Introduction
From ancestral use to prohibition to optimistic resurrection, the history of human interaction with psychedelics is complex. Research involving sessions with a trained therapist before, during and after psychedelic administration is progressing rapidly, and attempts to navigate the extremes of ‘magic and menace’ in the modern era.
However, the real-world impact of psychedelic therapy in the clinic has yet to be determined. There are many questions to be answered, and attitudes amongst clinicians, regulators and the public remain divided for a myriad of reasons. These include questions around efficacy, safety, regulation, resource allocation, and broader societal and cultural concerns (BMJ, 2024, McCrone et al., Reference McCrone, Fisher, Knight, Harding, Schlag, Nutt and Neill2023, McGuire et al., Reference McGuire, Cohen, Sisti, Baggott, Celidwen and Devenot2024, Metaxa and Clarke, Reference Metaxa and Clarke2024).
There are high levels of inter-individual variability in response to psychedelic therapy, and issues related to blinding, expectancy and self-selecting biases are just some of the challenges within the field (Aday et al., Reference Aday, Heifets, Pratscher, Bradley, Rosen and Woolley2022; van Elk and Fried, Reference van Elk and Fried2023). Some commentators, lamenting the failures of precision psychiatry, underscored by the bigger issue of a lack of a scientific basis in psychiatry, have suggested that the enthusiasm for these compounds signal psychiatry’s desperation rather than its salvation (Miller and Raison, Reference Miller and Raison2023).
Notwithstanding the challenges, clinical trial data, of increasing quality, suggests that psilocybin therapy may play a meaningful therapeutic role in major depressive disorder (Carhart-Harris et al., Reference Carhart-Harris, Giribaldi, Watts, Baker-Jones, Murphy-Beiner, Murphy, Martell, Blemings, Erritzoe and Nutt2021; Davis et al., Reference Davis, Barrett, May, Cosimano, Sepeda, Johnson, Finan and Griffiths2021; Raison et al., Reference Raison, Sanacora, Woolley, Heinzerling, Dunlop and Brown2023; von Rotz et al., Reference von Rotz, Schindowski, Jungwirth, Schuldt, Rieser, Zahoranszky, Seifritz, Nowak, Nowak, Jäncke, Preller and Vollenweider2023), treatment-resistant depression (TRD) (Carhart-Harris et al., Reference Carhart-Harris, Bolstridge, Day, Rucker, Watts, Erritzoe, Kaelen, Giribaldi, Bloomfield, Pilling, Rickard, Forbes, Feilding, Taylor, Curran and Nutt2018; Carhart-Harris et al., Reference Carhart-Harris, Bolstridge, Rucker, Day, Erritzoe, Kaelen, Bloomfield, Rickard, Forbes, Feilding, Taylor, Pilling, Curran and Nutt2016; Goodwin et al., Reference Goodwin, Aaronson, Alvarez, Arden, Baker and Bennett2022, Reference Goodwin, Aaronson, Alvarez, Atli, Bennett and Croal2023a, Reference Goodwin, Croal, Feifel, Kelly, Marwood, Mistry, O’Keane, Peck, Simmons, Sisa, Stansfield, Tsai, Williams and Malievskaia2023b) and substance use disorders (Bogenschutz et al., Reference Bogenschutz, Ross, Bhatt, Baron, Forcehimes, Laska, Mennenga, O’Donnell, Owens, Podrebarac, Rotrosen, Tonigan and Worth2022; Pagni et al., Reference Pagni, Petridis, Podrebarac, Grinband, Claus and Bogenschutz2024; Yaden et al., Reference Yaden, Berghella, Hendricks, Yaden, Levine, Rohde, Nayak, Johnson and Garcia-Romeu2024).
Preliminary clinical trial data across a range of other disorders, such as eating disorders, obsessive-compulsive disorder, and body dysmorphic disorder, point towards the possibility of transdiagnostic therapeutic applications and a personalized paradigm (Kelly et al., Reference Kelly, Gillan, Prenderville, Kelly, Harkin, Clarke and O’Keane2021; Moreno et al., Reference Moreno, Wiegand, Taitano and Delgado2006; Peck et al., Reference Peck, Shao, Gruen, Yang, Babakanian, Trim, Finn and Kaye2023; Schneier et al., Reference Schneier, Feusner, Wheaton, Gomez, Cornejo, Naraindas and Hellerstein2023).
