Ensuring psychedelic treatments and research do not leave anyone behind

Abstract

Psychedelics are a promising approach to caring for persons living with severe mental illness. However, as with all clinical treatments and research in the US, health equity concerns must be considered and addressed. Ensuring health equity and health justice in psychedelic care delivery and research will require strategies to not only reduce disparities and preempt future disparities among minoritized and marginalized populations.

Psychedelics are a promising approach to caring for persons living with serious mental illness. However, as with all clinical treatments and research in the US, health equity concerns must be considered and addressed. As we move forward from the Covid-19 pandemic, a time in which the world saw more clearly the vast health injustices that exist for some populations and the substantial advantages other populations hold in health, we must acknowledge that we are at an important watershed moment in advancing healthcare and health-related research. A true window of opportunity exists for psychedelic treatment advancement, but research and clinical care in psychedelics must center and address concerns about inequality, equity, and justice.

To be clear, there have been some research and commentaries in the psychedelic literature that speak to the need for advancement of health equity [1, 2]. With the high health inequities in severe mental illness and substantial challenges of treating refractory cases, a field of inquiry such as psychedelics holds high potential promise in addressing such inequities through research and clinical care [3]. Indeed, there are many challenges to the promotion of health equity in this field such as participation in contemporary clinical trials on psychedelics remain mostly homogenous with about 80% or more White participants [4–6]. Thus, it is important to note that architecture and design matter with respect to any clinical care treatment, delivery, or related research. And when trying to apply a health equity or health justice lens to ameliorate health inequities in severe mental illness and access to psychedelic research and treatment, one must scrutinize the processes that underlie research and clinical care in the field.

Designing a framework for implementation of clinical care and research that reflects and centers principles of health justice is critical in all areas of health care but especially with respect to psychedelics. Inequality and health disparities exist when policies or practices favor certain people or groups while actively disadvantaging others. Addressing equity requires recognizing that existing policies and practices are inequitable while at the same time providing people with different types of supports that allow them to achieve health and access needed healthcare and treatments despite disadvantages. However, most important in such a framework is to ensure that a diverse group of people evaluate why policies, practices, treatments, and research designs are inequitable and collectively work to modify or reconfigure these structures and practices so that everyone thrives, instead of a select few.

Acknowledging history is essential in building a health equity and health justice framework, given the US has a deep and long history of slavery, racism, and discrimination, including histories of egregious experimentation. Even today, systemic racism limits access of some minoritized and marginalized populations to novel health treatments including psychedelics. Not only racial and ethnic and sexual and gender minoritized populations and populations living with disabilities experience significant health disparities, many of the health care disparities that are especially prominent in these populations are in the same areas that psychedelics hold promise—depression, anxiety, suicidality, substance use.

The entire clinical care and research pipelines are fraught with structural racism and intersecting systems of oppression. For example, the design of research studies can systematically exclude certain participants and populations. If a study does not have diverse participants, the generalizability of the results may not apply to much of the population, The Health for All Project was designed to better understand how to improve clinical trial participation among minoritized and oppressed populations [7]. Currently, in psychedelic research, there are little data regarding the participation of many diverse groups in clinical studies including certain minoritized and persons living with disabilities and sexual and gender minorities [5]. Similarly, journals, editorial teams, reviewers, and publication opportunities are all fraught with bias and can further hinder the visibility of research in psychedelics that may include diverse populations. Trust is key, as healthcare, medicine and research have earned distrust have got to work diligently to regain that trust that has been severed with our egregious history.

Inequities also exist along the entire healthcare delivery pipeline for severe mental illness [5, 8]. Some of the critical healthcare access dimensions to consider are risk factor management, quality and consistency of care, training of a diverse and culturally humble workforce, financial issues such as insurance and reimbursement, social and economic determinants of health, health literacy, stigma, and trust. Frameworks such as EQUIP that aim to enhance equity in care delivery, may help inform an equity-oriented approach to integrating psychedelic assisted therapies into clinical practice [9]. Other evidence based intervention approaches in other fields of clinical care including community health workers and patient navigators both as interventions themselves and implementation strategies are crucial to build a bridge of trust to the healthcare system. Moreover, ethical and legal issues in psychedelic treatment use does need to be addressed with respect to the potential to promulgate versus benefit [10]. What is essential to this system working well is care delivery that prioritizes the needs of “all” patients.

In developing a framework for accessible and equitable implementation of psychedelic therapy, implementation science approaches that simultaneously examine the effectiveness of treatments but also how the treatments are accessed and delivered are critical. Implementation science and research study designs such as hybrid study design models aim to bridge the science-practice gap using a variety of approaches, including process models, determinant frameworks, and evaluation [11–13]. In combination with health equity research, implementation science can offer methods and test strategies intended to reduce disparities.

The healthcare and scientific workforce pose further challenges to advancing health justice, especially in psychedelic treatment and research. Diversity among researchers and clinicians is also critical to the impact and how connected the research studies are to minoritized populations. Trust in healthcare providers is more easily bridged when a member of the healthcare team possesses identities that are concordant to a patient. There are studies that show concordance especially amongst Black populations can drive health outcomes [14–16].

Building trust also means educating the community by having researchers go into communities where marginalized people live and engaging in meaningful iterative, and long-term dialog in partnership with community leaders, religious leaders, activists, and other trusted community members. Every community has different gatekeepers and arbiters of trust. Since American Indian and other Native and Indigenous communities have a long history of the use of psychedelics, acknowledging and valuing that history and then linking it to the treatment of mental health conditions is critical [17, 18].

In sum, ensuring health equity and health justice in psychedelic care delivery and research will require strategies to not only reduce disparities and preempt future disparities among minoritized and marginalized populations. With respect to research, diversity is critical not only among trial participants and patients, but researchers and clinicians as well. Multiple access dimensions require consideration, including risk factor management, quality and consistency of care, training of a diverse and culturally responsive and humble workforce, financial issues such as insurance and reimbursement, social and economic determinants of health, health literacy, stigma, and trust. Building trust among communities that have been historically marginalized, discriminated against and treated egregiously will require open, honest communication as the first step towards ensuring equitable access to psychedelic therapies and equitable design and participation access to psychedelic research.

Competing interests

MAS serves as a member of the NIH Advisory Committee for the Office on Women’s Health (ACRWH ORWH) Research at NIH and as a member of the CDC Community Preventive Services Task Force (CPSTF) and her written views are her own and not necessarily those expressed by the NIH ORWH nor CDC CPSTF.