How Dr. Tanmeet Sethi uses Psychedelic Medicine to Help Depression, Anxiety, and PTSD

What is Psychedelic Medicine and how does it work?

Wow! The Nettle Witch, MD has welcomed a lot of new subscribers in the past couple weeks. I’m thrilled. Welcome! And thank you so much to those who have been sharing these articles! I wanted to take a moment to orient you to what we do here. The first Tuesday of the month, I write an in-depth profile of a plant. The second Thursday of the month, we recently started Lectio Sweetgrass, a contemplative group discussion. The rest of the time, I share an eclectic mix of writing about medicine, spirituality, and occasionally throw in a few storytelling videos. I’m glad you’re here!

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On August 9, the FDA released its decision regarding the use of MDMA for use in psychotherapy for patients with post-traumatic stress disorder. They didn’t grant their approval and requested more clinical trial research regarding MDMA’s safety and efficacy. Jennifer Mitchell, a neuroscientist at University of California-San Francisco, who led the phase III clinical trials, said, ““From my perspective, I thought we met the criteria that the FDA requested, and I absolutely stand by our data.”

Tanmeet Sethi, MD

, a psychedelic medicine physician, who I am interviewing today, agrees, “This was very disappointing. [There was] so much hope in the community behind this positive decision and now this is a big setback. But we will have to keep moving forward and also, I think people want to know what they can safely try in the meantime.” 

I have been curious about psychedelics from an emotional and spiritual health perspective for quite a while, but I also came of age in the era of fried egg commercials and D.A.R.E. classes, so I have felt some resistance to experiencing it first hand. When I met Dr. Sethi and learned that she is a physician practicing psychedelic medicine, I had a lot of questions. She graciously agreed to answer them and let me share them with you. 

AW: What is psychedelic medicine? 

TS: I wouldn’t say there is an official definition of psychedelic medicine but in general, there is agreement that it is the use of a class of medicine that has the primary effect to alter mood, mental states and through these non-ordinary states, sometimes shift a person’s consciousness as well. 

AW: What do you do in an appointment with a psychedelic medicine doctor? 

TS: The critical part of this type of medicine is fundamentally different than most of conventional western medicine in that it is not just ingesting a medicine. There is accompanying preparation and then subsequent integration that the patient does with the provider. It’s not just “popping a pill” so to speak. In fact, it’s been shown that this entire process is what makes it so impactful for an individual.

If you saw a physician like myself who practices psychedelic medicine, you would have a series of appointments. You would get a full medical and psychiatric evaluation to ensure there are no contraindications to taking these medicines. The only federally legal medicine in this class is ketamine at this time. Some states have varying legality around psilocybin so there is less choice at this time of which psychedelic medicine to use but in the future, that will be part of the process, choosing the best one for the patient. Then you would have at least one preparation session to process the patient’s intentions around this process, discuss any fears they might have and review what the journey will be like logistically as well as the experience itself so the patient has some idea of what to expect.

You would have a facilitated journey with the medicine and your physician by your side. For ketamine, the journey lasts about 45-90 minutes but the whole appointment would be around 2 ½ hours. At some time in the subsequent 24-72 hours usually when neuroplasticity is at its peak with the medicine, you would have an integration session to process what happened in the journey. This is where the ‘magic’ really happens. This is similar to therapy and is called psychedelic-assisted therapy. It’s a process in which I help guide patients to their wisdom and meaning from the process so that they can integrate this learning into their daily life.

AW: How much of the benefit is due to the chemical action of psychedelics themselves, versus the focused attention and meaning making of the therapeutic relationship you build? For example, I love plant spirit medicine and I can imagine that having the focused attention and meaning making help of a trained professional could be very therapeutic.

TS: This is such a good question and honestly hard to answer other than with opinion. I say that because there aren't studies of using the medicines without trained guides. That would be an interesting study to compare with and without but not ethical in terms of study setup. My personal opinion is it makes a huge difference. For one, your intention and mind/heart set going in has a large impact on any treatment but especially one like this that can be so shifting. Also the guides themselves matter. If you have someone who is well trained in how to integrate the experience and sets up a safe, therapeutic relationship, you are going to be more likely to let your mind relax its protective mechanisms and go deeper in the journey.

AW: What are the benefits of psychedelic medicine? 

TS: The benefits that are studied most in psychedelic medicine center around depression, anxiety, PTSD and suicidal ideation. But there are studies in various conditions like OCD, disordered eating, burnout, end of life care and existential acceptance of death in terminal disease.

AW: What are the risks of psychedelic medicine? 

TS: Risks are present. There are some risks with some of the medicines for higher blood pressure for example which is why patients need to be screened. The risk for psychosis is also present for certain individuals with a predisposition to that. Each medicine has its own set of risks and that’s why it’s important to undergo this with someone well trained.

