Evaluating the Feasibility, Safety and Efficacy of Psychotherapy Assisted Psilocybin for Treatment of Severe OCD

Background and research rationale:

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder characterized by recurrent distressing thoughts and substantial anxiety, accompanied by repetitive behaviours or mental rituals performed to control or alleviate this anxiety. Individuals with OCD often have diminished quality of life, functional impairment , and cause substantial caregiver burden and personal and societal economic costs. Lifetime prevalence of OCD ranges between 1.9%-2.5%, with patients often not responding to the offered pharmacological or psychological treatment, and in extreme cases may even undergo neurosurgical interventions.

There are several possible physiological mechanisms leading to the development of OCD, which may indicate several possible effective treatment options. Nowadays there is a consensus that the dopaminergic and serotonergic pathways are central to the development of the disorder with the basal ganglia as the main area of its origin. Other brain areas involved in OCD are the orbitofrontal cortex and anterior cingulate cortex which are connected to the basal ganglia and are involved in regulating attention and awareness. Abnormal activity between these areas and other subcortical areas might explain why normally unconscious information processing, becomes consciousness, and requires additional resources for its regulation. It has also been suggested that the aversive emotional activity (anxiety, fear, disgust) experienced in OCD, relates to hyperactivity in the amygdala. The momentary relief brought on by the compulsive behaviour forms a positive feedback which perpetuate the disorder.

The gold standard of care for OCD today is a combination of selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT). Most patients will experience at least some symptomatic relief with these interventions; however, relapse of symptoms occur in 40%-60% of patients and around 25% of patients are unresponsive to treatment . Other existing treatments (either pharmacological or neurosurgical) possess a higher risk for serious side effects. It is important to note that even for those patients who are responsive to treatment there are still significant residual, impairing symptoms. It thus seems that there is a real and immediate need to explore new alternative options for the treatment of OCD that can widely and continuously benefit patients, with lower risk and fewer side effects.

A new and promising prospect of treatment in mental health is the use of psychedelic substances, which interact with the serotonergic pathways and induce a powerful subjective experience with the potential for psychological transformation. Specifically, psilocybin has received attention in research as a promising alternative in the treatment of severe mental illness. Psilocybin is a prodrug which is quickly converted by the body to psilocin (4-OH-dimethyltryptamine), a 5-HT2A receptor partial agonist. Both psilocybin and psilocin, which have psychoactive properties, are naturally occurring in Psilocybe mushrooms and are structurally similar to the endogenous neurotransmitter serotonin.

As a direct 5-HT2A agonist, psilocybin has a unique therapeutic potential compared with other pharmacological treatment for OCD such as SSRIs. Animal studies have shown increased cognitive flexibility, associative learning, cortical plasticity, and anti-depressive effects in response to 5-HT2A activation.

The first current clinical research with psilocybin examined the safety and efficacy of psilocybin in the treatment of psychological distress in patients with terminal advanced-stage cancer. The double-blind, placebo-controlled research was conducted in the Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center (Torrance, California). Researchers concluded that psilocybin is safe and well tolerated at 0.2 mg/kg dose.

Following this research two different research groups, in Johns Hopkins University, and in New York University, have received FDA approval to administrate a higher dose of psilocybin in a similar clinical population. These trails have shown promising results for safety, psychological distress reduction, and significant improvement in anxiety and depression.

In their research, Griffiths and colleagues, examined the efficacy of psilocybin in reducing anxiety and depression in 51 patients suffering from a terminal end-stage cancer and experiencing symptoms of anxiety and depression. This randomized, double-blind, cross-over trial investigated the effects of a very low (placebo-like) dose (1 or 3 mg/70 kg) vs. a high dose (22 or 30 mg/70 kg) of psilocybin. No serious adverse events attributed to psilocybin administration occurred. There were transient moderate increases in systolic and/or diastolic blood pressure after psilocybin (in 34% of participants in the high-dose session and 17% of participants in the low-dose session), none of these episodes met criteria for medical intervention. Nausea or vomiting occurred in 15% of participants in the high-dose session. An episode of physical discomfort (any type) occurred in 21% of participants in the high-dose session and 8% in the low-dose session. Psychological discomfort (any type) occurred in 32% of participants in the high-dose session and 12% in the low-dose session. An episode of anxiety occurred in 26% of participants in the high-dose session and 15% in the low-dose session. One participant had a transient episode of paranoid ideation (2% of high-dose sessions). There were no cases of hallucinogen persisting perception disorder (HPPD) or prolonged psychosis. Across the two dose sequence groups, the overall rate of clinical response at 6 months was 78% and 83% for depression and anxiety, respectively, and the overall rate of symptom remission at 6 months for all participants was 65% and 57%, respectively.

Ross and colleagues conducted a double-blind, placebo-controlled, crossover trial, with 29 patients with cancer-related anxiety and depression that were randomly assigned and received treatment with single-dose psilocybin (0.3 mg/kg) or niacin (active placebo), both in conjunction with psychotherapy (before and after drug administration). The most common adverse effects were non-clinically significant elevations in blood pressure and heart rate (76%), headaches/migraines (28%), nausea (14%), transient anxiety (17%), and transient psychotic-like symptoms (7%). The medical and psychiatric adverse effects attributable to psilocybin are all known, were transient, and tolerable. There were no cases of prolonged psychosis or HPPD, and no participants required psychiatric hospitalization. Psilocybin produced immediate, substantial, and sustained improvements in anxiety and depression, this effect was sustained at 6.5 months follow-up.

