“We don’t want to run before we walk”: the attitudes of Australian stakeholders towards using psychedelics for mental health conditions September 2023, Volume 33, Issue 3

Introduction

Almost 1 billion people globally experience a mental health condition at any time.¹ Mental health conditions have significant and broad negative impacts on the lives of the individuals experiencing them, as well as on their friends, family and the communities in which they live.^2,3 Mental health conditions also pose a high economic burden, contributing to greater student attrition, poorer employment prospects and, subsequently, reduced quality of life.⁴ Poor mental health was estimated to cost US$2.5 trillion (A$3.85 trillion) globally per year in 2010 due to reduced health and productivity, which is projected to increase to US$6 trillion (A$9.25 trillion) by 2030.¹ In Australia, $A11.6 billion ($451 per person) was spent on mental health-related services in 2020-21⁵, a number expected to grow in the wake of the COVID-19 pandemic.¹ The burden of mental health conditions must be prevented from worsening.

Psychedelics – psychoactive substances that can alter perception – are considered novel treatments for mental health conditions. Their use has been illegal to date in many countries, including Australia, and they are often stigmatised due to their negative history, specifically the US ‘War on Drugs’, an effort that has continued since the era of President Nixon (circa June 1971) that aims to penalise people using such agents.⁶ To date, there have been positive findings from trials of two psychedelic agents, psilocybin (which is obtained from certain types of mushrooms) and 3,4-methylenedioxymethamphetamine (MDMA), when used in conjunction with psychotherapy for the treatment of mental health conditions. A systematic review of seven studies examining the effects of psilocybin-assisted psychotherapy on primary and secondary depression found psilocybin (at a dose of 30–35 mg/70 kg) had a large and long-term effect⁷ (although more recent studies have opted for a fixed dose of 25 mg). A systematic review of five studies examining the effectiveness of MDMA-assisted psychotherapy for managing treatment-resistant post-traumatic stress disorder (PTSD) found the intervention to be likely safe and highly effective.⁸ Thus, the evidence base supporting psilocybin- and MDMA-assisted therapies appear promising, albeit limited.

At the time this study was conducted, psychedelics were classified as Schedule 9 (prohibited substances) in Australia and were not approved for clinical use. However, on 4 February 2023, Australia’s Therapeutic Goods Administration (TGA) reclassified MDMA and psilocybin to Schedule 8 (controlled substances), approving their clinical use for the treatment of PTSD and treatment-resistant depression (respectively), in conjunction with psychotherapy, from 1 July 2023.⁹ Prescribing is limited to authorised psychiatrists. Although reclassification is an important step towards including psychedelics in treatment regimens, the success of any innovation requires the support of those who might be impacted by it, including those who manage, deliver and use the medication.

Recent international research has examined stakeholder attitudes towards using psychedelics to treat mental health conditions. In Ireland, the majority of 99 mental health service users (59%) supported the clinical use of psilocybin and 72% supported further research.¹⁰ In the US, a survey of 323 psychiatrists revealed that 81% felt hallucinogens (e.g. psilocybin) deserve more research as treatments for psychiatric disorders.¹¹ Similarly, a survey of 366 psychologists found that 85% wanted more research, and many lacked an understanding of the clinical use of psychedelic-assisted therapy for mental health conditions.¹² In Australia, however, the attitudes of key organisational (e.g. medical peak bodies) and political stakeholders towards using psychedelics to treat mental health conditions remains unclear.

This study sought to address this gap by exploring the attitudes and positions of key Australian organisational and political stakeholders towards using psychedelics to treat mental health conditions in medically-supervised contexts in conjunction with psychotherapy. Specifically, this research was designed to identify some of the issues that might impede the clinical implementation of psychedelics.

