Pseudoscience and "Psychedelic" Hype
The recent Massachusetts ballot question debates about hallucinogens (so-called psychedelics) raised the question for me about pseudoscience and hype in psychiatry. The great founder of modern scientific medicine, William Osler, once touched on this point: With the public, he said, a touch of humbug often is necessary.
Often there is much more than a touch of humbug.
Boston magazine for instance had a major article in January 2024 on how hallucinogens were going to save the world (“Inside Boston’s psychedelic revolution”), with some impressive photo shoots: a celebrity in her fancy house, a national advocate in his local home, a psychiatrist hallucinogen “expert” in his socks gazing into the distance.
That’s a lot of humbug.
Of course proponents of hallucinogens claimed that these agents are better than sliced bread. But even those who opposed the ballot question often said things along the lines of the following: Hallucinogens have a great deal of potential; they may prove very effective for various purposes.
Everyone was enthusiastic.
But it’s good to stop for a moment and ask a few questions about enthusiasm. My friend the psychologist Donald Meichenbaum from Chicago is one of the founders of cognitive behavioral therapy. He has been in the field of psychology since the 1950s. Some years ago he published a paper with my friend the late Scott Lilienfeld of Emory University, called “How to spot hype in the field of psychotherapy: A 19-item checklist.”
A partial listing of their “Hype” checklist includes:
“Substantial exaggeration of claims of treatment effectiveness”
“Conveying of powerful and unfounded expectancy effects”
“Excessive appeal to authorities or ‘gurus’”
“Heavy reliance on endorsements from presumed experts”
“Extensive use of ‘psychobabble’”
“Extensive use of ‘neurobabble’”
“Tendency of advocates to be defensive and dismissive of critics…”
“Extensive reliance on anecdotal evidence”
These items characterize the hallucinogen advocates. These drugs have so much potential and there is so much enthusiasm, but when you look at the facts, there’s another story.
For instance, the agents studied the most in randomized trials, psilocybin, has been shown to be similar in clinical efficacy to standard serotonin reuptake inhibitors. The effect size difference between those agents is small and not clinically meaningful. Advocates claim that psilocybin would be “transformative” for treatment-resistant depression, while it’s proven no better than drugs we already have. The ballot question advocates focused on PTSD, but there’s not a single RCT of psilocybin in PTSD. They never mentioned that. There’s one RCT of MDMA in PTSD, but it’s results are not as simply beneficial as people claim. 90% benefit with MDMA is cited, but 70% benefit with placebo usually is unstated.
This highly-cited paper has relevance to all of psychiatry, like hallucinogens. Of course, psychotherapy is famous for hype: literally thousands of versions of psychotherapy are promoted for all kinds of uses. Some may work, but all claim they work. How can you tell? The short answer is science, but we all know that there many nuances to that answer. The longer answer is not only applying science, but ferreting out pseudoscience.
Let’s turn our attention there.
Pseudoscience, in a classic definition by the physicist Richard Feynman, is when superficial methods of science are used – inclusion and exclusion criteria, forest plots, odds ratios with confidence intervals – but the essence of science is left out. The essence of science is not the various experimental methods that are used, but rather a scientific mindset. That mindset involves the effort to refute one’s own ideas, not simply to find and distort data to support them. Feynman taught that this scientific attitude, which is very difficult to achieve, involves being rigorously honest with oneself, and by not deceiving oneself, one does not mislead others. Most people are not scientists; even most doctors technically are not scientists in the sense of being researchers themselves; hence they may not have a scientific mindset at the level that Feynman proposes.
This is certainly the case with many hallucinogen “experts,” whose apparent science is pseudoscience, not because of their methods, but because of their attitudes.
Pseudoscientists deceive themselves, adhering to a set of unchanging beliefs. Then they can mislead honestly, based on their own self-deception. Self-deception is a precondition for deception.
Science is a much harder task than pseudoscience, just as refutation of one’s beliefs is much harder than confirmation. This is why science is difficult, and many published scientific articles mislead.
Why do researchers engage in pseudoscience? Their work is not “research” in the sense of new knowledge. It’s social activism disguised as science. It uses scientific journals as a public relations tool, providing a patina of respectability for explicit opinion-based propaganda on the internet and in social media.
The hallucinogen pseudoscientific experts certainly would disagree, which proves my point. They believe they are engaging in science when they are doing the exact opposite of science. Feynman’s wisdom needs repetition: Pseudoscience is present when you use the superficial techniques of science, like meta-analysis or randomized trials, in the service of supporting your own beliefs, rather than seeking to refute those beliefs. Pseudoscientists deceive themselves first, then earnestly foist their false beliefs on others. They will not be convinced. Any critique is not aimed at changing their minds; it needs to be aimed at the larger community to prevent them from being misled by pseudoscientific experts. This is no easy task. It doesn’t lead to glitzy magazine pictures in socks, or photoshoots with celebrities. It doesn’t meet the dog bites man criterion for newspaper coverage.
It's simply science – honest, quiet, stubborn. Unwilling to accept humbug.
Pseudoscience is noisy; science whispers.
The heart of the issue is the entire concept of depression.
A friend of mine—a very nervous fellow, perhaps "apprehensive" is an even better term—was very excited about psilocybin to treat his problem, which he’s never found much relief from. I looked into it, not very deeply, and said to him, “You know, I’m not sure it will do much more for you than Prozac.” Funnily enough, he’d done okay on Prozac.
But he doesn’t have depression, let alone TRD, and in fairness to him, he doesn’t describe his problem in those terms. Still, it’s clear that the norm these days is to target as wide a customer base as possible. Certainly, there are plenty of drugs that are quite non-specific, but the new thing is to claim a drug is highly specific and then make the diagnostic category as wide as possible.
It may be that some of these drugs really are non-specific. I mean, in a discovery that surprises no one, nervous people might like getting high. And perhaps there is a place for that—stimulants can ginger someone up, tranquilizers can calm them down, and maybe getting someone “high” has some therapeutic use. But hallucinating is quite the nuisance side effect. Yet, like the extrapyramidal effects of antipsychotics, some psychedelic experts will tell you there’s no therapeutic effect unless the person goes full ape shit and is guided to enlightenment by their shaman.
Then of course, there is the intriguing question of ketamine and the role of opioid receptors. Is there something to Klein’s central pain component theory that responds to this sort of thing? Is it the reason ketamine doesn’t last?
Do any of them break the back of melancholia, though, or lead to good stability in mania? TRD, for people paying attention, is a wide church—made up of everything from unstable manics to lifelong anxious types, from melancholics who’ve never been offered anything stronger than Prozac to manic depressives who took lithium once (off the back of Zoloft) when depressed and didn’t like it. There is no sense anymore because there is no sense to the phenotypes. There is no basic psychopathology. You read a study, and they might as well call the patient group by some gobbledygook for all the sense you get of what the hell is actually wrong with these people. They might as well say, “We took a group of people with Gooby-Gooby Disease, got them blazed, and now they’re about eight miles high.”
I say bring back William Hammond’s “blow to the head.” I want to see “blow to the head” vs. Seroquel active comparator. That’s the showdown I want to see.
Or, here’s a controversial one for you—valproate vs. cautery. Which one are you going to bet the ranch on?
Magnificent essay, Dr. Ghaemi. It contains so much wisdom, and my only hope is that some of people involved with this new Flavor of the Month will pay attention to your teachings.