Full text of consultant psychiatrist Ben Sessa’s talk: Is MDMA psychiatry’s antibiotic? at TEDxUniversityofBristol conference.
Listen to the MP3 Audio here:
Ben Sessa – Consultant psychiatrist
Now you’ve probably heard of this compound in the context of the recreational drug Ecstasy.
But today I want to talk about MDMA, not as a recreational drug, but as a potential new treatment in medicine, and then a very important treatment for psychiatry, because MDMA could offer us, in psychiatry, for the first time, the opportunity to tackle trauma.
And psychological trauma, particularly that caused by child abuse and maltreatment, is at the heart of all or most psychiatric disorders due to anxiety and addictions.
Psychiatry is in need of this innovative approach because current treatments are failing patients.
Hi, my name’s Ben Sessa. I’m a child and adolescent psychiatrist. Now that means I trained as a medical doctor, then specialized in mental health, and then specialized in child and adolescent mental health.
But for the last five years, I’ve been working with adults with mental health disorders and addictions due to misuse of drugs. And that developmental pathway of my own, from working with child abuse into adults with mental disorders and addictions, has brought me to the door of MDMA.
And I’m going to propose today that MDMA could be important for the future of psychiatry as the discovery of antibiotics was for general medicine a hundred years ago.
So when we think about child abuse, we think about physical abuse, mental abuse, emotional abuse, sexual abuse, and neglect. And we think about noxious environments, we think about parents with mental disorders, we think about parents who are addicted to drugs, and social issues like poverty, and poor housing, poor education.
Now I’m going to illustrate my talk today with a patient, and I’m going to call her Claire.
Now, Claire was no single particular patient of mine. Rather, she’s an amalgamation of many different people I’ve met in the last 18 years working as a medical doctor. She’s certainly not the worst.
Now, what was Claire’s environment like as she was growing up?
Well, her mother was depressed. Now unfortunately, the family doctor didn’t have time to accurately diagnose and treat depression. Rather, Claire’s mother was put onto one antidepressant after another, never really got therapy.
Claire’s mother also had a lot of aches and pains, typical of what we call psychosomatic symptoms in depression, and, as a result, the family doctor put her onto opiate-based painkillers which she promptly became addicted to.
Now, Claire’s father, he was alcoholic, and he was often not around, in and out of prison, which is just as well because when he was there, he was physically abusive to Claire and her mother.
Okay. So what does this kind of chaotic, frightening environment do to the developing child brain?
I’m going to give you a brief neurophysiology lesson, if I may. There’s a part of the brain called the amygdala. Now, the amygdala is a very ancient part of the mammalian brain, and many other animals, other than humans, have an amygdala.
The amygdala lights up when stimulated by fear in the environment, by a frightening stimulus. It lights up and it says, “Fight or flight, get out!”
Now, there’s another part of the brain, a much more sophisticated part, called the prefrontal cortex, and it’s right here, at the front, above the eyes.
Now, the prefrontal cortex, only humans have, and it’s in the prefrontal cortex where we use logic and reasoning to rationalize the situation, and we can use our prefrontal cortex to overcome that instinctive fear response from the amygdala.
Now, when Claire was growing up, she never knew, from one moment to the next, whether the adult coming into the room, were they going to give her a kiss, or a cuddle, or do a jigsaw with her, or were they going to punch her, or kick her, or burn her with their cigarette.
Or were they going to rape her. Because, throughout her childhood, Claire was also subjected to sexual abuse.
Now, there’s a group of disorders called the anxiety disorders, and one of the most important is what we call posttraumatic stress disorder, or PTSD.
Now, PTSD, some of the core features: very low mood, anxiety, high levels of anxiety, what we call hypervigilance – this edginess, this jumpiness. Exactly how Claire felt, throughout her childhood and adolescence, never knowing whether the next assailant or assaulter was around the corner.
Another core feature of PTSD, what we call re-experiencing phenomena, flashbacks, in which the patient has sudden remembrances of these painful traumatic memories. They can just pop into the head at any time, triggered by some cue in the environment.
And when they have those experiences, those daytime flashbacks, they relive the trauma in all the sensory modalities, and this results in them freezing or dissociating to try and block out the pain.
Now, Claire experienced all of this as she was growing up. High levels of self-harm and suicide are associated with PTSD. Claire would cut her thighs and her breasts, pretty common form of cutting in children who’ve been sexually abused.
She was being sexually abused by clients of her mother because her mother had moved on from the addiction to painkillers and was using street heroin when Claire was a teenager.
And because of the way the war on drugs has set up, that reduces access to treatment for people with opiate dependence, she had to pay for her heroin use in sex work, and the clients would sexually abuse Claire.
Now, it’s very hard to treat PTSD and it has a high treatment resistance – 50% of people do not respond to the traditional treatments.
How do we treat it?
Well, we can treat it with medications. We can treat it with psychotherapies. And the medications we use, there’s a broad range of drugs. No single drug, and this is very important, no single drug cures PTSD. Rather, we treat the disorder symptomatically.