Methods

Participants were recruited via snowballing, professional networks and by leveraging familiarity with key stakeholders likely to have a position on the clinical use of psychedelics. Eligible participants were those employed by or involved with organisations considered relevant stakeholders on psychedelic drug law reform, clinical use or regulation (e.g. politicians, advocacy groups, and medical/ psychological representative bodies). Participants either held a senior role or had sufficient knowledge to comment on the position of their organisation or political party on the use of psychedelics to treat mental health conditions. Participants were asked to comment on their organisation or political party’s position on the topic rather than their own personal views. All participants were provided with an explanatory statement outlining the interview purpose and process and completed an online consent form.

The design of the interview guide (see Appendix 1, available from: doi.org/10.26180/24002403) took an interpretative approach and was informed by relevant literature, including our research exploring the attitudes of Australian adults towards the use of psychedelics to treat mental health conditions.¹³ We also leveraged our own professional expertise. All authors have PhDs in behavioural science, psychology, and medicines development. The development of new medicines for mental health conditions is the focus of the Neuromedicines Discovery Centre. MH is a registered and practising psychologist, and BW’s PhD topic was related to veteran mental health, a topic often discussed with psychedelics.

Thirteen semi-structured interviews were conducted with stakeholders between September 2022 and January 2023 via telephone or video conference and lasted approximately 45 minutes each. As the TGA announcement regarding the reclassification of psychedelics (in February 2023) was considered a surprise by many¹⁴, it is unlikely that anticipation of reclassification influenced the findings of this study.

Interviews were recorded, de-identified and transcribed. BK coded the transcripts using NVivo (Appendix 2, available from: doi.org/10.26180/24002403).¹⁵ Pattern-based inductive thematic analysis was used to identify common themes between interviews.¹⁶ Sentiment auto-coding was used to support the interpretation of attitudes between participants.¹⁶

Ethics approval and funding

Ethics approval for this research was provided by the Monash University Human Research Ethics Committee (ID: 30009). This project was funded by the Neuromedicines Discovery Centre at Monash University.The Standards for Reporting Qualitative Research (SRQR)¹⁷ informed the design and reporting of this study (Appendix 3, available from: doi.org/10.26180/24002403).

Results

The results of this study were originally published as part of a larger report on this topic provided to the funder.¹⁸

Participants

Participants included past and present state and federal, left- and right-leaning politicians (n = 4), representatives from medical or psychological peak bodies (n = 4), healthcare service providers and advocates (n = 3), a union (n = 1) and consumer body (n = 1). Politicians were mostly Victorian-based. The remaining participants were either representatives of national organisations or based in other states.

Themes

Three major themes were identified in the interviews:

1. More research is needed
2. Negative stigma impedes progression
3. Effective messaging is needed to inform positions.

More research is needed

All organisational representatives expressed concern regarding the quality of existing evidence, noting that insufficient evidence limits trust and, subsequently, prevents organisations from supporting the clinical use of psychedelics. Many representatives felt that the evidence “is not there yet” (Medical or psychological peak body #1) as it lacks maturity (i.e. due to a small number of publications) and/or has several methodological flaws (e.g. poor blinding practices, small sample sizes, short durations, lack of comparison to existing treatments, and narrow populations not reflective of the general population).

“We don’t want to run before we walk. We want to make sure that there’s a really good evidence base behind this.” (Medical or psychological peak body #4)

The lack of research contributed to hesitancy, but the knowledge of some positive research findings and increasing community support made representatives, and politicians feel “cautiously optimistic” (Medical or psychological peak body #4) yet simultaneously unwilling to confidently support the clinical use of psychedelics.

“[We] are quite excited and wanting to push things along quite quickly. [But] we tend to wait for the evidence to be a little bit stronger than it currently is [in psychedelics] before advocating for something very strongly.” (Healthcare service providers and advocates #1)

Many representatives and politicians stated that research is needed that considers cost-effectiveness, details the role of psychotherapy and other social supports, and intervention feasibility within the Australian context (e.g. the type of clinicians involved, the cost of the service and ways to ensure equity in service provision). This was considered particularly important by those representing clinicians who would deliver psychedelic treatment regimens and politicians who deemed it necessary to inform their position on the topic.