Psilocybin and 3′4-methylenedioxymethamphetamine (MDMA) have already been approved as treatments in Australia. This allows authorized psychiatrists to prescribe psilocybin and MDMA to patients diagnosed with TRD and treatment-resistant post-traumatic stress disorder (PTSD), respectively, outside of a clinical trial setting (Kisely, Reference Kisely2023).
In contrast, the United States Food and Drug Administration recently declined to approve MDMA-assisted therapy for the treatment for PTSD (Reardon, Reference Reardon2024). The expressed concerns related to expectancy effects, blinding, the lack of long-lasting benefits, together with poor standardization of psychotherapy, and safety data not being adequately recorded.
Alongside the impetus to improve the quality of future trials, it is important to examine the trajectory of knowledge and attitudes of psychiatrists to this rapidly evolving field. Variations in the knowledge and attitudes of psychiatrists may influence future research and the uptake of psychedelic therapy into clinical practice.
Previous studies focusing on psychiatrists’ attitudes generally show high levels of support for further research, alongside favorable attitudes towards the promise of psychedelic therapy in the treatment of psychiatric disorders (Berger and Fitzgerald, Reference Berger and Fitzgerald2023; Grover et al., Reference Grover, Monds and Montebello2023; Page et al., Reference Page, Rehman, Syed, Forcer and Campbell2021). Furthermore, in recent years, there appears to be an overall positive shift in psychiatrists’ attitudes toward the therapeutic potential of psychedelics (Barnett et al., Reference Barnett, Arakelian, Beebe, Ontko, Riegal, Siu, Weleff and Pope2023; Barnett et al., Reference Barnett, Siu and Pope2018; Žuljević et al., Reference Žuljević, Hren, Storman, Kaliterna and Duplančić2024b).
Some studies indicate that psychiatrists who are younger, male, and in training uphold greater optimism about the therapeutic potential of psychedelics and may perceive psychedelics as less risky (Barnett et al., Reference Barnett, Arakelian, Beebe, Ontko, Riegal, Siu, Weleff and Pope2023, Reference Barnett, Siu and Pope2018; Grover et al., Reference Grover, Monds and Montebello2023; Žuljević et al., Reference Žuljević, Hren, Storman, Kaliterna and Duplančić2024b). Another study of psychiatrists highlighted an openness to learn more about psychedelic therapy, alongside a lack of preparedness and training in the delivery of psychedelic therapy (Page et al., Reference Page, Rehman, Syed, Forcer and Campbell2021).
The accumulation of clinical evidence supporting the therapeutic potential of psilocybin, the ongoing phase 3 trials for TRD, and the approval of psilocybin as a medical treatment for depression in certain jurisdictions, underscores the need for empirically grounded insights into the ongoing discourse about the potential impact on clinical practice and public health.
This study seeks to bridge the gap between theoretical anticipation and empirical understanding by exploring the intricacies of psychiatrists’ perspectives on psilocybin therapy in the Irish context.
Methods
Ethical approval
Tallaght University Hospital/St. James’s Hospital Joint Research Ethics Committee approved this study (REC: 2020-08 List 29).
Survey design
A questionnaire was designed based on previous studies (Barnett et al., Reference Barnett, Siu and Pope2018; Corrigan et al., Reference Corrigan, Haran, McCandliss, McManus, Cleary, Trant, Kelly, Ledden, Rush, O’Keane and Kelly2022) to investigate the attitudes of psychiatrists to psilocybin with psychological support (psilocybin therapy). The survey consisted of 28 items. A 5-point Likert scale (strongly agree, somewhat agree, neither/neutral, somewhat disagree, and strongly disagree) was used to capture attitudes about psilocybin therapy. The last question (I have concerns about psilocybin with psychological support), contained a free text option (Please comment:). The anonymous survey was hosted online via the Qualtrics platform and consent for participation was obtained online. See the supplementary information (SI) for the survey.