AW: What kind of training do practitioners receive regarding managing complications of ketamine? As an ER doc, the one that comes to mind is spasm of the airway due to ketamine. 

The ketamine trainings only have a little about this, and many of the people getting trained are not physicians. It is important to have someone who is aware of all complications, in my opinion. 

AW: Who would benefit most from psychedelic medicine? 

TS: Who could benefit is a big question. We think most often of anyone suffering from one of the above mentioned conditions. But many people also explore psychedelics for spiritual growth and existential life questions which is why they have been used recreationally for so long. In this broken system, those are harder to justify because you can’t code them for insurance companies. But I would argue the search for meaning and joy is valid, even if the system doesn’t want to award a diagnosis code. 

AW: What evidence exists for the use of psychedelic medicine? How strong is that evidence compared to other treatments for similar conditions? 

TS: The evidence for psychedelic medicine is strong and growing. The evidence is strongest for depression, anxiety and PTSD. There are even a couple of head to head trials of psilocybin against a traditional antidepressant for example that show its efficacy in comparison, especially when you consider this medicine was taken twice in this trial as compared to a daily antidepressant. 

AW: Do different psychedelic agents produce different therapeutic effects? 

TS: This class of medicines is broad and includes medicines that have very different biochemical pathways such as ketamine, psilocybin, ayahuasca, LSD or MDMA. Some work on classic serotonergic pathways like LSD or psilocybin. Others like ketamine work on different receptors like NMDA. All of them produce a non-ordinary mental state and all work on expanding consciousness. The ‘mystical effect’ of these medicines in fact seems to be one of the most powerful ways they act but it’s also the least understood. 

AW: Could you share an experience you’ve had with ketamine? It’s one thing to hear about from a practitioner and another to hear about the experience itself. 

[Ketamine] is by definition a dissociative substance so often you feel transported outside of your body and have what is similar to the 'ego dissolution' experiences people describe with psychedelics. I think of one of my experiences often. In it, I came to a very frightening tunnel is the best way I can describe it. I felt very cold and could feel myself curling up to stay warm in my actual body as I lay there. I did not want to go further but my guide comforted me and reminded me I was 'in the medicine.' I had seen this place before on a previous ketamine journey and had decided to turn back. But this time I felt safe enough to go forward. It felt very long (time is impossible to measure while in a journey) and cold and scary. But I came through it and was met with the most blissful scene and feeling. It's too hard to describe, but it's as if I opened up to the entire cosmos and felt so held, loved and warm. The stars were almost talking to me. There was music playing which amplified the moment(s). But in the end, it's that bliss I remember often and that it's possible, even in a dark time. So I think of that when I am feeling alone and struggling. Not to dismiss any pain I am having but to remember the potential of what is available to me.

AW: What else do you think it is important for physicians and the general public to know about psychedelic medicine?

I think there’s a lot the public does not know and would be useful to understand.

1. These medicines are relatively safe but taking them with a skilled and trained provider is key. And having appropriate preparation and integration is also critical. I would counsel individuals to respect these medicines and their own bodies and do this safely.

2. These medicines have been known to Indigenous communities since the beginning of time. This is not a new way to heal. It is new to the western world. But never forget the knowledge and wisdom that came from global ancestors. The Western medical world likes to act like they have ‘discovered’ something but knowing the history is important.

3. Many people are scared of these medicines and remember the ‘fried egg on drugs’ analogy from the propaganda of the 70’s. That marketing was steeped in racism and suppression of anti-war protesters. This could be an entire interview in of itself but the Nixon administration has now been open that this was a concerted effort to sustain power. I was stigmatized by that marketing as well but it’s important to learn its roots to unlearn it for yourself. 

I’d like to thank Dr. Sethi so much for her time and wisdom. After hearing her perspective, I think this is a very promising therapy for conditions that are often difficult to treat or incompletely treated by the existing available treatments. I’m looking forward to learning more from her and others. As someone who works with ketamine fairly often to sedate patients for procedures, I am concerned that there is not more formalized and specific training on how to manage complications with ketamine. I think this is an area of growth for the field. 

Ketamine is incredibly safe medication, especially compared to the other medications I use to sedate patients for procedures. I want to emphasize that. Ketamine’s more common side effects (like nausea, vomiting, and agitation), though uncomfortable, are typically not serious. However, some of the rare side effects are very serious, but usually easy to manage if you possess the training, knowledge, and equipment to do so. I think that is where the additional training (especially for non-physicians) would be really beneficial. If you are struggling with depression, anxiety, and/or PTSD, this seems to be a great therapeutic option to explore, and I would recommend asking specifically about what complications occur and how your provider manages them to ensure your practitioner has the experience to monitor your safety during a ketamine journey.   

Have you ever used psychedelics therapeutically? If you’re willing to share your experience I/we’d love to hear about it.