“We’re really interested in, if effective, how would this work in the Australian context in particular, how might this be translated or scaled into clinical settings?” (Healthcare service providers and advocates #2)

“Who hasn’t heard a politician say, ‘This is evidence-based policy’, ‘We are basing this on the research’ … endlessly we talk about that.” (Politician #2)

Negative stigma impedes progression

Some organisational representatives and politicians noted that while the community are increasingly open to the clinical use of psychedelics, significant work is needed to reduce the negative stigma and misconceptions around their use that have accumulated over decades and been reinforced over time.

“…society’s changing. I feel like we’ve crossed a position where there is growing and … even majority support for a number of more progressive positions around drugs … I just sense that when we come out and say, ‘We should legalise cannabis’, … the quality of the reaction we’re getting is different, particularly among the under 40s … Everybody’s saying, ‘Oh, that’s sensible. Why wouldn’t you?’ For things where you can make a strong case, there’s growing support in older age groups as well.” (Politician #1)

Negative stigma was a strong theme, especially in the political context.

“My supposition on the politics of it is that the states don’t want to take the risk of … any sort of use of psychedelics being used against them politically with a fear campaign that’s going to lead to people selling stuff at the gates of schools … Again, total ignorance about how it’s proposed to be used.” (Politician #3)

The negative stigma surrounding psychedelics can make it difficult for politicians to support their use, particularly conservative party members who “support the total prohibition of psychedelics” (Politician #3).

“We know that what we’re talking about is a highly medicalised approach to the use of psychoactive substances … but still the fact that we’re talking about MDMA, the fact that we are talking about psilocybin or magic mushrooms … it still gets captured in that stigma. And that has made it … very difficult for our politicians to say:‘drugs are bad, unless you’re using them in this other [medically supervised] way’.” (Politician #2)

However, politicians suggested that the topic would be approached with more openness if they were exposed to research advancements, within the context of political discourse.

“There’s no champions of any consequence in the parliamentary parties making speeches, finding every opportunity to raise the issue. I think that seems to be missing on both sides of politics.” (Politician #3)

Effective messaging is needed to inform positions

Messaging that includes information about psychedelics and their use in mental health conditions must be carefully crafted to deliver an accurate message in an effective way. All organisational representatives and politicians believed that credible and trustworthy information must be created using high-quality research evidence and be delivered by trusted entities such as doctors and scientists, but also people with lived experience of treatment-resistant mental health conditions.

“When I want to learn more about psilocybin and the benefits of MDMA … I want to be learning from a doctor at Monash or the head of a drug and alcohol rehab … or the wife, a partner or the mother of someone who’s got PTSD. They’re the ones I want to hear from.” (Union #1)

Messaging must involve treatment safety and efficacy, implementation, complexity, and disease burden and counter misinformation and disinformation.

Politicians provided extensive insight into how effective messaging can influence political positions. Messaging regarding psychedelics must be crafted using plain language, demonstrate benefit over existing treatments, and be delivered directly and in person to the relevant minister. Messaging must also be framed in the context of the broader problem. For example, messaging might refer to the medically supervised use of psychedelics being part of the response to the recommendations made by the Royal Commission into Victoria’s Mental Health System.¹⁹

Messaging must also have a ‘human factor’. Information delivered to politicians should be in the context of demonstrable need. Personal stories of those living with mental health conditions and for whom conventional treatments are failing (e.g. veterans) were considered powerful by all politicians.

“Putting my campaign hat on, PTSD in our first responders and in our return servicemen, that is low-hanging fruit, and I think there’s also almost a zeitgeist moment right now when we’re looking at the mental health of our return service people, we’re looking at the completely awful statistics around their mental health, and in particular around suicide. So, at this point in time, it’s almost like we’re ready again for that.” (Politician #2)

Effective, evidence-based messaging is not just important for political persuasion. Healthcare providers and peak bodies also need it to inform training materials, treatment guidelines for clinicians, and public-facing statements regarding their position on using psychedelics for mental health conditions.

