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The Role of Psychedelic Agents in Treatment of Mood Disorders and Addictions: A Clinical Conversation with Scott Shannon, MD, and Robert Rountree, MD

2020; Mary Ann Liebert, Inc.; Volume: 26; Issue: 4 Linguagem: Inglês

10.1089/act.2020.29284.ssh

1557-9085

Scott Shannon, Robert Rountree,

Forensic Toxicology and Drug Analysis

Alternative and Complementary TherapiesVol. 26, No. 4 Free AccessThe Role of Psychedelic Agents in Treatment of Mood Disorders and Addictions: A Clinical Conversation with Scott Shannon, MD, and Robert Rountree, MDScott Shannon and Robert RountreeScott ShannonScott Shannon, MD, is the president and founder of Wholeness Center, in Fort Collins, Colorado, USA, an innovative clinic providing cross-disciplinary evaluation and care for all mental health concerns. He is also an assistant clinical professor of psychiatry at the University of Colorado-Children's Hospital in Denver, Colorado, USA.Search for more papers by this author and Robert RountreeRobert Rountree, MD, practices family medicine in Boulder, Colorado, USA.Search for more papers by this authorPublished Online:10 Aug 2020https://doi.org/10.1089/act.2020.29284.sshAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Scott Shannon, MD, has been a student of consciousness since his honors thesis on that topic at the University of Arizona in the 1970s under the tutelage of Dr. Andrew Weil, MD. MDMA-assisted psychotherapy became a facet of his practice before this medicine was scheduled by the Drug Enforcement Agency in 1985. He has published four books on holistic mental health including the first integrative psychiatry textbook for this field in 2001. His pediatric mental health textbook was published in 2014. He is a past president of the American Holistic Medical Association and a past president of the American Board of Integrative Holistic Medicine. In 2010, he founded Wholeness Center, in Fort Collins, Colorado. This innovative clinic provides cross-disciplinary evaluation and care for all mental health concerns and has become a national leader in ketamine-assisted psychotherapy. Dr. Shannon serves as a site principle investigator and therapist for the phase 3 trial of MDMA-assisted psychotherapy for post-traumatic stress disorder sponsored by the Multidisciplinary Association for Psychedelic Studies (MAPS). He has also published numerous articles about his research on cannabidiol (CBD) in mental health. Dr. Shannon founded the Psychedelic Research and Training Institute (PRATI) to train professionals in ketamine-assisted psychotherapy and deliver clinically relevant studies. Dr. Shannon is an assistant clinical professor of psychiatry at the University of Colorado-Children's Hospital in Denver, Colorado. He lectures globally to professional groups interested in a deeper look at mental health issues, safer tools, and a paradigm shifting perspective about transformative care.Robert Rountree: Tell us a little bit about your childhood. Where did you grow up? What did you most like to do when you were a kid?Scott Shannon: I grew up in upstate New York. My dad worked for General Electric, and then he was transferred to Phoenix when I was 12. Moving from rural upstate New York to urban/suburban Phoenix was a dramatic shift. I loved to spend time in nature, in the forest. Once I moved to Phoenix, that shifted to basketball. We played outside most of the year, even in 100°F heat.Dr. Rountree: So, what led you from being a basketball fan to pursuing a career in medicine?Dr. Shannon: There was a psychology class—well, actually, it is an interesting story. As a junior in high school, I was helping a friend study for a psychology class, and I was reading a textbook and asking him questions, and I said, “Wow, this is kind of interesting.”I went to a Jesuit all-boys school in Phoenix, and approached the teacher of the class, Mr. Kassel, and asked whether I could get in the class. It was toward the end of the first semester. And he said, “Well, this is a full-year course, and there is background material you need in the first semester.” He said, “Well, why don't you try studying a bit and taking the first semester final? And if you show that you put in some effort, I will let you in the second semester.” I said, “Wow, that's great.”So, I got the textbook, read it, looked at it, began to do some exploring. I took the final, and I got one of the highest grades on the final. Then, I went back to him to enroll in the class, and he refused to let me in. I think for some reason I threatened him. I am not sure. That experience lit a fire under me, and made me even more determined to learn.I actually ended up getting a job in the library, the Phoenix Library, so I could have access to more books on the topic. By the end of junior year, I knew I wanted to be a psychiatrist, and I was deeply interested in consciousness. So, my direction was set at that point.Dr. Rountree: Do you remember what was happening in society at that time? More