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Susan Kopka tried everything.

Through trial and error with several different medications and treatment options, Kopka came to learn that her mental health struggles were treatment resistant, meaning her conditions didn’t respond well to conventional medications. Living in Northern Michigan at the time, “there really were not very many options,” she recalls.

So, Kopka set her sights west. When researching alternatives, Kopka and her husband discovered SeattleNTC, a neuropsychiatric treatment center that offers ketamine treatments (a dissociative anesthetic that has some hallucinogenic effects) for depression and mental health conditions.

“We pretty much loaded up the van and headed out,” she says.

Since then, Kopka has tried several kinds of ketamine therapy with the clinic, including IV infusions, nasally delivered esketamine treatment, and ketamine-assisted psychotherapy. Six months later, “ketamine changed my life.”

“Before, it was like, ‘Am I going to go back to the hospital for the 17th time,’ which never helps,” Kopka says. “But I feel like I can always come back to it if I need to, which is a really good feeling. This has been a really amazing journey.”

That journey is just one of many highlighting the numerous positive effects of psychedelic substances such as psilocybin, LSD, MDMA, and others in a controlled therapeutic setting. So far, ketamine is the only psychedelic on the market approved to treat mental health conditions, but clinical trials on the others are unearthing treatment options once thought of as fringe medicine. However, regulatory hurdles, skepticism among many medical professionals themselves, and stigma continue to create significant obstacles to widespread adoption.

A Long, Strange Trip

Washington state, unsurprisingly, is among the national leaders studying the efficacy of psychedelic therapy. In 2021, Seattle decriminalized noncommercial activity around psychedelics, such as psilocybin, ayahuasca, ibogaine, and mescaline. Two years ago, the state legislature directed the Washington State Health Care Authority to create a work group to study whether to make psilocybin services available throughout the state. Last year, Gov. Jay Inslee signed a bill authorizing the University of Washington School of Medicine to study the potential of psilocybin therapy.

Run through the school’s Center for Novel Therapeutics and Addiction Psychiatry, the $1.4 million, three-year study will focus on the safety of using psilocybin (the compound commonly found in so-called magic mushrooms) to treat post-traumatic stress disorder and alcohol-use disorder. The Seattle-based trial is set to begin at the start of 2025. Participants will include around 30 to 40 military veterans and first responders with a documented history of these disorders.

For Dr. Nathan Sackett, co-director of the center and head of the study, the potential is limitless. Sackett’s motivation is borne out of frustration with the ineffectiveness of more traditional treatments.

“I was really frustrated by that,” says Sackett, whose interest in psychiatry has always been rooted in the realm of addiction. In researching psilocybin, Sackett discovered its potential to “accelerate the rate of change. Psilocybin has the potential to increase people’s motivation to engage in treatments in a larger way. The experience of consuming psilocybin in a therapeutic context provides an opportunity for people to look at themselves from a different angle.”

Studies show an estimated 5.5 million U.S. adults use psychedelics each year, though psilocybin remains illegal on the federal level. Many of those are adults who “microdose,” or take small amounts of psilocybin on their own to ease anxiety and improve cognitive function.

“Psychedelics kind of act as a catalyst for change and growth,” Sackett adds. “But that’s only going to be helpful if you have the support around you — that’s what separates recreational use from therapeutic use.”

Oregon and Colorado have both passed bills to decriminalize psilocybin and legalize supervised psychedelic therapy. Arizona, California, and Massachusetts have also recently taken steps to ease restrictions on the use of psychedelic mushrooms in medical settings.

Not So Fast

Many medical professionals and groups, however, remain skeptical, including the American Psychiatric Association, which cites “inadequate scientific evidence for endorsing the use of psychedelics to treat any psychiatric disorder except within the context of approved investigational studies.” A study published last year in the journal Therapeutic Advances in Psychopharmacology cited publication bias, holes in the approval process, insufficient data, and a lack of empirical evidence.

The National Institutes of Health recently analyzed currently registered psychedelic studies in the American Drug Trial Registry, and concluded that “it is evident that many of these studies are still in their infancy. Many researchers are still facing the challenge of first establishing the safety of hallucinogenic drugs.”

Other studies, however, have shown psilocybin’s promise. Research from Baltimore’s Johns Hopkins University has signaled that the compound can reduce conditions such as depression and anxiety, as well as ease smoking addiction. And similar to ketamine, it may be able to help promote neuroplasticity, or the brain’s ability to change. But magic mushrooms on their own aren’t a wonder drug. The benefits of psychedelics are more achievable when paired with professional and behavioral intervention.

“If the state is going to get involved in potentially increasing access to psilocybin,” Sackett says, “then the question remains, who should have access to it and is it safe for a broader patient population?”