“We recognise the need [of the organisation] to provide clear and substantiated information to the public about the differences between MDMA-assisted psychotherapy and illicit MDMA use.” (Healthcare service providers and advocates #1)

Discussion

This research sought to understand the attitudes and positions of key Australian organisational and political stakeholders towards using psychedelics to treat mental health conditions in medically supervised environments. Three main themes derived from interviews focused on: 1) the perceived inadequacy of research into the clinical use of psychedelics; 2) the negative stigma preventing politicians from supporting clinical psychedelic use; and 3) the need for effective messaging to gain support for the use of psychedelics to treat mental health conditions.

The most robust theme centred on the need for additional research, with participants suggesting the current evidence base for using psychedelics to treat mental health conditions needs to be strengthened to support clinical use. More research that focuses on (but is not limited to) the pathway for implementation that considers cost-effectiveness and equity, as well as the delivery and production feasibility within the Australian context, is needed to foster acceptance of psychedelics among stakeholders. The availability of real-world clinical outcome data (via clinical registries) following the recent down-scheduling of psilocybin and MDMA to Schedule 8 on the Australian poisons and therapeutic goods standard will hopefully provide key evidence of the effectiveness and safety of these medicines when used as adjuncts to psychotherapy. To ensure that real-world need is met, it is important to understand how potential patients find and connect with treatment options. One way that different pathways and accessibility and equity might be measured is by following the patient’s journey from symptom experience and initial help-seeking to receiving treatment, including psychedelic-assisted therapy. This may identify key moments that can impact accessibility, such as GP referrals and subsequent pathways and the point at which patients must decide if they can afford the treatment. While this evidence is unlikely to be produced prior to psychedelics being prescribed in Australia, it must form part of an ongoing research plan extending beyond the incomplete research agenda commenced in the 1960s.²⁰

At this point, it is important to review existing evidence to establish where knowledge gaps remain and to identify any evidence that addresses current perceived gaps.

Many participants felt there was insufficient evidence to support using psychedelics to treat mental health conditions. Importantly, insufficiency can be subjective; where some might consider an immature evidence base that includes some promising evidence (as is the case for psychedelics currently) insufficient, others might consider this sufficient evidence to base decisions. For example, some participants believed evidence regarding cost-effectiveness was inadequate. Yet, some recent studies have reported the effectiveness⁸ and cost-effectiveness of MDMA use to treat PTSD.^21-23 Evidence such as this likely informed the TGA’s reclassifying decision. No studies yet exist, however, for cost-effectiveness in an Australian context. Further, the perceived insufficiency of evidence may be influenced by psychedelics’ negative stigma, such that a higher perceived standard of evidence may be needed to garner support among organisational and political stakeholders.

Political participants consistently emphasised the negative stigma surrounding psychedelics as a barrier to gaining the political support necessary to make them available for clinical use. In the 1960s, the portrayal of psychedelics – particularly lysergic acid diethylamide (LSD) – as ‘mind altering’ and the association of recreational use of such drugs with particular political movements contributed to psychedelics gaining a negative reputation among US political and medical leaders.²⁴ This led to the medical use of psychedelics being banned, along with the spread of misinformation and fear, despite a significant body of research from the 1950s showing promising results for their use to treat mental health conditions.²⁴ While history cannot be erased, the study findings suggest that misinformation and fear that emerged during that time must now be respectfully challenged using high-quality evidence to support Australian legislators to create legislation to guide the implementation and regulation of psychedelics. While the regulatory processes may differ, in terms of stigma reduction, the use of psychedelics may follow a similar path to that which accompanied the approval of the use of medicinal cannabis in Victoria after 2016.

A recent narrative review examined the potential harms of psychedelics and found that many of the anticipated risks perceived to be associated with psychedelics were unsupported by evidence.²⁵ Translating research like this into plain-language messages might assist in addressing misconceptions. However, such messages are unlikely to lead to attitudinal change without additional research demonstrating psychedelics’ efficacy, safety and feasibility.

