A recent case study published in BJPsych Open sheds light on the complex and sometimes contradictory outcomes of psilocybin-assisted psychotherapy for treatment-resistant depression. The case describes a participant in a clinical trial who experienced increased suicidal thoughts and severe eating difficulties after receiving a psilocybin dose. Despite these challenges, the participant ultimately found the experience beneficial, leading to significant life changes that were not reflected in traditional depression rating scales.
Psilocybin, a psychoactive compound found in certain “magic” mushrooms, has garnered attention for its potential to treat conditions like depression, anxiety, and post-traumatic stress disorder. In clinical settings, psilocybin-assisted psychotherapy involves administering a controlled dose of the compound in a supportive environment, often accompanied by preparation and integration sessions. These sessions help participants process their experiences, making them an integral part of the therapy. The treatment aims to facilitate profound psychological insights or emotional breakthroughs that could alleviate symptoms of mental illness.
Psilocybin’s effects on the brain, including its ability to reduce rigidity in thought patterns and foster emotional openness, have been linked to therapeutic benefits. However, the altered states of consciousness it induces can also lead to challenging experiences. This dual nature of psilocybin underscores the importance of careful clinical oversight and support throughout the therapy process.
The participant, who was given the pseudonym Zakara in the case report, had struggled with depression for over a decade, with her current episode lasting two and a half years. Previous treatments, including standard antidepressants, had been ineffective. She entered the trial with significant depressive symptoms, moderate social anxiety, and a history of suicidal thoughts, though she had no immediate plans to act on them.
On the day of her psilocybin dose, Zakara was administered 25 milligrams of the compound in a controlled environment. The psilocybin session initially appeared promising. Zakara recalled themes and imagery from her childhood, which evoked a “feeling of goodness I haven’t felt since I was seven.” But the relief was short-lived. She described the experience as one of stark confrontation with suppressed emotions: “The psilocybin ripped the lid off and shoved it under my nose and said, ‘smell that.’ So, while it was extremely unpleasant, it was ultimately needed and important that I finally acknowledged I couldn’t live like that anymore.”
For Zakara, this unmasking of emotional pain revealed the extent of her struggles, which she had hidden even from herself. “The mask I wore from day to day in order to hide from everyone how unwell I was inside was blown to smithereens. I realised that it had not been an armour to protect a vulnerable core… It was a brutal cage that I had been slowly wasting away inside of.”
The immediate aftermath was marked by emotional and physical challenges. Zakara reported feeling “hungover” and described her mood as plummeting. Suicidal thoughts became more constant, and nausea prevented her from eating. “I was more or less unable to eat anything without being or feeling sick for the next few days and then was so anxious I had very low appetite thereafter. I did little more than lie on the sofa and cry,” she recounted.
Her inability to eat extended for months, eventually leading to significant weight loss, hair thinning, and fainting. During this time, she also experienced a resurgence of intrusive thoughts and anxiety, describing the struggle as “scrambling for comfort and unable to find it anywhere.”
Amidst these challenges, Zakara began to notice subtle, meaningful changes. Over time, she started making small adjustments to her daily life, such as joining a gym and quitting her part-time retail job for one that felt more fulfilling. She also reconnected with activities that brought her joy and began exploring old hobbies. One small but symbolic shift stood out to her: “Before participating I brushed my teeth if I remembered (which was rare), felt like it (rarer still) or had a social or public-facing event. Since, I’ve brushed my teeth every day.”
These functional improvements were not without setbacks. Zakara experienced a second serious adverse event months after dosing, during a period of personal upheaval. Feeling isolated and overwhelmed, she counted pills for a potential overdose and started writing a suicide note but stopped herself. She described this phase as an ongoing battle between despair and a new awareness of her emotional landscape. “I felt as though I had discovered a sick truth of life: That no matter how hard you try to climb to better things, you will never succeed… But to accept it was a pain that could only be cured by suicide,” she explained.
Despite these struggles, Zakara’s connection to her emotions continued to grow. “Things felt real for the first time in so long I can’t even remember—not just a haze that often felt like a simulation,” she reflected. This newfound emotional clarity allowed her to make lasting changes, even as her depressive symptoms remained high on clinical rating scales.
Reflecting on the experience, she remarked, “It’s probably a puzzle I will be putting together until I die, but whereas before I was struggling with countless pieces that had no context, the trial experience gave me a glimpse of the picture on the front of the box.”
By the end of the one-year follow-up, Zakara described herself as being in a better place overall, with a more stable mood and her appetite back to normal. Although her journey was fraught with challenges, she expressed a nuanced perspective on the trial’s impact. “I don’t want my experience to be used as a warning against the use of psilocybin therapeutically. But I also don’t want it to be brushed aside as a fluke, or as a non-responder (Oh boy, did I respond).”
“I sometimes wonder if I’m a masochist or suffering some kind of psilocybin-Stockholm syndrome, because I’ve never regretted participating in the trial and if I could go back in time I would do it again.”
Case studies have inherent limitations. They focus on a single individual or a small group, making it difficult to generalize findings. The subjective nature of personal accounts can introduce bias, and outcomes may be influenced by factors unique to the individual, such as their life circumstances or prior experiences. In Zakara’s case, her ability to guess she had received an active dose could have influenced her responses.
Despite these limitations, case studies are valuable in highlighting areas for further research. Zakara’s experience points to the need for more qualitative exploration of psilocybin therapy, particularly regarding its potential to worsen symptoms before leading to improvement. It also highlights the importance of long-term follow-up to better understand the lasting effects of the treatment.
As the authors of the report concluded: “this case illustrates that psilocybin administration could be followed by a worsening in suicidal ideation and prolonged adverse events that long outlast its acute effects. Paradoxically, it may lead to an improvement in functional outcome that is not clear on depression rating scales. As this is a single case report, no conclusions can be drawn, and further assessment is required to understand this phenomenon.”
Interestingly, broader research aligns with this duality, suggesting that adverse experiences with psychedelics can sometimes yield positive mental health outcomes. For instance, a study published in the Journal of Psychopharmacology found that 84% of participants who experienced a “bad trip” with psilocybin later reported benefits, such as personal growth and improved well-being, despite the psychological difficulty. However, prolonged or particularly intense bad trips were linked to risks like self-harm and enduring psychological issues. Similarly, research from the International Journal of Drug Policy found that many psychedelic users employ storytelling to reframe distressing experiences, attributing personal insights and emotional breakthroughs to their challenging trips.
The case report, “Worsening suicidal ideation and prolonged adverse event following psilocybin administration in a clinical setting: case report and thematic analysis of one participant’s experience,” was authored by Mourad Wahba, Caroline Hayes, Maartje Kletter, and R. Hamish McAllister-Williams.