specifically, what was the national feeling about the exploration of higher consciousness and human potential? Was that something that was really starting to be of interest?Dr. Shannon: It was the early ’70s. The psychedelic movement and early consciousness explorations had just taken off at that point. It was prominent in the lay and cultural consciousness. I became intrigued by that, but mostly about the brain, the mind, mental health, and mental illness. All of it just felt really exciting, interesting, and curious and, in some ways, terra incognita. It was unknown territory. And that really intrigued me.Dr. Rountree: Was there anybody in particular that moved you in that direction? Any mentors or sources of inspiration?Dr. Shannon: I had a mentor, Vaughn Huff, who was head of the honors program at the University of Arizona. He introduced me to a seminar on parapsychology and consciousness that really intrigued me. That is how I got interested in alternative medicine via Edgar Cayce at the time.When it came time to propose my honors thesis, I went to my advisors, and they were all studying rats in mazes. The psychology department was very behavioral at the time. They thought I was from another planet. They suggested that I go visit this doctor out in the desert—Dr. Andrew Weil. He was little known at the time. He became an advisor on my thesis, and then a mentor and a friend. I ended up going to medical school in Tucson, so that relationship just continued to develop. By the time I entered medical school, he was very involved in many elements of my development.Dr. Rountree: So you and Dr. Weil go way, way back.Dr. Shannon: Way, way back. I was an undergrad, and I think he had just finished a Fulbright Fellowship, where he traveled around Central and South America, and that resulted ultimately in his book The Marriage of the Sun and the Moon.1 It is a great book on the connection between nature and consciousness. He had just published The Natural Mind,2 which explored the relationship between consciousness and drugs, particularly cannabis.Dr. Rountree: Were the kind of ideas that you shared with him in your school considered pretty far out, or was that way of thinking taking hold?Dr. Shannon: Our interest in altered states and natural medicine was strong. Dr. Andrew Weil was such an incisive thinker, so very reasonable but provocative, and he engaged a lot of medical students. I would say by the end of my medical school term, at least a quarter of our class was really interested in these topics. But because there was no support for these topics in postgraduate and residency training, for many people it fell away as just a lapsed interest.I had gotten very depressed in medical school because it was nothing like what I thought it would be. By the time I graduated, I just really needed to be done with formal training as quickly as possible. I ended up doing a psychiatric internship at a Columbia program in New York, and then came back to Arizona to work with Gladys McGarey in setting up a rural holistic clinic. And because of Dr. Weil's influence, I got involved in methylenedioxymethamphetamine (MDMA)-assisted psychotherapy. I was doing that as part of my general practice in the early ’80s, before MDMA was scheduled in 1986. To this day, it is almost impossible to do research on any Schedule I agent.Dr. Rountree: So, you were a really early adopter of using psychedelic drugs in a therapeutic context. Or is there a better term for that category of mind-altering drugs that are not like conventional antidepressants or antipsychotics?Dr. Shannon: It is a new paradigm, but it is also an old paradigm. I think it has its roots in shamanic medicine and shamanism. You are using an agent as a catalyst for deeper emotional change and transformation in medication-assisted psychotherapy.MDMA, psilocybin, LSD, or even ketamine can be in that category of transformational tools, even though they are in different categories as medications. MDMA is an entheogen or an empathogen. It is not a classic psychedelic, whereas LSD and psilocybin are classic psychedelics. Ketamine is a dissociative anesthetic. But they all share an ability to have a profoundly altered interaction with yourself and reality.Dr. Rountree: Were you doing that research before your psych residency, or during?Dr. Shannon: That was before. That was as a general practitioner. I was working in a general holistic clinic learning acupuncture from Gladys McGarey while learning about homeopathy and Jungian depth psychology. I was just deeply curious. I actually ended up delivering a lot of babies while working at a county hospital. I hired a nurse midwife, and she and I did all the county deliveries for a year and a half at this rural remote hospital. I loved the magic of childbirth.I found it all very intriguing. I was doing home deliveries, but realized at some point while driving in to the hospital at 70 miles an hour at three in the morning that this was not the lifestyle I wanted, and I really missed