becomes available and how closely it aligns to the one that the FDA approved or how far it deviates from it.

Evan Banks

Right. Yeah. Interesting for the field and I guess something that we've also seen with the medical marijuana movement. But you wrote in your testimony, you said in your testimony that you think the pace of change here is going to be much faster.

Rajeev Ramchand

Yeah, I think we already see states and municipalities who are going in that direction, like Oregon, for example. The science on MDMA-assisted therapy is, the demand is is really high. Congressional interest is really high. I trust the FDA will do its due diligence in reviewing kind of the quality and the evidence from these trials to see what happens. But I think that the movement will be really quick. And that's why in my testimony, I focused on kind of the need for policymakers, the VA and others to kind of get ahead of that. We shouldn't be playing catch up. We should be really thinking proactively as monitoring the marketplace, monitoring what's happening so that we can think about what are these potential repercussions. And I'm not saying an adverse effect that could be really beneficial, things that happen as well, but we just had to be thinking about all possible avenues and how policymakers can ensure that this stays on course and doesn't, you know, turn into something. You know, really bad. And that means also thinking about how will we ensure equitable access to these treatments, but also how will we ensure that we can put guardrails in that people are using these substances safely?

Evan Banks

Yeah. You wrote, I believe, that the average cost for the treatment would be...

Rajeev Ramchand

$10,500, something around there. So it's far outpaces the cost, it's cost effective when we think about the costs that PTSD have to individuals in society. So it is a cost effective treatment, but it's much more expensive than current psychotherapies on the market, which really, because it's more time and labor intensive, most psychotherapies on the market right now just require, I shouldn't say just, they--it's labor costs. It's the psychotherapist labor cost of their labor. And you know the things that go along with scheduling, administrative costs. This this protocol that we're investigating, the three sessions with MDMA are eight hours long, two therapists, in a controlled setting. You know what I mean? It just kind of adds up. Right. So $10,500, I think, is a conservative estimate. That's what the cost effectiveness when they label that out, that doesn't take into, you know, people who want to might profit off of this and things of that nature. So, that's kind of a conservative estimate. So.

Evan Banks

Wow. There is a huge equity aspect to that.

Rajeev Ramchand

Right. Something about the cost also that concerns me from an equity aspect is that if there's not education that goes out with this, so if people think it's just the pill and not are just the drug and not the psychotherapy, that kind of goes along with it, then they might be unwilling to spend $10,500, but they can get ecstasy or MDMA on the street. The problem with that is that there's no control over the safety and the quality of that drug. It could include adulterants like methamphetamine, but it also could, it doesn't come with psychotherapy. And we don't know what the effects would be without psychotherapy. So there's a lot of there's a lot of issues at play. If this were to get approved and become more, get marketed.

Evan Banks

Do we have a timeline on when these treatments would start being offered by the VA?

Rajeev Ramchand

Somebody at the testimony, another witness said that they're thinking early 2025. Okay.

Evan Banks

But we have this kind of legal patchwork now with states like Oregon, Colorado, I believe, have sort of these, it's a legal patchwork where it's legal for medical use. In some states, it's legal for...

Rajeev Ramchand

Well, in two states, Colorado and Oregon, we've already seen conditions where it is state legal. It's still illegal under federal law. And then the rest of states and municipalities, it really represents a patchwork of policies and which is something similar to what we saw from marijuana use as well. Federally, what's interesting is that federally, the legislation that we've seen being considered really has to do with more research and treatment orientation, so more research into these substances. That's kind of what's happening federally. But at the state level and the city level, that's where we see people talking about kind of the criminal justice, legal kind of aspect of it. There's one and then there's a combination. There's a bill that Cory Booker just introduced, reintroduced I forget what it's called, but it's essentially this bill would say anything designated breakthrough therapy status by FDA would be considered for a reclassification in the Controlled Substance Act from a schedule one to some other drug, even a schedule two drug, which would, you know, so so but that would be done in the guise of that research is for research purposes, again, to make it more accessible, easier to do research on these substances.

Rajeev Ramchand

A veteran who was testifying at the hearing said something that made me really think a lot. One of the issues with these treatments from a scientific perspective is the placebo effect. Essentially, when you're on MDMA, you know you're on MDMA, right? So the sugar pill condition is pretty you you know, if you've received it and you know, if you haven't received it essentially. So it's it's very hard to blind, as we say, scientifically. So that's been a challenge for a while. But what this veteran described as he said, you know, I think of the substance as like anesthesia. It's the the anesthesia isn't the curative fixture. It's providing the context in which we perform surgery or in which we perform something. And so he likened the experience of being under MDMA, receiving psychotherapy, he described it as like the anesthesia that's needed to conduct psychotherapy, especially as you're reading about these, you know, the psychotherapy, which is quite hard to do emotionally. So that's made me think, well, how do we and I don't know this and this is what I've started to do, like, how do we test new anesthesia, anesthetics? How do we how do they come onto the market? What are we are comparing them against something else?