These trails and others have shown safety of treatment and high efficacy in reduction of anxiety and depression symptoms with sustained effect at 6 months follow up. These findings taken together with the theoretical understanding of psilocybin mechanism of action and with the understanding of the neuro-psychological pathology of OCD, encourage investigating the potential of psilocybin as a novel significant treatment for this disorder. Research of beneficial effects of psilocybin for patients with OCD is in its infancy, but preliminary findings show potential efficacy in treatment of the disorder.

Matsushima and colleagues, used a mice model for OCD and found that psilocybin (both syntactic and in mushroom form), significantly inhibited compulsive behaviour (marble burying) without affecting locomotor activity. In addition, several case reports showed beneficial effects of psilocybin for people with OCD. For example, Leonard and Rapoport (1987) and Moreno and Delgado (1997) reported that among drug-users with OCD, there was a worsening of symptoms under the influence of cocaine, but a remission of symptoms for hours/ days following psilocybin use. Wilcox (2014) described a case in which a patient with OCD self-medicated with psilocybin, once every three weeks, experienced a preserved effect of reduced anxiety, obsessive thoughts, and compulsive behaviour. In another case report, a patient suffering from a body dysmorphic disorder (spending about 4 hours a day examining himself in the mirror), has experienced a significant reduction in distress and a notable change in body perception following multiple dosing of psilocybin.

Moreno et al. 2006 conducted a semi open-label trial examining the effect of psilocybin on nine participants with mild to severe OCD, which had at least one "treatment failure" defined as a lack of significant improvement after an adequate treatment. Doses were 25 (very low dose \[VLD\]), 100 (low dose \[LD\]), 200 (medium dose \[MD\]), and 300 (high dose \[HD\]) µg/kg. LD, MD, and HD were assigned in that order, and VLD was inserted randomly and in a double-blind fashion at any time after the first dose (LD). In measurements during the 24 hours after each dose all participants have experienced a significant relief in symptoms (23%-100% as measured by the Yale-Brown Obsessive-Compulsive Scale \[YBOCS\]) in at least one of the sessions. Two of the subjects reported that their symptomatic improvement lasted most of the following week after testing. One subject achieved long-term remission at the end of the 4 test sessions, as measured at 6-month follow-up. There was, however, no clear dose-response relationship to the change in YBOCS score and no correlation between YBOCS score reduction and the perceived intensity of the psychedelic experience.

These preliminary findings stress the need for further research to examine the efficacy of psilocybin in the treatment of OCD. In addition, the only clinical trial to date did not include psychotherapy for patients while under the influence of psilocybin. Earlier studies have shown that a preliminary therapeutic relationship before psilocybin administration increases the probability for a "peak experience" during sessions. Furthermore, two more recent studies have emphasized the importance of psychotherapy during and before psilocybin sessions, touching on 'intent' and formulating an early and strong therapeutic relationship. There is also a reference to the, "psychedelic afterglow", an effect lasting for days and even weeks after a psychedelic session during which there is a unique window for a meaningful transformative psychotherapeutic intervention, most likely owing to the increased psychological plasticity following a psychedelic experience.

The current study has two main goals: 1. Determine the safety and efficacy of psilocybin for patients suffering from OCD. 2. Elucidate the psychological mechanisms contributing to the beneficial effect of psilocybin on OCD symptoms.

Research Plan:

The current research aims to examine the feasibility, safety and efficacy of psychotherapy assisted psilocybin for treatment of severe OCD. The protocol includes 15 therapeutic sessions, of which 12 are one-hour sessions, and three are eight hours' experiential sessions (session 4,8,12) under the influence of psilocybin. In the first experiential session participants will receive a safety dose of 10mg/70kg. In the second and third sessions, participants will receive a therapeutic dose of 30mg/70kg. Three preparatory sessions will take place before the first experiential session, and three integration sessions will take place after each experiential session.

The research will include 15 participants, and will include the following phases:

Selection phase:

Research team will screen participants via phone interviews. Participants answering the inclusion criteria will be invited to receive and sign consent forms. Research member will collect demographics and health status data and register the participants according to study protocol.

Preparatory and final registration phase:

It is known that SSRIs have

• 5-Dimension - Altered States of Consciousness (5D-ASC) [Срок оценки: 7 hours after drug administration]
• Mystical Experience Questionnaire (MEQ) [Срок оценки: 7 hours after drug administration]
• Emotional Breakthrough Inventory (EBI) [Срок оценки: Morning after drug administration]
• Persisting Effects Questionnaire (PEQ) [Срок оценки: Baseline to 6-month follow-up]
• Quality of Life Enjoyment and Satisfaction Questionnaire - Short Form (Q-LES-Q-SF) [Срок оценки: Baseline to 6-month follow-up]
• Community Observer Questionnaire [Срок оценки: Baseline to 6-month follow-up]