the mind and all these elements around consciousness. So, I went back to the Columbia program in Cooperstown, New York, did my psychiatry residency, and during that time I got interested in the creativity of children's mental health. I chose to do a child fellowship at the University of New Mexico, where I was able to dig deeper into Jungian psychology. It was one of the two programs in the United States that had any affiliation with Jungians at all. And we actually had a Jungian child analyst, one of two or three in the world, Mara Sidoli, who worked in Santa Fe, who we studied with. But there were also Jungian analysts in Albuquerque. I think because of my program's strong cross-cultural emphasis, the Jungian work really tied in well, and it fit well with my interests. So that was very synchronistic for my development.Dr. Rountree: Did the predominant psychopathology model at that time place as strong an emphasis on pharmacology as it does today?Dr. Shannon: Particularly in the area of children, it was really a transitional time. I think the adult field had gone through that transition somewhat earlier. But with children, there was really this emphasis on relationship, connection, family, and systems work. I think pharmacology had not penetrated quite as much by then. We worked in a children's psychiatric hospital. We got to work with kids who were hospitalized for six and eight months, and that just does not happen anymore. Today, it is a three, five-, seven-day stay, medicate them, and move them on.Dr. Rountree: Are you dismayed by what has happened in current child psychiatry as far as the tendency to immediately put every troubled child on multiple drugs?Dr. Shannon: Yes, I am and always have been. I am upset about it for a couple of reasons. One is that the evidence is really inadequate. And two is that the safety concerns are rising. For instance, there is a recent study out of the state of Tennessee Medicaid population where they looked at 250,000 children on atypical antipsychotics that are being widely used in pediatrics now, and they found that the death rate was three to four times the control death rate.3 These are children who are dying not from suicide, but from the metabolic and cardiovascular illness caused by the medications. To my mind, that is just intolerable and unacceptable.Dr. Rountree: Do those drugs even help? What are they doing to the child's mind and body?Dr. Shannon: Well, they work for a short period of time, and that is the issue. There was quite a period of time when I was managing children who had been severely abused in residential treatment centers, and we found that these children would arrive heavily medicated out of a state hospital, and then in about four to six weeks, they would start their regression again. The medication would wear off in effectiveness, but it also rendered the child incapable of learning. We pretty quickly moved to a model that was more built on relationships and dietary changes and a lot of other things that were more sustainable in the long run.Dr. Rountree: When you say “we,” do you mean the people you were working with? Was this in your training, or was this in your practice?Dr. Shannon: This was in the setting of a residential treatment program in Colorado. After my child fellowship, I moved to northern Colorado, where I have been for the past 30 years. Once there, I worked in a number of settings, including long-term residential treatment centers for severely abused children leading teams of dedicated staff.Dr. Rountree: You landed in Fort Collins and opened a private practice?Dr. Shannon: Well, I actually landed in Greeley, which is nearby. We lived in Fort Collins, but I liked the work environment better in Greeley. I was invited in to develop a child/adolescent treatment program at a freestanding psychiatric hospital where I was given the freedom to be creative. After doing that for a few years with a concomitant private practice, the medical director left, and I was called in to be medical director. I did that for about four years, and at that time was learning acupuncture and brought acupuncture into the hospital setting. This was probably during mid-’90s.Dr. Rountree: Their arms were open wide to letting you do that?Dr. Shannon: They credentialed me in. In a rural environment you were known more by your work, then by a philosophy. I was the second physician in Colorado to be credentialed with acupuncture privileges in a hospital setting.Dr. Rountree: Were you finding acupuncture to be helpful for mood disorders?Dr. Shannon: I found it most helpful for treating substance abuse. We would have people coming into the hospital in acute withdrawal from cocaine, methamphetamine, and heroin. You could apply a few acupuncture needles, using the NADA (National Acupuncture Detoxification Association) detox protocol, and see incredible results. People would go from screaming, rabid, and aggressive to sleeping within 15 minutes. It was quite impressive.Dr. Rountree: Wow. You can't help but