Evan Banks

There's not really a way to control. Yeah, you know.

Rajeev Ramchand

What I mean? So it's like. But, but it's also, you know, we, we're not going to perform surgery without anesthetic, right? Like, we, we know that it works. So it's we're at a point with anesthetics where we're just thinking about, is this one better than what we are currently using. We don't really have that with in this case. So but it is an interesting analogy that I think provides another framing for how we think about the mechanism of action, if you will.

Evan Banks

So we're still not entirely sure medically, physically, what happens in your mind when you take a substance like MDMA. But what are we we do know, at least anecdotally, some of the effects that it has had on on people's mental health. What are some of those effects? Why do people why do people do this?

Rajeev Ramchand

So we're documenting those right now in the study that we're doing currently have ongoing at RAND and looking closely, what I'm most familiar with are the clinical trials. So MDMA, in the context of psychotherapy. And what I'm most interested in is reduction in PTSD symptoms to the point that, you know, our people, if you think about, you know, the symptoms of PTSD, hyperarousal, intrusive thoughts, nightmares, things like that. So those are decreasing, are very able to condition the mind to to decrease those symptoms to the point that an individual no longer meets the thresholds of PTSD criteria, that that they're not affecting them in such an adverse way as to be really disrupting their lives. We all have nightmares. We all have intrusive thoughts. But PTSD is when those are really kind of severe and problematic. So if we're reducing those to the point that they can function well and these Phase three trials seem to suggest that people are improving. So, you know, that's that's that's what ultimately what I'm what I'm interested in and ensuring that they're doing it as safely as possible.

Evan Banks

What should the VA do next?

Rajeev Ramchand

Plan and monitor. So I think that they should be thinking through the processes for how they might deliver this therapy. So if it becomes approved, are they going to offer it in-house? Are they going to outsource? So the VA does both. They have something called the Community Care Network. They have in, you know, internal processes. If they do it internally, they're going to have to think, okay, so how are we going to offer this treatment within our settings that require two therapists, three times during 15 sessions, spending eight hours with a, you know, a physician on staff in case something happens. Who's going to be included and excluded? Who's going to be eligible? Because, you know, it might be more expensive. And how can we accommodate all this while still ensuring that all of our patients get seen in a timely way? Right. We can't take everyone off the floor doing what they've been doing for depression and other PTSD treatments and put them all in, you know, the psychotherapy providers. So how do we kind of what's that perfect mix, if you will? If they decide to outsource that, though, it's the questions are, well, who? This is an emerging marketplace. Like, so how do we vet or trust those providers? How do we ensure that they'll stay around for a long, long time that they don't collapse? How will we monitor the quality of care that they get? They really don't have a mechanism right now to monitor quality care provided outside of their own walls, if you will. So those are the questions that I think VA should be really seriously considering right now.

Evan Banks

That's something that I learn from some of your other work is that the VA actually does a very good job of doing things like publishing wait times for care that happens inside the walls of the VA, but they don't do that for community-based care.

Rajeev Ramchand

Yeah, it's really. They don't.

Evan Banks

There could be quality of care differences.

Rajeev Ramchand

Yeah, I mean, there could absolutely be quality of care differences that, you know, the VA is constantly under a microscope in terms of wait times, in terms of quality of care. And having worked in this in this field for a while, they're pretty transparent for the most part about what they offer and what they provide. But all the outsourced care is to our own providers, and it's really hard to outsource to health systems that we are that you and I kind of, I don't know if you're a veteran...

Evan Banks

I'm not.

Rajeev Ramchand

So I don't go to the VA, but it's very hard for me to, you know, to go to my health care plan and say, you know, in D.C., what's the average wait time if I want to see a dermatologist or a psychologist? I don't know what the answer is. But I know in trying to get care for a family member, they had to wait six months to see a psychiatrist. So it can be a very long time.

Evan Banks

What other kinds of long term research are you working on that's related to this?

Rajeev Ramchand

So currently I'm working on a project that's led by a colleague of mine, Beau Kilmer. And we're looking at this emerging legal landscape. So we're doing a multimodal kind of investigation. That would be a critical review of the literature, interviews with subject matter experts, a national representative survey to better understand the legal context of these of these conditions, as well as kind of the science. So kind of bridging that gap between what's happening in the scientific world, what's happening legally at the state level and at the federal level. And what are some recommendations to make sure that the entities who are kind of overseeing this process or are looking at it are making sure that we're lock in step and making sound and reasonable? Yeah, very, very RAND how are we making evidence-informed policy decisions.

Evan Banks

Thanks for being on the show.

Rajeev Ramchand

Thank you.

Evan Banks

That's it for today's episode. If you're interested in learning more about this topic, check out the show notes at rand.org/podcast. We'll see you next week. RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis.