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Inclusion of People of Color in Psychedelic-Assisted Psychotherapy

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Michaels et al. BMC Psychiatry (2018) 18:245

https://doi.org/10.1186/s12888-018-1824-6

  • RESEARCH ARTICLE
  • Open Access

Inclusion of people of color in psychedelicassisted psychotherapy: a review of the literature

Timothy I. Michaels1* , Jennifer Purdon1,2, Alexis Collins1 and Monnica T. Williams1,2

Abstract

Background: Despite renewed interest in studying the safety and efficacy of psychedelic-assisted psychotherapy for the treatment of psychological disorders, the enrollment of racially diverse participants and the unique presentation of psychopathology in this population has not been a focus of this potentially ground-breaking area of research. In 1993, the United States National Institutes of Health issued a mandate that funded research must include participants of color and proposals must include methods for achieving diverse samples. Methods: A methodological search of psychedelic studies from 1993 to 2017 was conducted to evaluate ethnoracial differences in inclusion and effective methods of recruiting peopple of color. Results: Of the 18 studies that met full criteria (n = 282 participants), 82.3% of the participants were non-Hispanic White, 2.5% were African-American, 2.1% were of Latino origin, 1.8% were of Asian origin, 4.6% were of indigenous origin, 4.6% were of mixed race, 1.8% identified their race as “other,” and the ethnicity of 8.2% of participants was unknown. There were no significant differences in recruitment methodologies between those studies that had higher (> 20%) rates of inclusion. Conclusions: As minorities are greatly underrepresented in psychedelic medicine studies, reported treatment outcomes may not generalize to all ethnic and cultural groups. Inclusion of minorities in futures studies and improved recruitment strategies are necessary to better understand the efficacy of psychedelic-assisted psychotherapy in people of color and provide all with equal opportunities for involvement in this potentially promising treatment paradigm.

Keywords: Psychedelic-assisted psychotherapy, Ethnic differences, Minority recruitment, People of color

Background

The promise of psychedelic medicine

healing practices has been covered elsewhere [2], understanding its roots within the historical origins of
The use of altered or non-ordinary states of conscious- psychedelic-assisted psychotherapy serves as an imness for medicinal purposes is neither novel nor modern, portant reference point, given that modern psychebut rather dates back thousands of years to the spiritual delic medicine has struggled to include marginalized practices of indigenous communities across the world. communities, especially people of color, in this moveFor indigenous peoples, psychedelic use is considered a ment, and is only now beginning to acknowledge the both a sacred and healing act, that requires the guidance importance of their inclusion [3–5].

  • of a highly trained spiritual leader (shaman), and entails
  • Western medicine’s exploration of psychedelics for

psychoactive rituals that bring humans closer to the treatment purposes can be divided into two distinct spiritual world, in an effort to treat both physical and periods, with the first occurring between 1950 and 1985 spiritual ills [1]. While the full history of indigenous (herein referred to as the “first wave,”), when synthetic psychedelic compounds were just being discovered, and the second (herein referred to as the “second wave”) beginning around the late 1990s and continuing to this day [6]. This periodic distinction has been observed by

* Correspondence: [email protected]

1Department of Psychological Sciences, University of Connecticut, Bousfield Psychology Building, 406 Babbidge Road, Unit 1020, Storrs, CT 06269, USA Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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others The “rediscovery” of psychedelics as medicine by promising findings have often been limited to small, preWestern science first occurred during a period in which dominantly White samples, limiting the generalizability of biomedical therapeutic interventions in psychiatry were findings and excluding people of color from potential limited, as psychopharmacology had not yet become therapeutic benefits. Beyond a broad lack of representamainstream practice [7]. Newly synthesized psychedelics tion of people of color in psychedelic-assisted psychotherwere not considered controlled substances, and therefore apy studies, the conceptualization of psychopathologies their clinical and research use was relatively unrestrained. rarely include important cultural considerations such as Given that psychoanalysis was a mainstay of treatment, ini- the importance of including race-based trauma when tial research on psychedelic medicine examined whether recruiting participants of color for MDMA-assisted psypsychedelic drugs could facilitate the process of psycho- chotherapy for PTSD [24]. In the United States, this lack therapy, thereby accelerating the treatment process of psy- of inclusion goes directly against federally mandated efchological disorders [8]. Yet ultimately, the combination of forts to report and recruit diverse samples in clinical trials.