wonder why that approach is not the standard of care.Dr. Shannon: Well, I think there are now 1000 programs around the world that have adopted the NADA program, mostly detox centers. I think it is not so much about effectiveness, it is just not in our paradigm. That is the bigger issue.Dr. Rountree: So, the individuals who approve the standards just cannot wrap around the concept?Dr. Shannon: Well, you need an advocate, really. I was an advocate for it in our system, and I had credibility and a position of authority, so I could bring it in. But in other hospitals, if you do not have a physician or, in this case, a psychiatrist who really advocates for it, can teach about it, and help people to understand the benefits of it, then it is just going to be ignored.Dr. Rountree: Weren't you one of the first graduates of the medical acupuncture course started by Dr. Joseph Helms?Dr. Shannon: I do not know whether I was one of the first. When I was in Arizona in the ’80s, Brian Berman went through the program with Helms, and that inspired me. It took until 1993 before I got around to it. I then went back and did a refresher course maybe 10 years ago. Actually, Gladys McGarey and her husband, Bill McGarey, brought in acupuncturists and taught the first medical CME course on acupuncture in the late ’60s in Phoenix. Acupuncture was one of those things that was extremely pivotal in changing my understanding of human health.Dr. Rountree: Was that based on the systems biology, as in the perspective of Traditional Chinese Medicine systems?Dr. Shannon: Yes, that idea of systems biology and the five-element theory looks deeply at the cross-symptomatic foundations of imbalances and how, by treating one issue, a number of other issues could resolve that were seemingly unrelated.Dr. Rountree: Do you think that course does a good job of communicating those concepts? Is that a training you would recommend for other doctors?To Contact Dr. Scott Shannon, MDScott Shannon, MDEmail: scott@wholeness.comWebsite:www.pratigroup.orgDr. Shannon: Yes, I think it is a great course. I found it really helpful, positive, and practical. Joe previously worked through UCLA and now he teaches through Helms Medical Institute (https://hmieducation.com).Dr. Rountree: You have been in practice for a long time, during which I am sure you have witnessed a dramatic evolution in thinking about how mood disorders should be treated. I am wondering what your perspective is on why so many people are affected by mood disorders, especially children. What is going on in our society? What do you think is the reason that more and more people are so profoundly unhappy or have really serious mood disorders, including anxiety, depression, and psychotic disorders?Dr. Shannon: It is definitely a phenomenon. I think it is multifactorial. On one level, we have overstimulation, lack of sleep, and an inadequate diet that is overprocessed, with less vitamins and minerals, particularly magnesium, and less omega-3 oils.I think we have a culture that is overstimulating, that is, increasingly disconnected, in which people often live very isolated lives. I think there is a lack of activity and exercise, a lack of contact with nature. I think we have too much obesity and inflammation in our bodies in this country.And so really, in terms of my course of studying the human mind, the first probably 20 years was looking at psychology, depth psychology, and systems thinking. Then the next 10 years, which was more in the heyday of integrative medicine and the early onset of functional medicine, was understanding how our biology affects our mental health, whether it is inflammation, the microbiome, food sensitivities, etc.In the past 10 years, I have really come to understand that there is a strong spiritual vacuum that exists in most people's lives and in our culture. That is what drew me back into psychedelics. I think, better than any avenue that I have encountered, perhaps other than long-term meditation practice, psychedelics really help to open up a spiritual perspective to reconnect with our whole being, the whole person, and the whole planet.Dr. Rountree: That is an interesting point, because it brings you back around full circle. You started doing that work in the beginning, and then you dove into the medical trenches where you delivered babies and took care of addicted people and attended to the entire gamut of medical conditions. And now you have ended up exploring the psyche again. I believe the word you used in your lecture at the recent Scripps Natural Supplements Conference in San Diego was “psychonaut.”Dr. Shannon: Yes, it has felt like that. A psychonaut is someone who is drawn to and enjoys exploring the inner realms. I think I have always been a psychonaut. I have been a 40-year practitioner of meditation and have enjoyed long-distance running, quiet time in nature, and other forms that I think lend themselves to that exploration.Psychedelics are really intriguing to me, and it is really my current focus. In