If the patient’s depressed, give them an antidepressant. If their mood fluctuates, give them a mood stabilizer. If they can’t sleep, give them a hypnotic.
And if that edginess and that fear spills over into paranoia and psychosis, give the patient an anti-psychotic drug. And they have to take these drugs day in, day out, for weeks, months, decades. They have to keep taking them because the drugs we use to treat trauma, when it’s due to this level of severity, do not attack the root cause of trauma. They paper over the cracks.
A good analogy would be taking aspirin or ibuprofen when you have a fever. Now, fever is caused by an infection, by a microorganism. Sure, you can take paracetamol or ibuprofen, and this will lower the temperature, make you feel a bit better, but it doesn’t attack the root cause.
And that’s what we do when we give these patients these daily SSRI drugs. We paper over the cracks, we maintain the symptoms at a manageable level.
We also use psychotherapies to treat PTSD, and there’s again a broad range of these: DBT, CBT, EMDR, trauma-focused psychotherapy, CAT, APT …
Now, all of them have a pretty similar approach which actually is an old wives’ tale which is: a problem shared is a problem halved.
“Let’s talk about your trauma. Claire, tell me about your rape.”
Now that’s fine for 50% of patients, but for a significant half, they just cannot do that. As soon as Claire is asked to talk about her rape, she freezes, she flees, she drops out of treatment.
Now, by the time she was 15, Claire had been removed from the family home, and she was brought up in a succession of foster placements, and children’s houses, and hostels where the abuse continued.
She would self-harm cutting, and she started drinking, and, by the time she was 18, she was using heroin as well. Sometimes working in psychiatry can feel pretty desperate, can feel pretty hopeless.
Sometimes it feels as if psychiatry is a palliative care profession. And this is the truth because the treatments we use do not get to the root cause of the problem, the trauma; they paper over the cracks.
And I think the pharma industry knows this, and they queue up, and they provide us with product after product to give to our patients that doesn’t quite cure them, but it gets them slightly better to function. And they have to keep taking them.
I would say that we’re in psychiatry, today, where we were in general medicine 100 years ago. Now, 100 years ago, in general medicine, humanity was losing the battle to the infectious diseases. Oh, we were very good at classifying and diagnosing them. We knew who got smallpox.
We knew people died of post-operative surgery. We knew there were microorganisms, but we didn’t have a treatment. And then, at the beginning of the 20th century, we discovered the antibiotics. Not symptomatic treatment, but treatment that goes to the core of the cause, and we started getting on top of infectious disease.
Now, psychiatry, today, is in a similar place. We’re very good at classifying and diagnosing. Our epidemiology is superb. We write these thick diagnostic manuals. We know who gets depression. We know who gets anxiety. We even know the cause: trauma, child abuse, maltreatment, poor social conditions.
But our treatments are lousy.
And I’m quite shocked the way the empathy switch and our understanding of these patients seems to be switched off. We have lots of gushing sentimentality for the little five and six-year-old who’s being abused, and we throw money at our television sets on these campaigns to improve the lives of these poor little innocent victims.
But let me tell you what happens to that little five- or six-year-old when they’re 11 or 12. On goes the hood, start smoking weed. By the time they’re 16, they’re buying and selling amphetamine, and by the time they’re Claire’s age, in their mid-20s, they’re addicted to heroin and alcohol.
And, suddenly, we have lost our empathy. These people are public enemy number one. “It’s your fault, Claire. You brought this upon yourself. It’s your lifestyle choice.”
And I’m quite shocked, and having worked in pediatrics and seeing the developmental trajectory that is so inevitable, from early trauma into adolescent, and then adult mental health and addictions, we have to hold on to that sense of compassion and evidence-based understanding about the developmental trajectory there.
So it does sound desperate, but all is not lost: MDMA.
MDMA has some fascinating qualities. Indeed, I would suggest that if you were to invent a hypothetical drug to treat trauma, it would be MDMA. The way it works, in terms of receptors and subjective psychological effects, ticks all the right boxes.
At one level of receptors, it causes an increased positive mood, lowering of depression, lowering of anxiety. At another group of receptors, it speeds the patient up, mild stimulation which motivates them to engage in therapy.
At another level, it relaxes the patient, paradoxically, at the same time as the stimulation, and this puts the patient into the optimal arousal zone where they can engage in psychotherapy.
But perhaps the most important thing about MDMA, and the most important clinical tool, is its ability to provide a sense of empathy, and understanding, and emotional security. It can hold the patient in a place where they can think about and access their trauma like they’ve never been able to do before.
One of the ways in which MDMA works is it increases the release of a hormone called oxytocin. Now, oxytocin is released from the brains of breastfeeding mothers. It’s a hormone that engenders a sense of attachment and bonding, and that’s what’s happening in the patient who takes MDMA.
And, also, it acts directly on the amygdala to reduce that fear response, while, at the same time, boosting the prefrontal response, allowing the patient to see things in a new light, a positive light.
So let’s go back to Claire. She’s 40 now. She’s been in and out of psychiatric hospitals, having tried to take her own life in the inception. She’s been on all the antipsychotic, antidepressant, mood-stabilizing drugs. She’s tried all the psychotherapies, but she cannot engage because she will not talk about her feelings.
