Psilocybin Mushroom Therapy for End-of-Life Anxiety

(Editor’s note: The following is from Judith Gordon, who is a clinical professor of psychology at the University of Washington and is on the board of directors for End of Life Washington (EOLWA). This is the first in a three-part series on the potential of psilocybin-assisted therapy for people facing severe anxiety and emotional trauma at the end of their lives. — KTB)

The medical community has made great progress in developing treatments that extend life. Partly in response to those efforts, the field of palliative care has grown substantially in the last two decades and focuses on ameliorating the suffering of individuals whose lives are prolonged by technological advances in medicine but often at the cost of quality of life. EOLWA recognizes the evolution of palliative care as an important contributor to the quality of life of dying people. This is why EOLWA supports efforts to legalize the use of psilocybin-assisted therapy for the emotional, existential, and spiritual suffering often experienced by terminally ill individuals.

Psilocybin is a psychoactive substance found in certain mushrooms that have been used for thousands of years to enhance spiritual experiences. It acts on serotonin brain receptors, resulting in changes of perception, cognition, and emotion. The U.S. government studied psilocybin in the 1950s and 1960s for potential use in treating a variety of behavioral health problems, such as post-traumatic stress disorder, addiction, obsessive-compulsive disorder, treatment-resistant depression, pain, and psychological or existential distress caused by cancer.

Due to the political and cultural climate at the time and fears raised by recreational use of psychedelic drugs such as LSD, psilocybin was placed on a Schedule I list of drugs under the Comprehensive Drug Abuse Prevention and Control Act of 1970. This legislation made it illegal to possess, manufacture, or distribute psilocybin and other hallucinogenic drugs. Government-supported clinical trials resumed in the 1990s, including with terminally ill cancer patients suffering from existential or psychological distress. Some of the most notable studies have been conducted at Johns Hopkins University and New York University.

Brain imaging technologies show how psychedelics temporarily affect neural networks such as the default mode network, which is thought to be the basis for the sense of self and fundamental assumptions about the nature of reality. Modifying it seems to result in a “re-wiring” of the brain, creating healthier networks that allow for greater cognitive flexibility.

When properly administered, clinical trials indicate that psilocybin-assisted therapy is effective in relieving emotional and existential distress at the end of life for 65-85% of terminally ill people. In a significant number of subjects, it produced immediate meaningful and enduring reductions in psychiatric and existential distress, as well as improvements in quality and meaning of life, acceptance of death, optimism, and spiritual perspective. There may be some initial anxiety or nausea, but these have no lasting negative impact.

At least two-thirds of subjects rated the experience as being one of the most personally meaningful or spiritually significant events in their lives, giving them the peace of mind to make the best of their remaining time alive. These positive outcomes are highly superior to conventional drug therapies for depression and anxiety, which often have negative side effects, may take weeks to take effect, are effective only as long as they are being taken, and typically show 40% effectiveness. In addition, people with serious illnesses rarely have the energy to engage in psychotherapy.

Most study protocols feature one 6-8 hour session with a single dose. Sessions are highly controlled to ensure that the three most important factors for a positive outcome are provided: 1) an approved manufacturer with standardized dosages (substance); 2) clear positive expectations, arrived at through preparation and information about the experience beforehand (set); and 3) a safe, comfortable environment with trained guides (setting). A post-session integration debriefing is conducted by the same guides.

Preliminary screening for any contraindications related to medications, medical conditions, or serious psychiatric conditions is essential. These protocols and precautions are in great contrast with self-directed recreational use, which often involves a drug from an unknown source with uncertain dosage and no trained guide and can potentially cause serious adverse psychological reactions. There is nothing recreational about this therapy. It can involve significantly challenging emotional work — but with potentially large rewards.

The dramatic breakthroughs reported in the research present the possibility that the severe depression, anxiety, and hopelessness experienced by many people facing death can be significantly ameliorated. Judgment and decision-making can be impaired by serious depression. An additional benefit to psilocybin-assisted therapy may be that reductions in depression and anxiety will help people more easily engage in clear decision-making about how they want to spend their remaining time as well as choices about how they want to die. Palliative medicine and other groups working with individuals facing terminal illness should support the humane and compassionate option of psilocybin-assisted therapy.

On September 18, 2020, EOLWA approved a policy supporting psilocybin-assisted psychotherapy as a legal part of palliative care for terminally ill individuals. A good introduction to this topic is the book, How to Change Your Mind by Michael Pollan.