Participants and procedure
The survey of psychiatrists practicing in Ireland was conducted over six weeks in February and March 2023. Recruitment emails were sent with information on the study and a secure link to a Qualtrics survey. Respondents affirmed that they were psychiatrists. The survey was distributed via national psychiatry trainee and consultant online mailing lists encompassing both rural and urban clinical sites. The survey was also distributed at the in-person Irish College of Psychiatrists NCHD conference and at journal club meetings at Tallaght University Hospital and St James’s Hospital, Dublin. To facilitate accessibility, the survey was available in hard copy and via a QR code.
Data analysis
Data were collected using Qualtrics and analyzed using SPSS Statistics version 27.0. Descriptive statistics were calculated for each survey item. The number of people who responded Strongly Agree and Agree were summed and presented as net agree percentages. Similarly, the number of people who responded Strongly Disagree and Disagree were summed and presented as net disagree percentages. See SI Tables for expanded data. Mann-Whitney U tests and Kruskal-Wallis tests were used and adjusted for multiple comparisons. GraphPad was used for the figures.
Results
Demographics
A total of 151 psychiatrists completed the questionnaire. There was one missing value for professional grade and age. See Table 1 for demographic and professional characteristics.
Demographic and professional characteristics
Total sample attitudes
Attitudes to psilocybin therapy for various conditions
Of all the 151 participants, 81.5% (n = 123) agreed that psilocybin therapy shows promise for the treatment of psychiatric disorders, ranging from 80.1% (n = 121) for depression, 58.3% (n = 88) for chronic pain, 53.6% (n = 81) for anxiety, 45.0% (n = 68) for drug and alcohol addiction, 38.4% (n = 58) for eating disorders, 37.7% (n = 57) for depressive episodes in bipolar affective disorder, 29.1% (n = 44) for emotionally unstable personality disorder (EUPD), and 8.6% (n = 13) for psychotic disorders (Figure 1 a, Table S1).
Total sample attitudes to psilocybin therapy. (a) Therapeutic potential for various conditions (% net agree): depression (80.1%), chronic pain (58.3%), anxiety (53.6%), addiction (45.0%), eating disorders (38.4%), bipolar depression (37.7%), EUPD (29.1%), psychotic disorders (8.6%). (b) Funded (86.8%), medical treatment status (86.8%), willing to refer (86.8%), consider treatment themselves (78.1%), knowledgeable (40.0%) and adequately trained (10%).
Attitudes and acceptability
Less than half of the participants (40.0%, n = 60) reported being knowledgeable about psilocybin. Furthermore, 80.8% (n = 122) reported they did not feel adequately prepared or trained to participate in the delivery of psilocybin therapy (Figure 1 b, Table S2).
The majority of participants (86.8%, n = 131) agreed that psilocybin therapy should be granted medical treatment status if supported by evidence from clinical trials and provided in licensed facilities under the supervision of psychiatrists; 86.8% (n = 131) supported funding psilocybin research; 86.8% (n = 131) would be willing to refer a patient if it was licensed and clinically indicated; and 78.1% (n = 118) would consider psilocybin therapy themselves if they had a mental health disorder, and if it was an evidence-based and licensed therapy (Figure 1 b, Table S2).
In relation to possible subjective effects, many agreed that psilocybin may aid in fostering deeper connections with oneself, others, and nature (66.9%, n = 101), and may lead to mystical or spiritual experiences (79.5%, n = 120) (Table S2).
Influence of gender
There were no significant differences between males and females (Table S3).
Influence of professional grade: consultant compared to trainee psychiatrists
The total sample was divided into consultant psychiatrists (24.0%, n = 36) and non-consultant hospital doctors (NCHDs) (76.0%, n = 114), which can act as a proxy for trainee psychiatrists. Mann-Whitney U tests, adjusted for multiple comparisons, indicated that consultant psychiatrists were significantly more likely to agree that psilocybin should be illegal for recreational purposes compared to trainee psychiatrists (p = 0.005) and were significantly more likely to strongly disagree that psilocybin therapy could potentially be a treatment in psychotic disorders (p = 0.025) (Figure 2, Table S4).
