Novel rapidly acting drugs to treat depression and other psychiatric disorders: MDMA

by J.E - Newcastle University

Methylenedioxymethamphetamine (MDMA) is an ingredient in recreational ecstasy and has shown promising results in the management of difficult-to-treat post-traumatic stress disorder (PTSD). It is a Class A, Schedule 1 drug which restricts its use clinically and makes research into it more complicated.

Existing treatments for PTSD include psychopharmacology and psychotherapies. A wide variety of drugs are used- they have a limited efficacy. MDMA has unique psychopharmacological effects. It is reported to reduce the feelings of fear whilst maintaining a clear head. The patient is alert and conscious. MDMA can be administered without evidence of harm to pre-screened patients. The patient can experience 2-4 hours of increased well-being, possible euphoria, sociability increases as does self-confidence and extroversion. The reduction of fear temporarily - without inhibiting access to emotions – can make it effective with psychotherapy.

There have now been a number of studies of using MDMA to assist psychotherapy for PTSD[1] [2-5]. In one of these trials, comparing psychotherapy alone or with MDMA for patients with PTSD, 20-30% of participants did not complete the study for one reason or another. The response rate, if psychotherapy was completed, was 60-95% for those patients receiving just psychotherapy, but 83.3% who received psychotherapy plus MDMA [3]

MDMA is used as an addition to psychotherapy, rather than a stand-alone drug [6]. MDMA is used on one or a few occasions during psychotherapy sessions to overcome obstacles to successful psychotherapy and to improve the therapeutic experience. It is hypothesised that the experience itself, rather than simply the pharmacological effects of the drug, might lead to improvement in symptoms or sustained remission of severe Difficult-to-Treat PTSD. MDMA can enhance inner awareness. Patients often reported deeply meaningful therapeutic experiences with a long term follow up-an increased self-awareness and understanding and enhanced spiritual life. The therapeutic process is not limited to the period of drug effect but continues over time [4].

During MDMA assisted psychotherapy there is a:

• Reduction in avoidance of particular thoughts or issues, and defensiveness
• Clearer memory of past events
• Willingness and ability to process past events

It does not make revisiting traumatic memories easy, but can make it possible for patients who have not been able to process the trauma during months/years of psychotherapy.

MDMA acts on several chemicals called neurotransmitters (specifically serotonin, dopamine, noradrenaline) and also on hormones oxytocin and prolactin. MDMA can also increase interpersonal trust. Patients can revisit traumatic experiences without being overwhelmed by anxiety.

Patients are monitored throughout the session - blood pressure, pulse, and temperature. The session is carried out in a comfortable aesthetically pleasing environment with equipment and drugs and an emergency doctor available to treat any medical emergencies.

The onset of MDMA effects occur after 45-75 mins, reach a peak after 2-2.5 hours, and last for around 4-5 hours.

The most common side effects experienced include:

• Dizziness
• Feeling cold
• Impaired balance
• Nausea
• Tight jaw

These typically resolve over a period of hours/days.

In research studies, the patient is in a safe clinical setting with nurses who do not know if the patient has taken the MDMA or a placebo. The conditions are comfortable and pleasant, and the patient usually remains overnight so any medical emergencies can be treated. Generally, Borderline Personality Disorder and bipolar disorder type 1 are excluded from research studies.

Currently, MDMA assisted psychotherapy for PTSD is still primarily only being used in research studies. It is not routinely available in the UK on the NHS.

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