  • widespread use of these substances, serious ethical viola-
  • The following study aims to provide a comprehensive

tions (i.e., administration to physically-restrained subjects, review of inclusion and recruitment across ethnic/racial sexual abuse between therapists and clients), major meth- groups in current (1993-present) psychedelic-assisted psyodological flaws, and concerns over safety led to defunding chotherapy studies, in an effort to characterize the scope of research and ultimately the scheduling of psychedelics and importance of this issue while identifying areas for as controlled substances [8, 9]. While many researchers growth. To provide the necessary context around these isand subjects continued to espouse the therapeutic benefits sues, we first review the prevalence and presentation of of psychedelic-assisted therapy for the treatment of depres- psychopathology in people of color and the importance of sion, addiction, and other disorders, this area of investiga- cultural considerations in the design and implementation

  • tion lay dormant for several decades.
  • of clinical trial research. Upon reporting findings on the

Several important factors contributed to the resur- rates of inclusion and recruitment strategies in psychedelic gence of psychedelic medicine in the late 1990s follow- studies, we conclude by summarizing current efforts to acing a several decade-long hiatus. Instead of launching knowledge diversity issues in the field and provide considinto therapeutic investigations, early research during the erations for future directions. second wave consisted of pre-clinical animal and basic science studies that were carefully conducted to establish

Prevalence of psychological disorders across people of

the pharmacological properties and safety of these color substances [2, 8]. With the creation of the Multidiscip- Population-level prevalence rates of psychopathology are linary Association of Psychedelic Studies (MAPS), a often underestimated in people of color [25], and varinon-profit pharmaceutical organization, by Rick Doblin ability between studies can be driven by differences in 1986, researchers were no longer reliant upon govern- across age groups, in socio-economic status, and in ment funding and could pursue FDA drug development study sampling methodologies [26]. Yet converging evi[10]. The medicinal potential for scheduled substances dence suggests that in the US, people of color experiwas also no longer novel, given that research into the ence psychological distress at a rate equal to and healing properties of both cannabis [11, 12] and keta- sometimes higher than non-Hispanic Whites. For inmine [13] had been underway since 1975. Coupled with stance, the lifetime prevalence of PTSD in Black Amerithe fact that many psychiatric illnesses still lacked effect- cans is 8.03%, which is higher than the prevalence rate ive pharmacological treatment, these factors paved the in Hispanic/Latino Americans (5.59%), Asian Americans

  • way for the second wave of psychedelic research.
  • (1.84%), or Non-Hispanic Whites (6.45%) [27].

  • Recent renewed interest in psychedelic-assisted psycho-
  • While the lifetime prevalence of substance dependence

therapy has benefited from avoiding the mistakes of the (drug and alcohol) in Hispanic Americans is comparable past by focusing explicitly on ethical, methodological and to the prevalence in Black Americans, the rate of Generclinical safety issues. It has also taken a careful and gradual alized Anxiety Disorder (GAD) of 5.89% is higher than approach to re-introducing this controversial area of any other ethnic group, with the exception of study, working closely with regulatory bodies and federal non-Hispanic Whites [27]. Notably, there are some disagencies [10]. Indeed, initial results from second-wave orders for which Hispanics are at a relatively lower risk, (2000-present) psychedelic research has demonstrated the including dysthymia, oppositional-defiant disorder, and efficacy of psilocybin [14–16] for the treatment of depres- attention deficit hyperactivity disorder [28].

  • sion, addiction, and OCD, LSD [14, 17–19] in the treat-
  • Although Asian Americans generally report lower life-

ment of depression, anxiety, and substance use, ayahuasca time prevalence rates for most psychological disorders [20, 21] for the treatment of depression and addiction, and [29], a recent study reported that they experience OCD MDMA [22, 23] in reducing trauma symptoms. Yet these at a similar rate to Black Americans [30]. For Asian

Michaels et al. BMC Psychiatry (2018) 18:245

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Americans, the lifetime prevalence of experiencing a se- color, likely contribute to difficulties in generalizing clinvere depressive episode is also comparable to that for ical trial design and recruitment. Race-based trauma and

  • Black Americans [31].
  • PTSD symptoms provides an especially relevant example

Despite adequate data on the lifetime prevalence of psy- of the unique factors related to the pathogenesis of psychopathology in Black Americans, there remain discrep- chopathology in people of color and well as diverse clinancies in accurate diagnosis that further reinforce barriers ical presentations that are often not considered by to treatment. Although several studies report similar life- clinicians and researchers. Microaggressions are forms of time prevalence rates of OCD between non-Hispanic aversive racism that, whether intentional or not, commuBlacks and other ethnic groups [28, 30, 32], the diagnosis nicate hostile or negative racial biases and insults to a is often missed during structural clinical interviews, redu- target person or group [42, 43]. These racial slights may cing enrollment in treatment trials [33–35]. For Black be perceived as harmless, but they are considered a form Americans the issue of appropriate diagnosis and recruit- of everyday discrimination and racism that induce emoment extends to anxiety disorders as well [36] and despite tional and traumatic stress responses in those afflicted. In similar lifetime prevalence rates of a major depressive epi- a study of Latinos, traumatic stress responses were the sode in Black Americans [37] compared to Non-Hispanic mechanisms by which microaggressions contributed to White Americans [28], there are large disparities in treat- symptoms of depression and anxiety [44]. Discrimination