Differences in attitudes between consultant and trainee psychiatrists. Illegal for recreation (% net agree) Consultants 61.1%, Trainees 29.8%; therapeutic potential for bipolar depression: Consultants 27.8%, Trainees 41.2%; therapeutic potential for EUPD: Consultants 22.2%, Trainees 30.7%; therapeutic potential for psychotic disorders: Consultants 2.8%; Trainees 10.5%. Consultant psychiatrists were significantly more likely to agree that psilocybin should be illegal for recreational purposes (p = 0.005) and were significantly more likely to (strongly) disagree that psilocybin therapy could potentially be a treatment in psychotic disorders (p = 0.025).
Consultant psychiatrists trended towards more disagreement about the potential therapeutic role of psilocybin therapy in the treatment of bipolar depression, but the differences were not statistically significant when adjusted for multiple comparisons (Figure 2, Table S4).
Influence of age
The total sample was divided into those who were under 40 years of age (73.3%, n = 110) and those who were 40 years of age and older (26.7%, n = 40). Professional grades closely aligned with age, as only three consultants were under 40 years of age, and seven NCHDs were over 40 years of age. Psychiatrists under 40 years of age were significantly more likely to disagree that psilocybin should be illegal for recreational purposes (p = 0.025).
Psychiatrists over 40 years of age were more likely to disagree that psilocybin therapy had potential as a treatment in psychotic disorders, but this was not significant after adjusting for multiple comparisons (Table S5).
Influence of self-reported knowledge on attitudes to psilocybin therapy
Out of the total sample, 40% (n = 60) of psychiatrists agreed that they were knowledgeable about psilocybin compared to 34% (n = 51) who disagreed. After adjusting for multiple comparisons, psychiatrists with self-reported knowledge compared to no self-reported knowledge were significantly more likely to agree that psilocybin could enhance connections with oneself, others and nature; (81.7%, n = 49 v. 58.8%, n = 30, p = 0.012); were significantly more likely to agree that psilocybin therapy could be a treatment for anxiety disorders (68.3%, n = 41 v. 39.2%, n = 20, p = 0.006); for drug and alcohol addiction (61.7%, n = 37 v. 27.5%, n = 14, p = 0.003); for eating disorders (61.7%, n = 37 v. 21.6%, n = 11, p < 0.0001); for bipolar depression (48.3%, n = 29 v. 31.4%, n = 16, p = 0.012); for EUPD (43.3%, n = 26 v. 25.5%, n = 13, p < 0.0001); and felt more adequately prepared/trained to participate in the delivery of psilocybin therapy (21.7%, n = 13, v. 2.0%, n = 1, p = 0.03) (Figure 3, Table S6).
Influence of self-reported knowledge on attitudes to psilocybin therapy. Psychiatrists with self-reported knowledge were more likely to agree that psilocybin could enhance connections with oneself, others and nature, held more positive attitudes towards the potential of psilocybin therapy as a treatment for anxiety, addiction disorders, eating disorders, bipolar depression, and EUPD, and felt more adequately prepared to participate in the delivery of psilocybin therapy compared to psychiatrists with no self-reported knowledge (% net agree, % neutral, % net disagree).
Attitudes to safety and legality, and concerns about psilocybin therapy
Approximately one fifth of the total sample thought psilocybin was potentially addictive (21.9%, n = 33), and a small minority (6.6%, n = 10) thought psilocybin was unsafe even under medical supervision (Figure 4 a, Table S7).
Psychiatrists’ concerns about psilocybin therapy. (a) Illegal for recreation (37.1%), potentially addictive (21.9%), unsafe under medical supervision (6.6%) (total sample, % net agree). (b) 15.9% (n = 24) of the total sample expressed at least one concern about psilocybin therapy in the open-ended question. Concerns were grouped into 9 themes. Numbers represent the frequency of reported concerns.