the past nine months, we set up a nonprofit called the Psychedelic Research and Training Institute (PRATI) here in Fort Collins, and we are focused on delivering training to physicians and practitioners. Currently, it is ketamine-assisted psychotherapy, but that is really our best stand-in and proxy for psychedelic medicine at this point.We are doing training and helping people to roll out a business in psychedelic medicine. We have been funded by philanthropists to deliver a program to help therapists interested in psychedelic medicine learn the practicalities of setting up and running a clinic.We are engaging in CBD research. We published four articles in the past number of years, and are looking to undertake cannabis research as well. And we are also involved in MDMA research. I am one of the site principle investigators for the phase 3 study of MDMA-assisted psychotherapy.Dr. Rountree: Do you get it through an IND?Dr. Shannon: Yes, I have a Schedule I license, and we are in an FDA-approved study. It is amazing how difficult it is to get that FDA approval. That is why there is very little research done on cannabis. We have an interest in publishing on cannabis edibles, because it is a huge area of growth and current use in this country, and there are only six published studies on cannabis edibles in PubMed. This is an area of exploding use. People are using it for sleep, for depression, for anxiety, and for trauma. And we know very little about cannabis edibles. Because of the federal government, it is very difficult to do any cannabis research, frankly.Dr. Rountree: With the ongoing legal changes, first making medical marijuana legal and then legalizing recreational marijuana, we have seen an explosion in the use of this particular psychoactive plant. What do you believe that profound popularity tells us about what is going on with the public psyche?Dr. Shannon: The culture has realized that we were deceived by the war on drugs and that many illegal substances have great healing potential with manageable risk. For example, many people find cannabis to be an effective stress reliever. I think we have seen alcohol up close, so we know well the drawbacks that alcohol has. I think there are many people, particularly in the younger ages, teens, and 20s, who are more drawn to cannabis than alcohol. I think we are also seeing this huge resurgence in Boomers, people of my generation, in their 50s and 60s, who are drawn back to cannabis for not just recreation, but also often for pain control, for sleeping, and for menopause treatment.And I think there is a growing deep suspicion about big pharma. We are certainly seeing it in psychiatry now, where others are beginning to realize that long-term use of antidepressant medicines or other categories of medicines creates neurotransmitter adaptation and changes that make it difficult for people to get off these medications.We have got 15 million people in this country on antidepressants for three years or more. That number has tripled in the past 15 years. There are huge numbers of people that would like to get off their antidepressant, but do not believe that they can. They have tried, and it has not been successful. We now see the risks of prescribed medications in better perspective.Dr. Rountree: Is that because of the antidepressant withdrawal syndrome that I have heard you discuss in your lectures? It seems to be increasingly clear that this is a reproducible physiologic phenomenon. It is not just that the person felt better on the drug and then felt worse again after stopping it—there is actually something untoward going on neurophysiologically when the person suddenly stops the medication?Dr. Shannon: Yes, that is right. We know that there are postsynaptic receptor sensitivity changes when you are on any of these agents that manipulate neurotransmitters. The body is always trying to adjust and accommodate through homeostatic mechanisms to keep our being stable.Then this creates this ongoing dance between the medication, the receptor sensitivity changes, and the dose. That is why when someone gets stabilized on a psychiatric medicine, they are not good for the rest of their lives, they are good for a few weeks to a few months, and then they need to come back for their monthly “med checks” to have the dose changed and ultimately to have the medication changed.When you treat as many people as I do who are undergoing ketamine-based treatment with treatment-resistant depression, you hear all about people who have been on 20 different psychiatric meds over the past 20 years. Some of them have been helped a little. Many of them have been helped not at all. And they have not found good relief. As many as a third of people who are treated for major depression end up having treatment-resistant depression.Dr. Rountree: When you say treatment-resistant, do you mean resistant to conventional pharmacotherapy?Dr. Shannon: Yes, they are resistant to antidepressant medication. That is what that implies. What intrigues