So she comes into a course of MDMA-assisted psychotherapy. What does it look like?
Well, it’s weekly sessions, maybe eight, ten, twelve weeks long, with two therapists, male-female pair. You do not take MDMA every day, you do not take it every week. Over that course of 12 sessions, you’ll take the MDMA three times, and the other sessions, you talk about the material that’s released on the MDMA session.
So what does Claire actually feel when she takes this MDMA?
What she feels is a sense of warmth and understanding, and a sense of contentment within that relationship she’s having with the therapists.
MDMA is like a life jacket, like a bulletproof vest, to wear to go into battle with your trauma. This is not ecstasy! She’s not enjoying some raver’s euphoric ecstasy delight. This is still trauma-focused psychotherapy, and it’s still hard and distressing for her, but she can just about do it with MDMA on board.
So when the therapist says, “Claire, tell me about your rape” – now in the past, just the word rape, and she’d be out the door, but on MDMA she says, “Yeah, I can talk about that! I can see him now coming into the room, I can smell the whiskey on his breath, and I can feel the stubble on his face as he’s raping me.”
And she talks about it, and she explores it, and she reflects upon it, and she can begin the process of healing. And from here, she can start her journey. She can attack the root cause of her problems, not just maintain the symptoms at a level.
So, does it work?
Well, we’ve known about MDMA for a very long time, and, indeed, we’ve used MDMA in underground therapy for 30 or 40 years, and there are thousands of positive anecdotal cases. I get five emails a week from all over the world, “Dr. Sessa, I’ve had PTSD for years. I’ve tried everything, and now I tried MDMA, and I’m starting to make a breakthrough!”
Now, anecdotal reports like that are interesting, but they’re not science, so we’ve done the science and some important studies in recent years.
Big study in the States showed that a single course of MDMA therapy, 16-week course, patient takes MDMA three times, tested against the placebo – at the end of that course, 85% of the people no longer met the diagnostic criteria for PTSD. Not just a relief of symptoms, they didn’t have PTSD!
Now that cohort were then followed up three years later, the same – no PTSD. Many of those people had come off their daily medications. They were cured! We don’t use the “cure” word in psychiatry. We’ve become learned helpless in this position of … This is the truth!
If you’re diagnosed with a severe mental disorder, like anxiety or depression, in your 20s, and the developmental root of that disorder is severe child abuse, there’s a pretty good chance, and I’m sorry to say this, there’s a pretty good chance you will still be going to psychiatric clinics in your 60s and 70s.
Now that is not good enough, and we’re in this position because we’re not tackling trauma.
So, it works, but is it safe?
Well, when we think about safety of clinical MDMA, what we must not do is look at the risks of recreational ecstasy. I don’t even know what ecstasy is anymore! Ecstasy is over here; what is ecstasy? Some dodgy pill, bought in some dodgy club, off some dodgy geezer, that may or may not contain MDMA, plus or minus whatever far more toxic substance.
And indeed, when you hear about the very high-profile deaths of people who take ecstasy, it invariably is not MDMA.
So, let’s not look at ecstasy as a measure of MDMA. Let’s look at clinical MDMA. Now, when you use clinical MDMA, you take it under medical supervision, it is pure.
The MDMA that I’m using in my studies is 99.98% pure. Very expensive! We do it under medical supervision with a doctor, and a nurse, and a psychologist. And under those conditions, the risks are reduced to an absolute minimum.
Indeed, after 40 years of MDMA research, there has not been a single serious adverse drug reaction, not one. And certainly no deaths.
So, we need to do this research, and we need to do this research in an evidence-based, compassionate way, looking at the data. We need to ignore the sociopolitical agenda that says any drug that’s being used recreationally must also be very bad and dangerous. That sort of attitude hampers research.
And we need scientists to drive this. It works, it’s safe, and it offers patients like Claire, for the first time in their life, an opportunity to break through from that trauma and not become a lifelong chronic PTSD sufferer.
So, where are we going with MDMA research?
Well, we’ve had some studies, we’ve got more coming here. I’m doing a study in Cardiff with neuroimaging in which we’re going to give patients with PTSD MDMA and placebo, and we’re going to look at that relationship between the amygdala and the prefrontal cortex.
We’re also doing a study here in Bristol, giving patients with alcohol use disorder MDMA, because underlying the root of this addiction is trauma. So, this is an exciting time.
Now people say, “This is controversial!” And indeed, I was introduced as a controversial speaker. I’m not controversial. I’m a very boring conservative doctor. I like data. I like evidence-based data that helps my patients.
I’ll tell you what’s controversial. What’s controversial is that more people have died returning from Afghanistan and Iraq because they’ve committed suicide because of their untreated PTSD than ever died in the conflict out there. That is controversial, and that is unethical.
So, this is an important time for science. MDMA could be the antibiotic that psychiatry has been waiting for. We owe that population of patients who are being failed, we owe them this research. We owe this to Claire!