Twenty-four psychiatrists (15.9% of the total sample) expressed at least one concern about psilocybin therapy in the open-ended question. Responses were grouped into 9 themes (Figure 4 b). The numbers in brackets represent the number of times each theme was mentioned.
The most frequent theme related to an Evidence Deficit (19), which comprised of: lack of robust evidence and comparison trials (13), lack of long-term data (3), real-world effectiveness as treatment (2), and duration of therapeutic effect (1).
The second most frequently reported theme related to Harmful effects (13), which comprised of abuse potential (drug seeking) (6), harmful effects (non-specified) (2), harmful effects (psychosis) (2), individualized and unpredictable effects (2), and repeating mistakes of the past (1).
The third most frequent theme related to various concerns with psychological support/training (5), which comprised: psychological support as a means to make psychiatrists feel they are acting responsibly (1), psychological support not aligned with established therapy (1), qualifications and training of therapists (1), awareness of cultural aspects in therapist training (1), benefit from psychological support rather than psilocybin (1).
The fourth most frequently reported themes were lack of personal knowledge about psilocybin (4) (no sub-themes) and biases in reporting (4), comprising positive biases in the reporting of studies/trials (2), biases in participants subjective reporting (1), and patients exaggerating symptoms to gain access to the trials (1).
The fifth most frequently reported theme was psilocybin therapy being resource intensive (3), comprising concerns about extra staff and time required (2), and diverting resources from established evidence-based therapies (1).
The remaining themes relate to equitable access (1), political and social biases impeding scientific approach (1) and micro-dosing (1).
Discussion
This study provided further insights into the attitudes of psychiatrists to the rapidly evolving field of psilocybin therapy. It showed that the vast majority of psychiatrists in Ireland agreed that psilocybin therapy shows promise in the treatment of psychiatric disorders and supported further research. Most psychiatrists would be willing to refer their patient if it were a licensed treatment. However, less than half of respondents reported feeling knowledgeable about psilocybin therapy and a small minority reported feeling adequately prepared or trained to participate in the delivery of psilocybin therapy.
A small minority (6.6%) of respondents agreed that psilocybin therapy was unsafe under medical supervision, and one fifth (21.9%) of the total sample had concerns about the addictive potential of psilocybin, which appears somewhat disproportionate to the existing evidence base (Calderon et al., Reference Calderon, Bonson, Reissig, Lloyd, Galati and Chiapperino2023; Henningfield et al., Reference Henningfield, Coe, Griffiths, Belouin, Berger, Coker, Comer, Heal, Hendricks, Nichols, Sapienza, Vocci and Zia2022; Johnson et al., Reference Johnson, Griffiths, Hendricks and Henningfield2018). Approximately 15% of the total sample reported at least one concern, related to themes which included: lack of robust clinical evidence, long-term effectiveness, superiority to current interventions, harmful effects, cost and accessibility, and impartiality.
Our results are broadly in line with previous studies showing that the majority of psychiatrists hold favorable attitudes towards the potential of psilocybin therapy across a range of mental health disorders and are supportive of further research (Barnett et al., Reference Barnett, Arakelian, Beebe, Ontko, Riegal, Siu, Weleff and Pope2023; Berger and Fitzgerald Reference Berger and Fitzgerald2023; Grover et al., Reference Grover, Monds and Montebello2023; Page et al., Reference Page, Rehman, Syed, Forcer and Campbell2021). In terms of perceived therapeutic utility across the various mental health disorders, unsurprisingly, and in line with the current gradient of evidence, the greatest level of agreement for a possible therapeutic indication was for the treatment of depression. There were more tentative views on therapeutic indications of psilocybin therapy for the other mental health disorders. While self-reported knowledge of psilocybin was low in our study, those who reported knowledge held more positive attitudes towards the potential of psilocybin therapy.