  • ment attrition rates [38].
  • is also associated with increased anxiety, affective, and

Overall, it is evident that people of color experience substance abuse disorders among African Americans, significant rates of psychological distress comparable to Hispanic Americans, and Asian Americans [45]. Exposure non-Hispanic whites, and furthermore experience sig- to race and ethnic based discrimination is related to innificant barriers to treatment that likely increase the risk creased lifetime prevalence of generalized anxiety disorder for long-term negative outcomes. It is therefore critical in African Americans [46]. Yet despite the common conthat novel treatment paradigms include minorities in all tribution of racism to PTSD symptomatology across stages of research thereby improving our understanding people of color, it would be a mistake to assume equivaof efficacy in people of color and improves changes of lency in clinical presentation, as recent studies have

  • treatment effectiveness in the community.
  • highlighted important differences in how individuals of

varying ethnicities response to traumatic experiences [47]. For these reasons, it is important for psychedelic research

Symptom presentation in people of color

The unique clinical presentation of mental illnesses in to address the relevance of ethnic and race-based trauma people of color is often overlooked in the hegemonic, symptoms in relation to mental illnesses across different White U.S. mental health care system. This may be due, in ethnoracial groups. The invalidation and avoidance of part, to long-standing social and economic barriers to psy- racial-cultural issues by clinicians has had detrimental chological treatments for minorities [39, 40] and a shameful consequences on relationships between mental health history of the medical establishment subjecting minorities practitioners and their patients or clients of color [48].

  • to significant harm as a direct result of medical research
  • The role of ethnic identity is another important factor

participation [41]. For instance, one study reported that the that often ignored in mental health care settings. Low ethunderutilization of mental health services by undocu- nic identity in African Americans has been linked to poor mented Latinos exposed to intimate partner violence (IPV) self-esteem, problems with adjustment, poor achievement, can partially be explained by common healthcare barriers delinquency, eating disorders, and substance abuse [49, 50]. among immigrants, including language, insurance, eco- Although African Americans report a significantly stronger nomic barriers, and documentation status (Perez and For- ethnic identity than European Americans [49], there are tuna 2005). The impact of these factors cannot be still many cultural and systemic barriers that limit access to understated when attempting to reconcile the great need mental health care and lead to the underutilization of these for targeted mental health treatment for people of color services in the African American community. Given the and low rates of engagement with the mental healthcare above, it is not only crucial that mental health providers system. While a full discussion of these factors is beyond examine the relationship between race and ethnic based the scope of this review, and has been covered extensively discrimination and psychopathology but also incorporate elsewhere [39–41], it provides a framework for considering an understanding of and explicit discussion of ethnic barriers to recruitment in psychedelic science research and identity in conceptualization and treatment. for the importance of incorporating culturally specific conceptualizations of clinical presentation.

Mandate for inclusion

Both such external constructionist factors and intrinsic In order to ensure that ethnic and racial minorities are factors, such as differences in the manifestation and clin- adequately represented in research studies in the United ical presentation of psychological symptoms in people of States, Congress passed the NIH Revitalization Act of