me the most about this new development in psychedelic medicine—whether we are talking about ketamine, MDMA, or psilocybin—is that we are looking at treatment that may occur once, twice, or three times in the person's life, and that is it.We do not have to worry about ongoing maintenance and suppression of symptomatology and postsynaptic receptor sensitivity changes. We are talking about something that is transformative for the person.Dr. Rountree: That would not be a good model if you are in the business of selling pharmaceuticals.Dr. Shannon: Yes, big pharma has no interest in this. The way they see it, getting someone on antidepressants is an annuity model of income for them—ongoing maintenance for a long time.Dr. Rountree: Yes. I saw a guy a couple of weeks ago who had been a very successful businessman. But then he made some bad decisions for which he suddenly lost a lot of money. This threw him into a terrible depression. He saw a psychiatrist who spent about five minutes talking with him before starting an selective serotonin reuptake inhibitors, after which his condition deteriorated. He went back to the psychiatrist and told him, “I am getting worse.” And the psychiatrist said, “Well, maybe you need to increase the dose.” And he just kept pushing it and pushing it with no improvement. The psychiatrist finally ran a genetic test for drug-related SNPs, but the information was not particularly helpful. My client said they just kept going down the exact same path of trying one pharmaceutical after another, despite the fact that he was not responding to any of them.Dr. Shannon: I see that so much, Bob. This is a very narrow path in modern psychiatry, which is psychopharmacology. When all you have is a hammer, everything looks like a nail. As a result, psychiatry has lost much in the way of interpersonal skills and focus. The biopsychosocial–spiritual model of human existence has been left behind. My profession ignores this whole spiritual realm almost entirely. Psychedelics have such a spiritual power to awaken and there is such a deep spiritual need for people in our society at this time. I think that is why Michael Pollan's book How to Change Your Mind has been so popular and resonant, and why the interest in psychedelics is resurging after 50 years.Dr. Rountree: One thing I have heard you say about mainstream psychiatric drugs is all they really are attempting to do is suppress symptoms. You said that you want to use something that helps people access their psyche, instead of suppressing their psyche?Dr. Shannon: Yes. Our current psychiatric medications do not cure anyone. They suppress symptoms. They control symptoms. It is a suppressive model that often requires increased medication use over time. What we are looking at is a model that is more evocative of the psyche and helps people to understand deeper conflicts, deeper traumas, and resolve them.There was a recent editorial in JAMA Psychiatry looking at the data from the phase 2 studies of MDMA-assisted psychotherapy for the treatment of post-traumatic stress disorder (PTSD),4 and they said if this pans out, we may be looking at the first pharmaceutically mediated cure in psychiatry, and that we treat people with PTSD with MDMA-assisted therapy for three sessions, and a high percentage of them no longer have PTSD and do not need any kind of ongoing maintenance or pharmacology.Dr. Rountree: Is that why the title of your recent talk at Scripps—which was excellent, by the way—was “Psychedelics Will Change Mental Health Care”? This is a profound thing to say.Dr. Shannon: I think they are, and I think we are abandoning the monoamine model, which is that norepinephrine, serotonin, and dopamine mediate all psychiatric illness. If we are only smart enough as psychiatrists, we could cure all these illnesses. That was really the premise and promise of pharmacology back in the ‘80s, when I launched my career. There was excitement that medications such as fluoxetine (Prozac®) and risperidone were going to cure mental illness. By the time we reached the year 2000, we would be routinely curing people with these medications. And really, what we have seen is just the opposite, that psychiatrists are using more and more medications. At one point recently, antipsychotics were either the number-one or number-two drug category in terms of sales in the United States.And this model does not cure people. We have more mental illness now than we did then. Depression is going up rapidly in children and teen populations. Suicide has risen 30% in the past 20 years. We are really at a crisis point, and no prominent researcher in neuroscience holds the serotonin theory of depression anymore. This is really being rapidly abandoned.We are moving to a model of network and hubs in brain connectivity. We are moving to a model of the connectome in the brain. This is a model that medications really are not that relevant for, because we cannot target neural hubs with medication. We cannot target specific pathways. We can do tha