Younger psychiatrists tended to hold more favorable attitudes to the potential of psilocybin therapy for the treatment of people with emotionally unstable personality disorder and bipolar depression compared to older psychiatrists. A recently published pilot trial suggested that psilocybin therapy may be a viable option in depressive episodes in bipolar affective disorder type II (Aaronson et al., Reference Aaronson, van der Vaart, Miller, LaPratt, Swartz, Shoultz, Lauterbach, Sackeim and Suppes2024). However, it is important to note, that our study did not distinguish between bipolar affective disorder type I and type II, and is thus a limitation.
As expected, the least amount of agreement for a possible therapeutic indication was for psychotic disorders. Only a small minority (8.6%) agreed that psilocybin therapy might be useful for such disorders, which is unsurprising, considering psychosis or even family history of psychosis are exclusion criteria for clinical trials. In contrast to some of the preceding studies, our study did not identify significant differences between male and female psychiatrists (Barnett et al., Reference Barnett, Arakelian, Beebe, Ontko, Riegal, Siu, Weleff and Pope2023; Barnett et al., Reference Barnett, Siu and Pope2018; Grover et al., Reference Grover, Monds and Montebello2023).
In general, previous surveys of psychologists and other mental health professionals show similar attitudes to the potential of psychedelic therapy, and high levels of support for further research (Davis et al., Reference Davis, Agin-Liebes, España, Pilecki and Luoma2022; Hearn et al., Reference Hearn, Brubaker and Richardson2022; Kucsera et al., Reference Kucsera, Suppes and Haug2023; Meir et al., Reference Meir, Taylor, Soares and Meyer2023; Meyer et al., Reference Meyer, Meir, Lex and Soares2022). More positive attitudes to psilocybin, greater self-reported knowledge and personal history of psychedelic use may be associated with greater openness to engage patients with psychedelic therapy (Davis et al., Reference Davis, Agin-Liebes, España, Pilecki and Luoma2022; Hearn et al., Reference Hearn, Brubaker and Richardson2022; Meir et al., Reference Meir, Taylor, Soares and Meyer2023; Meyer et al., Reference Meyer, Meir, Lex and Soares2022). Some studies have started to examine differences between mental health disciplines, but a consistent picture has yet to emerge (Armstrong et al., Reference Armstrong, Levin, Xin, Horan, Luoma, Nagib, Pilecki and Davis2023; Ginati et al., Reference Ginati, Madjar, Ben-Sheetrit, Lev-Ran, Weizman and Shoval2022; Olafsson et al., Reference Olafsson, Kvaran, Ketilsdottir, Hallgrimsdottir, Sigurdsson and Sigurdsson2023).
Our survey suggests that should psilocybin be licensed in the future, the overwhelming majority (86.8%) of psychiatrists would consider referring their patients, if clinically indicated. This is higher than the rate of psychologists (77%), in a previous study, who agreed they would inform eligible patients about psychedelic therapy (Meir et al., Reference Meir, Taylor, Soares and Meyer2023). Alongside the positive shift in American psychiatrists’ attitudes toward the therapeutic potential of psychedelics, approximately half reported intentions to incorporate psychedelic-assisted therapy into their practice if regulatory approval is granted (Barnett et al., Reference Barnett, Arakelian, Beebe, Ontko, Riegal, Siu, Weleff and Pope2023; Barnett et al., Reference Barnett, Siu and Pope2018).
Similar to previous surveys of psychologists (Davis et al., Reference Davis, Agin-Liebes, España, Pilecki and Luoma2022) and psychiatrists (Page et al., Reference Page, Rehman, Syed, Forcer and Campbell2021), our study highlighted that psychiatrists feel under-prepared to participate in the delivery of psychedelic therapy. Again, this is unsurprising, given that phase 3 trials are not yet complete. While not all psychiatrists will prescribe or administer psychedelic therapy should it be licensed, it is nonetheless important that psychiatrists have some understanding of the potential indications, risks and limitations.