Ketamine has been marketed in the U.S. since the 1970s as an injectable, short-acting anesthetic. In 1999, ketamine became a Schedule III non-narcotic substance under the Controlled Substances Act, and in 2019, the FDA approved the use of certain versions of ketamine for treatment-resistant depression available only at a certified doctor’s office or clinic.

Two kinds of ketamine treatments are available for depression, both of which SeattleNTC offers: IV-administered ketamine and nasal esketamine. Additionally, SeattleNTC offers ketamine-assisted psychotherapy, in which a patient engages in therapy sessions while using ketamine.

“The model of psychedelic assisted therapy is that you’re taking the person and letting them take the lead,” says Suzanna Eller, SeattleNTC’s director of psychotherapy services. “The goal is for them to take all of their inner knowledge, and then lead themselves eventually to healing.”

This kind of treatment provides an alternative for those that haven’t found success with traditional medications — which happens more often than not. One study from the Cleveland Clinic Journal of Medicine found that only around a third of patients find that their symptoms decrease after their first antidepressant medication. For those that don’t find relief after the first medicine, other conventional prescription medications were found less likely to work on subsequent tries.

While these medications can be a lifesaver for patients who aren’t able to ease their conditions, Eller warns that psychedelics aren’t all sunshine and rainbows. Using these treatments recreationally comes with serious risks, especially if you already have certain conditions or have a family history of some psychotic disorders.

A proper environment is one of the most important factors in avoiding a so-called bad trip — or, as Eller calls it, a “challenging experience.” In a therapeutic setting, the patient can avoid any risks that may come with being in the wrong setting, with the wrong people, or taking too large of a dose. Instead, patients have several sessions of preparatory work to build rapport with their therapist and understand their fears, creating a “safety net” during the treatment to navigate thoughts and emotions.

“There has been so much hype around psychedelics that there are people who are thinking this is the answer to everything,” Eller notes. “A big part of what most people experience when they experience a bad trip with recreational use is usually from having been in a bad setting.”

Slow Progress

Though ketamine remains the current FDA-approved standard for psychedelics in therapeutic contexts, research into psilocybin and MDMA (colloquially known as ecstasy) are revealing even more opportunities for treatment. “While ketamine is a great tool, it’s likely that some of these other medicines can provide longer-lasting benefits,” Eller says.

A Food and Drug Administration advisory panel in June voted overwhelmingly against approving MDMA for use in treating post-traumatic stress disorder. MDMA sits at Schedule 1, which the Drug Enforcement Administration defines as “drugs with no currently accepted medical use and a high potential for abuse.” The FDA will make a final decision in August. Approving the use of MDMA would make it significantly easier to research the compound, as well as decrease criminal penalties for possession.

“I suspect strongly that the use of psychedelics in a therapeutic context will continue,” Sackett says. “I think there is enough of a need that psychedelics are here to stay. I think the big question is how to optimize those treatments to get the best effects over time.”

That seemingly slow progress, however, must make up for decades of lost time. In 1970, The Richard Nixon-era Controlled Substances Act and the War on Drugs significantly impeded access to psychedelics, labeling substances like psilocybin, LSD and MDMA as Schedule 1 in the first place. Getting permission to study these substances was nearly impossible, says Dr. Sunil Aggarwal, co-founder and co-director of the AIMS Institute in Seattle. That effectively halted research into their benefits for two decades.

“There was a lot of fear and scare tactics,” he says, “and it was unfortunate because there was a lot of research potential that was lost.”

Even though research picked up again in the 1990s and has since accelerated, gaining access to psychedelics still comes with significant barriers. Aggarwal is currently trying to get patients of his palliative care practice access to psilocybin via state and federal Right to Try laws, which allow patients with terminal or life-threatening conditions access to certain drugs before they have been approved by the Food and Drug Administration. Aggarwal’s request was denied by the DEA, claiming he can only access the drugs as a researcher, but he is appealing the decision in the Ninth Circuit Court of Appeals.

Stigma and misconceptions of these substances also make it difficult for many to think of psychedelics as more than just party drugs. The War on Drugs of the 1970s cemented the idea that psychedelics are dangerous and addictive, despite the fact that studies had previously shown the opposite, he adds.

The residual has lasted decades, Sackett notes, leading many to dismiss these forms of treatment. “Unfortunately, there is a large portion of the population that doesn’t fully appreciate that all drugs are not created equal, or that a drug is very context dependent,” he says.

One of the biggest misconceptions, however, is that these drugs have no real advantages at all. The benefits of psychedelics extend far beyond the trip itself. As Aggarwal says, “It will stay with you longer than just that afterglow.”