Crucially, members of the public (including key stakeholders) can only become aware of the extent of the psychedelics evidence base if it is deliberately disseminated to them. Participants considered effective communication as pivotal to enhancing support for psychedelics in treating mental health conditions. Clear and consistent messaging about treatment will be imperative to inform the public, influence political decision-making, and counter potential misconceptions, misinformation and disinformation. Frameworks such INSPIRE may be used to guide the development of clear and accessible communications that also encourage action.²⁶ It is important to measure if strategies such as these influence public perceptions and support as part of a future research agenda.

Credible and trusted information sources – such as scientists from respected universities – must be used to deliver messages as they are likely to be persuasive and subsequently believed.^26,27 Further, scientific information should be complemented by personal stories of lived experience. Narratives that evoke emotions such as empathy, particularly those of valued community members such as emergency service personnel, could provide powerful leverage for change.²⁸ Communication strategies regarding the clinical use of psychedelics should go beyond knowledge-based education and use persuasive techniques that challenge attitudes, biases and emotions that can influence the debate around psychedelics. Communication strategies are necessary not only to inform the general community and political views and legislative behaviours but also to support clinicians in gaining the knowledge and confidence they need to prescribe psychedelics.²⁹

The findings suggest significant effort may be required to convince those charged with designing legislation and supporting clinicians about the role of psychedelic-assisted options in treating mental health conditions. The timely findings of this study provide practical learnings that can inform approaches taken to increase support for the use of psilocybin and MDMA.

Strengths and limitations

The design of this study was informed by experts in the fields of psychedelic research and behavioural science to discover the issues that might impede the clinical implementation of psychedelics. The majority of interviews were completed by one author (BK) who, despite knowing the field, is professionally distanced from it, a strategy adopted to prevent any potential corruption of participant opinions.

Using a qualitative approach allowed in-depth exploration of stakeholder and politician positions on psychedelics, which would not be possible using a survey. Obtaining the views of a larger and more diverse group of key stakeholders and politicians was difficult due, in part, to the controversial nature of the topic potentially preventing responses to invitations (particularly for politicians). Further, the availability of politicians was limited by the impending Victorian State election and the associated Government “caretaker period” during the data collection period. Thus, data collection was ceased due to approaching deadlines rather than saturation. Transcripts were not checked by participants prior to analysis.

Given the data was collected under the premise that psychedelics could only be used in research and not clinically, it is important to read the findings in the context of psychedelics being on the cusp of unanticipated reclassification for clinical use in Australia.

Future research

Much about psychedelic therapeutic use in Australia is still unknown, including where pharmaceutical-grade psychedelics will be obtained, how they will be regulated, and the costs and potential subsidies for medicines and associated therapies. These unknowns highlight the current lack of clarity around what the provision of psychedelic-assisted psychotherapy will look like in Australia and who will be able to access it.³⁰ Prospective research is needed now that psychedelics can be prescribed to truly understand their impact on treating mental health conditions in Australia, including their associated economic and societal costs and/or benefits. In the short-term, high-quality review-level evidence is required to address misinformation and reduce fears related to the perceived negative effects of psychedelics.

Conclusion

This study explored the attitudes and positions of key organisational and political stakeholders towards using psychedelics to treat mental health conditions in medically supervised contexts in Australia. Although participants expressed cautious optimism surrounding the clinical use of psychedelics, there was also hesitation regarding supporting their use due to perceived insufficient evidence and negative stigma. Although more empirical research is needed into the efficacy, safety and feasibility of psychedelics in the Australian context, a more pressing need is for review-level research to inform effective messaging that challenges misconceptions and disinformation. Overall, there is support among organisational stakeholders and politicians for an increased investigation into the use of psychedelics for treating mental health conditions. Still, more needs to be done to gain support for the recent changes to introduce clinical use of psychedelics in Australia.

Acknowledgements

The authorship team would like to acknowledge Professor Rod Glover and Holly Cooper for their assistance with participant recruitment. We also thank the participants for their contribution to this research.

Peer review and provenance

Externally peer reviewed, not commissioned.

Copyright:

© 2023 Kunstler et al. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.