It appears that personal use of psychedelics may be common among psychedelic therapists (Aday et al., Reference Aday, Skiles, Eaton, Fredenburg, Pleet, Mantia, Bradley, Fernandes-Osterhold and Woolley2023). However, it is not yet clear whether personal recreational/naturalistic psychedelic use would influence the actual therapeutic outcomes in psychedelic therapy. This also raises interesting issues regarding disclosure of such information, both for service users and professionals (Boehnke et al., Reference Boehnke, Cox, Weston, Herberholz, Glynos, Kolbman, Fields, Barron and Kruger2023). Our survey, intentionally, didn’t enquire about personal use of psychedelics. However, it is notable that 78.1% of psychiatrists in our study would consider psilocybin therapy themselves if they had a mental health disorder and psilocybin therapy was licensed.
A recent survey of 419 European psychiatrists (not involving Ireland) using the recently developed Attitudes on Psychedelics Questionnaire showed that 24.3% had previous personal experience with psilocybin, and that past psychedelic use and personal experience with psychedelic-assisted psychotherapy and psychedelic research were both strongly associated with more positive attitudes on psychedelics (Žuljević et al., Reference Žuljević, Hren, Storman, Kaliterna and Duplančić2024b). Future larger studies examining nation-specific differences would be interesting.
The use of psilocybin in most regions, including Ireland, is illegal and the legal status of psychedelics is a complex and often divisive issue. Curiously, 31.1% of the total sample disagreed that recreational psilocybin should be illegal, with trainee psychiatrists holding more liberal views on the legalization of recreational psilocybin. A far larger proportion (86.8%) of the total sample supported medical treatment status for psilocybin therapy.
Our study provides insights into psychiatrists’ concerns about psilocybin therapy and largely overlap with previous studies of psychiatrists (Hartter et al., Reference Hartter, Däumichen, Jungaberle, Schmidt, Wolff, Gründer and Jungaberle2024; Žuljević et al., Reference Žuljević, Breški, Kaliterna and Hren2024a). The primary concern reported by respondents was the lack of a robust evidence base for psilocybin therapy. Indeed, the accumulation of well powered, high-quality clinical trial data with long follow-up periods will likely play the main role in addressing the apprehensions of psychiatrists.
It is important to note that there have been no phase 3 trials of psilocybin therapy conducted to date. The largest trial of a single dose of psilocybin with psychological support in TRD showed an antidepressant response rate of 37% at week 3 in the group that received the psilocybin 25 mg dose, dropping to 20% at week 12 (Goodwin et al., Reference Goodwin, Aaronson, Alvarez, Arden, Baker and Bennett2022). A preceding and smaller trial did not show superiority over the SSRI escitalopram, at least in the primary outcome measure (Carhart-Harris et al., Reference Carhart-Harris, Giribaldi, Watts, Baker-Jones, Murphy-Beiner, Murphy, Martell, Blemings, Erritzoe and Nutt2021). Regardless, an additional, potentially effective therapeutic strategy would be welcome and would potentially open avenues to advance personalized treatment approaches and optimize therapeutic outcomes (Kelly et al., Reference Kelly, Clarke, Harkin, Corr, Galvin, Pradeep, Cryan, O’Keane and Dinan2023).
Our survey did not specifically ask about cost or accessibility, but both were communicated as concerns. The optimal delivery of psilocybin therapy has not yet been fully deciphered (McGuire et al., Reference McGuire, Cohen, Sisti, Baggott, Celidwen and Devenot2024). The development of a Psychedelic Science Research Centre, embedded within the public health system in Ireland, perhaps using a hub and spoke model, could optimize existing resources, provide standardization, quality and accountability, accessibility (particularly for those in marginalized/vulnerable communities), together with an opportunity to facilitate the collection of long-term data.
Developing closer links with the College of Psychiatrists of Ireland, perhaps via the establishment of a Psychedelic Medicine Special Interest Group, together with advocacy groups, such as IDPAT (Irish Doctors For Psychedelic Assisted Therapy), and Patient and Public Involvement networks (Close et al., Reference Close, Bornemann, Piggin, Jayacodi, Luan, Carhart-Harris and Spriggs2021) could foster a vibrant and collaborative ecosystem of education, training and innovation in psychedelic research in Ireland and could help to align attitudes/knowledge with the most up to date and best quality evidence. This growing and diverse inter- and cross-disciplinary collaborative research community in Ireland may also create opportunities for linking with international networks.