Michaels et al. BMC Psychiatry (2018) 18:245

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1993, which mandates that minorities and women be in- Methods cluded in representative numbers for all studies con- Definition of psychedelics ducted or supported by the NIH [51]. The Act states Within the field of psychedelic science, there remains that not only must recruitment be conducted in manner much debate regarding how to define what constithat is fair to persons from ethnic/racial minority tutes a “psychedelic” drug; differing definitions have groups, and they must be included in studies unless important implications for the plants and compounds there is clear scientific evidence ruling out important under clinical investigation. One common approach in declinical or public health importance for their inclusion fining psychedelic compounds is based on these substances’ [52, 53]. By 1995, the NIH refused to fund any project neurobiological mechanism of action. Using this approach, that did not adhere to such policies and required grant psychedelics are generally categorized into two broad proposals to include strategies by which to achieve diver- chemical classes: indolamines, such as psilocybin, DMT sity in their samples. Following the 1993 act, diversity in and LSD, which primarily act on monamine neurotransmitNIH clinical research has increased on an absolute basis, ters such as serotonin (5-HT), and phenylalkylamines, such from approximately 1 million minority participants in as MDMA and mescaline, that derive their name from their 1995 to almost 15 million in 2016. Yet on a relative action on calcium channel blockage [55, 56]. basis, participation rates for people of color have been relatively stagnant, representing 36.7% of all enrollment unique behavioral effects of these drugs. Behavioral in 1995 and 37.2% of all participants in 2016 [51, 54]. Pattern Monitor (BPM) studies in rats have shown that
A second approach to classification relies on the
While these guidelines do not apply to research psychedelics exhibit a distinguishable profile of behavfunded outside the NIH, and many psychedelic studies ioral effects analogous to the enhanced sensitivity and conducted in the USA are privately funded, the NIH reactivity to environmental stimuli that occurs in mandate reflects the importance of this issue and should humans [55]. For instance, results from a recent study serve as a benchmark for non-government funded re- on psychopathological, neuropsychological and personalsearch within the US. To our knowledge, there are no ity differences between regular ayahuasca users and consimilar mandates from government funding institutions trols showed that individuals using ayahuasca regularly in countries outside the United States. Yet given the im- scored significantly higher on self-report measures of portance of inclusion in clinical research, the prevalence self-transcendence, and demonstrated increased cogniof psychological disorders in other cultures, and mental tive enhancement when matched with controls [57].

  • health inequities that exist in all industrialized nations,
  • Yet others [10] have argued that limiting the term psy-

we believe that the NIH mandate should serve as an chedelics to the above definitions excludes certain sub-

  • international standard.
  • stances, such as cannabis and ketamine, that subjectively

induce “hallucinogenic” effects and are believed to have medicinal and clinical benefits [11, 13]. For the purpose

Purpose of present investigation

The authors of this investigation sought to determine the of the present investigation, the term psychedelic is limrates of inclusion for people of color in psychedelic-assisted ited to compounds that primarily exert their effects psychotherapy studies by conducting a review of such through 5-HT agonist. These compounds are not only literature from 1993 to 2017. Our objective was to deter- similar from a neurobiological perspective but also are mine if the existing data on psychedelic treatments was suf- also most consistently utilized in psychedelic-assisted ficient to generalize to all people of color. Furthermore, psychotherapy, whereas other substances, such as cannagiven differences in the manifestation and clinical presenta- bis and ketamine, not only differ substantially in their tion of psychological symptoms in people of color, we were psychopharmacology, but can exert clinical benefits also interested in whether rates of inclusion reflected differ- without a psychotherapy component. ences in recruitment methodology or in how pathology was conceptualized in the relevant research. Although the stud- Selection of studies for inclusion ies reviewed herein were conducted in many different We performed a thorough and extensive search for studcountries, each with their own important histories related ies that utilized a psychedelic substance either alone or to historical disenfranchisement, oppression, and people of in conjunction with psychotherapy in the treatment of a color representation, we believe the importance of ethnora- psychological disorder. For the purpose of the present cial diversity in psychological research writ-large and their study, psychological disorder was defined as any condiinclusion in psychedelic science specifically transcends na- tion included in Axis 1 of the Diagnostic and Statistical tional boundaries. In providing recommendations going Manual of Mental Disorders IV Text Revised forward, we note the need for considering country-level (DSM-IV-TR) or the International Statistical Classificadifferences in conducting research that will likely impact tion of Diseases and Related Health Problems 9th edi-