Conclusions
Overall, this study showed that psychiatrists in Ireland held positive attitudes towards the potential of psilocybin therapy. Yet, most did not feel knowledgeable about psilocybin therapy and did not feel adequately prepared to participate in the delivery of psilocybin therapy. A minority expressed concerns related to lack of robust evidence, long-term effectiveness, superiority to current interventions, potential harmful effects, cost and accessibility, and impartiality. Addressing the knowledge gap and aligning attitudes of psychiatrists, service users and the public, based on the best available evidence will be key if psychedelic therapy is to prevail in a clinical setting.
Limitations
While our study provides valuable insights into psychiatrists’ attitudes toward psilocybin therapy and contextualizing them within the broader landscape of psychedelic research, certain aspects may warrant further critical examination and elaboration.
While the survey was distributed via national mailing lists for consultants and trainees, we acknowledge that these mailing lists often aren’t comprehensive and certain trainees or consultants may be missing. In addition, these mailing lists may not include psychiatry NCHDs who are currently working but not in training. The survey may have been forwarded appropriately amongst clinical colleagues and we are unable to estimate the number of participants the survey was sent to via email.
Additionally, the number of psychiatrists who declined to participate in the survey via hard copy or QR code is not known, so it is not possible to estimate the number of psychiatrists the survey was distributed to in-person. We appreciate that our sample may not be fully representative of all psychiatrists practicing in Ireland. As such, we acknowledge the potential influence of non-response bias and its implications for the reliability of the reported attitudes. We further acknowledge that our sample was predominately composed of trainees, and therefore may not fully reflect the broader attitudes of psychiatrists. This lack of sample representativeness may have led to a possible overinflation of positive attitudes.
Exploration of attitudinal variations according to, for example, speciality training, would be interesting, but subgroup analyses lack sufficient power to derive meaningful interpretations. We did not ask about personal psychedelic use, leaving that aspect to future studies, and our survey did not distinguish between bipolar affective disorder type I and type II.
We fully appreciate the nuances of the ongoing debate between psychedelic therapy and psychedelic-assisted psychotherapy (Aday et al., Reference Aday, Horton, Fernandes-Osterhold, O’Donovan, Bradley, Rosen and Woolley2024; Goodwin et al., Reference Goodwin, Malievskaia, Fonzo and Nemeroff2024a, Reference Goodwin, Malievskaia, Fonzo and Nemeroff2024b; O’Donnell et al., Reference O’Donnell, Anderson, Barrett, Bogenschutz, Grob, Hendricks, Kelmendi, Nayak, Nicholas, Paleos, Stauffer and Gukasyan2024). However, for the purposes of this paper and for simplicity, we opted for psilocybin/psychedelic therapy.
We acknowledge some of the survey questions, particularly related to ‘mystical or spiritual experiences’ are suboptimal. Alas, a discussion around this issue is outside the scope of this paper.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ipm.2024.49.
Acknowledgements
We would like to thank the respondents who took part in this survey. More broadly, we would like to sincerely thank all of our research participants in the psychedelic trials and other studies, whose contributions of time and spirit make this research possible. We would also like to thank the staff at Sheaf House. We thank Christopher Connolly for his feedback on the paper.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
JRK is principal investigator (Ireland) on COMPASS, GH and Transcend Therapeutics sponsored clinical trials in Dublin, Ireland. JRK has consulted for Clerkenwell Health and has received grant funding from the Health Research Board (ILP-POR-2022-030, DIFA-2023-005). AH is supported by the Health Research Board (ILP-POR-2022-030, DIFA-2023-005). PSH has been in paid advisory relationships with the following organizations regarding the development of psychedelics and related compounds: Bright Minds Biosciences Ltd., Eleusis Beneft Corporation, Journey Colab Corporation, Reset Pharmaceuticals Inc., and Silo Pharma. PSH has received research funding from the NIH and Hefter Research Institute.
Ethical standards
Tallaght University Hospital/St. James’s Hospital Joint Research Ethics Committee approved this study (REC: 2020-08 List 29). The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
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