  • issues of inclusion.
  • tion (ICD-9) equivalent. When applicable for more

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    SEPTEMBER 2017 | WWW.THE-SCIENTIST.COM HEALING WITH HALLUCINOGENS THE THERAPEUTIC BENEFITS OF PSYCHEDELIC DRUGS DO MICROBES TRIGGER ALZHEIMER’S? THE FUNCTIONAL CONSEQUENCES OF DNA BASE MODIFICATIONS TAKING KIDS TO CONFERENCES PLUS WEANING STEM CELLS FROM FEEDER LAYERS NUMBER ONE FOR: DEPENDABILITY DATA INTEGRITY EASE OF USE No other name is as trusted as BioTek to bring you affordability without compromising performance. Learn more. Visit www.biotek.com/readerwasher. ISO certified and FDA registered for highest quality standards. REGISTER FOR FREE TO RECEIVE The Scientist’s website OUR DAILY E-NEWSLETTER features award-winning life science news coverage you won’t fi nd in the magazine, as well as features, profi les, scientist-written opinions, and spectacular videos, slide shows, and infographics. www.the-scientist.com be INSPIRED drive DISCOVERY stay GENUINE Even more from less for RNA. ® ™ NEBNext Ultra II RNA NEBNext Ultra II Directional RNA produces the highest yields, Library Prep Kits for NGS from a range of input amounts 2,000 NEBNext® Ultra™ II Directional RNA ® 1,800 Kapa Stranded Kapa HyperPrep Do you need increased sensitivity and specificity ® ® 1,600 Illumina TruSeq Stranded from your RNA-seq experiments? Do you have 1,400 ever-decreasing amounts of input RNA? Our new 1,200 (ng) 1,000 NEBNext Ultra II RNA kits are optimized for low Yield 800 ng to µg inputs, have streamlined, automatable Total 600 workflows and are available for directional (strand- 400 specific, using the “dUTP method”) and non- 200 0 directional library prep. Compatible with poly(A) PCR Cycles 9 13 16 mRNA enrichment or rRNA depletion, the kits are Total RNA Input 1 µg 100 ng 10 ng ® available with the option of SPRISelect beads for Poly(A)-containing mRNA was isolated from 10 ng, 100 ng and 1 µg of Universal Human size-selection and clean-up steps.
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    1521-0081/68/2/264–355$25.00 http://dx.doi.org/10.1124/pr.115.011478 PHARMACOLOGICAL REVIEWS Pharmacol Rev 68:264–355, April 2016 Copyright © 2016 by The American Society for Pharmacology and Experimental Therapeutics ASSOCIATE EDITOR: ERIC L. BARKER Psychedelics David E. Nichols Eschelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina Abstract ...................................................................................266 I. Introduction . ..............................................................................266 A. Historical Use . ........................................................................268 B. What Are Psychedelics?................................................................268 C. Psychedelics Can Engender Ecstatic States with Persistent Positive Personality Change . ..................................................................271 II. Safety of Psychedelics......................................................................273 A. General Issues of Safety and Mental Health in Psychedelic Users.......................275 B. Adverse Reactions . ..................................................................276 C. Hallucinogen Persisting Perception Disorder . ..........................................277 D. N-(2-methoxybenzyl)-2,5-dimethoxy-4-substituted phenethylamines (NBOMe) Compounds............................................................................278 Downloaded from III. Mechanism of Action.......................................................................279
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    Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Yale Medicine Thesis Digital Library School of Medicine 1966 Some effects of lysergic acid diethylamide on visual discrimination in pigeons Daniel I. Becker Yale University Follow this and additional works at: http://elischolar.library.yale.edu/ymtdl Recommended Citation Becker, Daniel I., "Some effects of lysergic acid diethylamide on visual discrimination in pigeons" (1966). Yale Medicine Thesis Digital Library. 2386. http://elischolar.library.yale.edu/ymtdl/2386 This Open Access Thesis is brought to you for free and open access by the School of Medicine at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Yale Medicine Thesis Digital Library by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. YALE MEDICAL LIBRARY Digitized by the Internet Archive in 2017 with funding from The National Endowment for the Humanities and the Arcadia Fund https://archive.org/details/someeffectsoflysOObeck i’f SOME EFFECTS OF LYSERGIC ACID DIETHYLAMIDE ON VISUAL DISCRIMINATION IN PIGEONS by DANIEL 1. BECKER A Thesis Presented to the Faculty and the Officers of the Yale University School of Medicine in partial fulfillment of the requirements for the degree of Doctor of Medicine September 1966 Department of Psychiatry Yale University School of Medicine ACKNOWLEDGEMENTS The author gratefully acknowledges his debt to Dr. James B. Appel and Dr, Daniel X, Freedman. Dr. Appel's continual contributions of instruction, guidance and encouragement were invaluable. The experiments were conducted under his supervision In the Psychopharmacology Laboratory, Departments of Psychiatry and Pharmacology.
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    VU Research Portal High Resolution Screening of biologically active compounds and metabolites Kool, J. 2007 document version Publisher's PDF, also known as Version of record Link to publication in VU Research Portal citation for published version (APA) Kool, J. (2007). High Resolution Screening of biologically active compounds and metabolites. General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ? Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. E-mail address: [email protected] Download date: 10. Oct. 2021 High Resolution Screening of biologically active compounds and metabolites High Resolution Screening of biologically active compounds and metabolites Jeroen Kool The financial support of Merck Research Laboratories, Organon, the Jurriaanse Stichting and Bester for the publication of this thesis is gratefully acknowledged. Printed by Printpartners Ipskamp Cover: designed by Steven Straatemans and Jeroen Kool © Jeroen Kool, Beverwijk 2007, All rights reserved. No part of this thesis may be reproduced in any form or by any means without the prior written permission from the author.